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Update in Geriatrics
- William J. Hall, MD; and
- Rosanne M. Leipzig, MD, PhD
- From University of Rochester School of Medicine, Rochester, New York; and Mount Sinai School of Medicine, New York, New York.
2000-2001 Series: Update Sessions from ACP-ASIM's 2000 Annual Session
Margaret Ring Gillock, Editor; David Cramer, MD, Co-Editor; and Paul T. Kefalides, MD, Co-Editor
This, the “millennial” edition of Update in Geriatrics, is based on a review of studies culled from about 30 peer-reviewed English-language journals—those most likely to be found in the libraries of community hospitals. All the studies were published in 1999 or early in 2000, and for the most part they are evidence-based trials rather than reviews or anecdotal reports. The guiding principle was that the information from these studies should be of immediate clinical use, not necessarily to geriatricians but to internists in a primary care practice, almost all of whom regularly encounter older, sometimes frail patients in the office setting, in the hospital, or when visiting a nursing home.
Insomnia
Between 12% and 25% of elderly persons in good general health have chronic insomnia. Normal aging is characterized by lighter sleep, less rapid-eye-movement sleep, and more arousals. Conditions such as sleep apnea and myoclonic jerks also become more prevalent. Older persons poorly tolerate drug treatment of disordered sleep. The use of sedative–hypnotics, for instance, can lead to falling, driving accidents, and impaired memory.
Cognitive–Behavioral Approach Provided More Enduring Relief of Chronic Late-Life Insomnia Than Use of a Benzodiazepine
Morin and colleagues' randomized study, undertaken at an academic medical center, is the first placebo-controlled clinical trial comparing behavioral and pharmacologic treatments, separately and combined, for late-life insomnia. The 78 participants, 50 women and 28 men (average age, 65 years), had had chronic primary insomnia of either the sleep-onset or maintenance variety for 6 months or longer and had experienced fatigue, impaired function, or disordered mood as a result. The participants were highly educated, were not depressed, and did not have the sleep apnea syndrome (apnea–hypopnea index > 15). The participants were treated as outpatients for 8 weeks and followed up after 3, 12, and 24 months with the aid of polysomnographic monitoring, sleep diaries, and questionnaires filled out by the patient's companion. The Sleep Impairment Index (a seven-item scale that yields a quantitative index of insomnia severity) served as a collateral outcome measure. Eighteen patients were randomly assigned to cognitive–behavioral therapy alone, 20 were assigned to pharmacotherapy, 20 were assigned to a combination of these measures, and 20 were assigned to placebo. The drug and placebo portions of the study were double-blinded, and combined treatment was blinded only for medication. Temazepam was taken 1 hour before bedtime at an initial dosage of 7.5 mg per night and a maximum of 30 mg for at least 2 nights per week On average, patients took 20 mg of the drug 5 nights each week. The 90-minute weekly cognitive–behavioral therapy sessions, with 4 to 6 participants, focused on the following:
1. A behavioral component incorporating sleep restriction therapy and stimulus control procedures. The “sleep window,” prescribed for the first week of treatment, was 6 hours. This window was gradually altered according to each participant's sleep efficiency (ratio of total sleep time to time in bed), which was based on the previous week's sleep diary date. Stimulus control measures were aimed at showing patients how to associate the bed and bedroom, as well as bedtime-related events, with actual sleep rather than with lying in bed trying to sleep. Participants were asked to retire only when sleepy, to use the bedroom only for sleep (and sexual intercourse), to go elsewhere if they were not asleep within 15 to 20 minutes, to get up at the same time every morning, and to limit daytime napping to less than 1 hour.
2. A cognitive component intended to rectify faulty beliefs and attitudes that frequently make insomnia worse, such as unrealistic expectations about how much sleep one needs and the desirability of spending excessive time in bed.
3. An educational component that distinguished between normative and pathological sleep in late life and focused on “sleep hygiene”: diet, exercise, caffeine, and alcohol, for example.
All active treatments proved more effective than placebo, and combining cognitive–behavioral therapy with pharmacotherapy tended to improve sleep more than either component by itself. Time awake after sleep began was reduced 63.5% in the combined treatment group, 55% in the cognitive–behavioral therapy group, 46.5% in the drug treatment group, and 17% in the placebo group. Patients given cognitive–behavioral therapy alone sustained their improvement at follow-up, but those given only temazepam did not; in addition, the participants felt more satisfied with the cognitive–behavioral approach. Combined treatment, in contrast to cognitive–behavioral therapy alone, was associated with improved sleep efficiency and a decrease in awakenings at all follow-up intervals. The patients' companions and experienced clinicians agreed with the participants that cognitive–behavioral therapy was better than combined treatment. Total sleep time increased by 10 to 20 minutes and sleep efficiency from about 73% to 83%, with no significant differences among the drug, cognitive–behavioral, and combined treatment groups. The Sleep Impairment Index, which includes the daytime sequelae of insomnia, pointed to improvement that was not statistically significant.
This trial, despite a small sample, indicates that a cognitive–behavioral–educational approach is effective long-term management for older persons with insomnia. A sensible strategy might be to start with medication and then either add the behavioral element or continue with cognitive–behavioral therapy after withdrawing drug treatment.
Delirium
During acute hospitalization, 7% to 30% of older adults become delirious, not including patients who are already delirious when admitted. Inclusion of the latter patients would bring the total into the 50% range. More than 2 million elderly persons are affected each year, at a cost to Medicare of more than $4 billion. Far more than simply an annoyance, delirium has several potentially serious outcomes, including the need for restraints and psychoactive drugs, pressure sores from confinement, deteriorating general health, and post-traumatic stress syndrome, in which the family and even the attending physician may participate. Patients who become delirious when hospitalized are likely to remain in the hospital nearly twice as long as those who do not, and there is a substantially greater risk for being institutionalized after discharge. Because delirium is most often a multifactorial syndrome that develops when a patient who is vulnerable for any reason is subjected to hospital-related insults (drugs or procedures), a comprehensive intervention strategy aimed at forestalling delirium was evaluated in patients 70 years of age or older admitted to the general medical service of a teaching hospital.
Targeted Interventions Significantly Reduced Risk for Delirium in Elderly Hospital Patients
Patients in an intervention unit who were not delirious when admitted were prospectively and individually matched to those in two units providing standard care. Patients with profound dementia and others with whom clear communication was not possible were excluded, as were patients hospitalized for less than 48 hours. Delirium was recognized by using the Digit Span Test, the Mini-Mental State Examination, and the Confusion Assessment Method (the latter is based on inattention, a fluctuating course, disorganized thinking, and altered consciousness). These criteria are about 90% sensitive and specific for delirium in hospitalized patients. The participants, 61% of them women, had an average age of 80 years. An interdisciplinary team, including a geriatric nurse-specialist, geriatrician, specialists in therapeutic recreation and physical therapy, and trained volunteers, administered interventions targeted to patients with specific risk factors. Risk factors, targeted patients, and interventions were as follows:
1. Cognitive impairment (all patients): daily sessions stressing orientation, activities such as word games, structured reminiscences, and discussions of current events.
2. Sleep deprivation (all patients at risk): encouraging high-quality sleep nonpharmacologically by providing warm drinks, back massage, and relaxation tapes or music; minimizing noise; and adjusting treatment schedules so as not to interrupt sleep.
3. Immobility (all patients): early mobilization, as much walking as feasible, and range-of-motion exercises.
4. Impaired vision (vision < Jaeger 20/70, binocular near vision): use of appropriate visual aids, specially adapted telephone keypads, and large-print books.
5. Impaired hearing (hearing < 7 of 12 whispers on the Whisper Test): use of portable amplifying devices, removal of ear wax, and special communicative techniques (such as staff members' ensuring that patients see their lips when conversing).
6. Dehydration (ratio of blood urea nitrogen to creatinine ≥ 18): encourage oral fluid intake to prevent or correct dehydration.
Delirium developed in 10% of patients in the intervention group and 15% of patients receiving usual care (matched odds ratio, 0.60 [95% CI, 0.39 to 0.92]). Twenty patients had to be treated to prevent one case of delirium. Days of delirium totalled 105 in the intervention group and 161 in the usual care group, and the total number of episodes was 62 and 90, respectively; both differences were statistically significant. When delirium did occur, it was no less severe in patients receiving the intervention. Similarly, the risk for delirium recurrence did not differ between groups. Adherence to the entire intervention program reached 87%. The program cost an average of $327 per patient and $6341 for each case of delirium prevented.
Observations in this well-designed study reinforce the idea that primary prevention remains the most effective means of dealing with delirium in elderly patients. This seemingly aggressive intervention can be undertaken at almost every community hospital in the United States.
Dementia and Feeding Tubes
The role of tube feeding in patients with advanced dementia is receiving increasing attention. These patients often have difficulty eating, and food-related problems increase as the dementia progresses. Patients may be apathetic or may actively resist feeding, or they may experience dysphagia or aspiration. Caregivers are increasingly using enteral feeding tubes, although the benefits and risks of this measure remain uncertain.
Literature Search Yielded No Data Directly Supporting Tube Feeding for Patients with Dementia
Finucane and colleagues performed a MEDLINE search extending over more than three decades to gain insight into whether the benefits of tube feeding outweigh the risks among patients with advanced dementia. The outcomes of interest, in addition to survival, were functional ability, patient palliation, malnutrition, infection, pressure sores, and aspiration pneumonia. No randomized trials comparing tube feeding with oral feeding were found, and few studies of any type investigated patients with advanced dementia. No evidence suggested that tube feeding prolongs survival in dysphagic patients. In fact, in a series of more than 5000 patients having problems with chewing or swallowing, tube feeding was associated with increased 12-month mortality (relative risk, 1.44). Fatal arrhythmias have been described in connection with placement of a nasogastric tube. None of the outcomes analyzed, including pressure ulcer formation, were improved by tube feeding. The expected decline in function was not slowed by tube feeding, and there are no indications that patients were made more comfortable. In addition to aspiration pneumonia, which has been described in up to two thirds of patients, tubes may be a source of infection, both locally in the nose and sinuses and in the form of nosocomial bacteremia. Other problems include tubal occlusion and leakage; about two thirds of nasogastric tubes must be replaced. It is not uncommon for dysphagic patients to report being hungry or nauseated shortly after starting tube feeding.
In a conservative alternative to tube feeding, patients with dementia who are carefully fed by hand live as long as patients without dementia. Worse, it may be necessary to restrain patients to prevent them from removing the tube. The overall evidence from the literature gives no strong indication of benefit from tube feeding of patients with severe dementia, and there is a significant risk for adverse effects. On balance, the negative aspects of tube feeding seem to predominate, and patients are not in general rendered more comfortable. More helpful may be curtailing unneeded medication (particularly anticholinergic drugs), carefully selecting foods, and taking care to position patients properly. Gillick (1) has argued that we must begin viewing advanced dementia as a terminal condition and recognize that the routine use of gastrostomy tubes is not warranted by the medical evidence. Family concerns and religious imperatives must be considered, but in the context of an objective account of the risks and benefits to be expected from tube feeding.
Dizziness
Between 13% and 18% of older adults describe being dizzy. This symptom creates an immediate and ever-present risk for falling; after 2 years, patients with dizziness are much more likely to be disabled. A “typical” patient is a woman 78 years of age who has cataracts, impaired hearing, cervical spine abnormality, peripheral neuropathy, and atrial fibrillation and who takes eight or more drugs daily.
Clinical Features Reliably Pointed to a Cardiovascular or Vestibular Origin of Dizziness in Most Older Patients
With the goal of developing a differential diagnosis of dizziness in older adults seen by primary care practitioners, Lawson and colleagues conducted a prospective case–control study in 50 consecutive patients older than 60 years of age and 22 age- and sex-matched controls who presented to general practitioners. The study aimed to identify the clinical characteristics at presentation that had the greatest utility. Patients were later referred for extensive neurocardiovascular and otolaryngologic work-up. By use of a standardized protocol, patients were asked about syncope, falling, and circumstances provoking the dizziness. Attempts were made to distinguish between lightheadedness and true vertigo. The examination included an assessment of cognitive function, psychiatric screening, vision and hearing tests, and a check for orthostatic hypotension. Benign paroxysmal positional vertigo was assessed by using the Dix–Hallpike maneuver.
The patients had been symptomatic for a median of 12 months, and nearly half of them had fainted or fallen. More definitive specialty-based evaluation led to a cardiovascular diagnosis in 28% of cases, in which the predominant features were syncope, lightheadedness, paleness, a need to sit or lie down, and symptoms worsening on prolonged standing. A peripheral vestibular disorder, identified in 18% of patients, was most likely when patients reported having vertigo. A central neurologic disorder was found in 14% of patients, and another 18% had multiple diagnoses. Peripheral vestibular disorders were infrequent. In 22% of patients, the symptoms could not be ascribed to any identifiable cause. The prognostic indicators were validated in 50 additional older patients with dizziness. Tests of vestibular function were not informative, and neither an abnormal gait nor positive result on a Romberg test predicted the final diagnosis. Only 3 patients had orthostatic hypotension.
It appears that clinical features alone can predict specific causes of dizziness in a majority of older persons. For this reason, these measures frequently preclude the need for expensive and potentially harmful laboratory procedures and can point the way to an appropriate consultation. The presence of cardiovascular disease makes a cardiovascular cause (such as orthostatic hypotension, carotid sinus hypersensitivity, or vasovagal syncope) far more likely. Otolaryngologic work-up is most productive when a patient has predominantly vertiginous symptoms. A recent population-based cross-sectional study of nearly 1100 persons older than 72 years of age identified seven features that were statistically associated with dizziness: anxiety, depression, impaired balance, hearing deficit, previous myocardial infarction, postural hypotension, and the use of five or more drugs. Among the roughly 15% of individuals who described dizziness, 90% had at least one of these features. On the other hand, five or more features equated to an 80% likelihood of being dizzy. The investigators concluded that dizziness might better be considered a geriatric syndrome resulting from impairment in multiple systems (2).
Depression
True depression—not just mood disorder—affects one in six adults living in the community and is even more prevalent in those who are institutionalized or receiving long-term care. Older white men are the demographic group most likely to succeed in committing suicide, and increasing evidence suggests that depressed older persons are at increased risk for dying of comorbid conditions, including myocardial infarction. In addition, disability from either medical illness or cognitive disorder tends to be amplified. On a positive note, as many as 80% of depressive episodes in older adults may be effectively managed by psychotherapy or medication. Elderly persons, though, are relatively vulnerable to recurrent depression.
Combining Antidepressant Medication with Interpersonal Psychotherapy May Be an Optimal Long-Term Strategy for Preventing Recurrent Major Depression in Elderly Persons
The respective merits of maintenance therapy using interpersonal psychotherapy and antidepressant medication in the form of nortriptyline—and of combined treatment—were examined in a double-blind, placebo-controlled trial in 107 patients with recurrent nondelusional unipolar major depression. The average patient age was 67 years, and one third of the patients were 70 years of age or older. All patients had recovered fully (defined as a score ≤ 10 on the 17-item Hamilton Depression Rating Scale) after open treatment with nortriptyline and weekly interpersonal psychotherapy, as well as lithium or perphenazine in about half of cases. After remission had continued for 16 weeks, the patients were assigned to receive nortriptyline (maintaining a plasma level of 80 to 120 ng/mL), placebo, or monthly maintenance interpersonal psychotherapy combined with either nortriptyline or placebo. All three active treatment regimens proved significantly better than placebo. Recurrence rates during the 3-year study period were 20% for patients receiving both nortriptyline and interpersonal psychotherapy (CI, 4% to 36%), 43% for patients receiving nortriptyline alone (CI, 25% to 61%), 64% for interpersonal psychotherapy alone (CI, 45% to 83%), and 90% for placebo (CI, 79% to 100%). Combined treatment was superior to interpersonal psychotherapy and placebo and also tended to be better than nortriptyline alone. Only combined treatment effectively prevented recurrences in the first year in persons 70 years of age or older. Few patients dropped out for reasons other than recurrent depression.
This, the first placebo-controlled comparison of maintenance drug treatment and psychotherapy in elderly patients with depression, shows that combining interpersonal psychotherapy with antidepressant medication substantially reduces the risk for recurrent major depression and is reasonably safe even for patients older than 70 years. It seems appropriate to view recurrent late-life depression as a chronic disorder requiring maintenance treatment, and it remains the case that relapses are frequent even with the best maintenance therapy. It is hoped that newer antidepressant drugs will prove superior to nortriptyline and that in combination with interpersonal psychotherapy will produce even higher remission rates.
Hypertension
The established consensus that treating hypertension in older adults is highly beneficial inspired the Swedish Treatment of Older Patients with Hypertension trial. Stroke, congestive heart failure, and myocardial infarction occur less often and dementia may be less frequent in patients treated for isolated systolic hypertension. The key clinical questions to ask when treatment of older patients is being contemplated are which patients to treat and whether all available antihypertensive drugs have essentially the same potential benefit and risk.
Newer Antihypertensive Drugs Proved No Better than Conventional Agents for Controlling Blood Pressure or Forestalling Cardiovascular Deaths and Major Events in Elderly Patients
Hansson and colleagues examined whether newer antihypertensive drugs are more advantageous in controlling hypertension (>180 mm Hg systolic, >105 mm Hg diastolic, or both) than older, “conventional” agents in a prospective trial of 6614 patients ranging in age from 70 to 84 years. Patients were randomly assigned to receive either conventional agents (50 mg of atenolol, 100 mg of metoprolol, 5 mg of pindolol, or a fixed ratio of 25 mg of hydrochlorothiazide plus 2.5 mg of amiloride daily) or more recently introduced drugs (10 mg of enalapril, 10 mg of lisinopril, 2.5 mg of felodipine, or 2 to 5 mg of isradipine daily). The patients actually were assigned to receive a conventional drug, a calcium-channel blocker, or an angiotensin-converting enzyme (ACE) inhibitor rather than a particular drug in each category of agents and were followed for 4 years. The goal was to maintain blood pressure (which at the outset averaged 194/98 mm Hg) at a value less than 160/95 mm Hg. During treatment, blood pressure averaged 160/80 mm Hg regardless of which class of drug was administered. The conventional and newer drugs did not differ with regard to total or cardiovascular mortality or the risk for stroke, myocardial infarction, atrial fibrillation, or congestive heart failure. Fatal cardiovascular events occurred at a rate of 19.8 per 1000 patient-years with both older and newer drugs. The relative risk was 0.99 (CI, 0.84 to 1.16). When last seen, nearly half the patients were taking more than one antihypertensive drug, and only two thirds were still taking the drug to which they were initially assigned. Prominent adverse events included ankle edema in patients taking calcium-channel blockers, a dry cough in those receiving an ACE inhibitor, and dizziness in roughly one fourth of patients taking all types of drugs.
Modern antihypertensive drugs failed to perform better than long-used and generally less expensive agents in this trial of elderly hypertensive patients. Factors other than blood pressure–lowering potency may be relevant to prescribing decisions in this population. An example is the value of ACE inhibitors and β-blockers for patients who recently had myocardial infarction and those with heart failure. Adverse drug effects are another important consideration for this population. From a cost standpoint, thiazide diuretics remain an attractive option for first-line treatment.
Treatment of Postmenopausal Osteoporosis
Declining estrogen levels during menopause are associated with loss of bone mass, more fragile bone, and an increased risk for fracture, particularly in the spine. Drugs are now available that show considerable promise for preventing some of the disability and dysfunction associated with osteopenia in older women. Risedronate, a potent bisphosphonate already approved for use in Paget disease and multiple myeloma, is now an alternative to etidronate, which must be administered cyclically, and alendronate, which, although widely used, may carry some risk for gastrointestinal toxicity. Raloxifene, a selective estrogen receptor modulator, prevents bone resorption; like risedronate, however, its value for preventing spinal fractures in women with postmenopausal osteoporosis has only recently been investigated.
Risedronate Safely Decreased the Risk for Recurrent Vertebral Fracture over 3 Years in Postmenopausal Women with Osteoporosis
Whether daily risedronate therapy reduces the risk for fracture in postmenopausal women was examined in a double-blind, placebo-controlled trial of 2458 women younger than 85 years of age who were at least 5 years past menopause, had established osteoporosis, and had sustained at least one vertebral fracture. They were randomly assigned to receive 2.5 or 5 mg of risedronate per day or a placebo for 3 years. All participants received calcium and, if needed, vitamin D supplements. The risk for new vertebral fractures decreased 41% (CI, 18% to 58%) over 3 years in women given 5 mg of risedronate per day compared with the placebo group. Nonvertebral fractures occurred 39% (CI, 6% to 61%) less often in the high-dose group than in the placebo group. These patients also had significant increases in bone mineral density over the 3 years of observation: 5.4% increase in the lumbar spine, 1.6% in the femoral neck, and 3.3% in the femoral trochanter. Levels of bone-specific alkaline phosphatase decreased by about one third from baseline in women given 5 mg/d. Bone biopsies indicated that turnover was reduced by about 50% after risedronate therapy. Withdrawals from the study and adverse events, chiefly involving the digestive tract, were similarly frequent (17%) in all groups.
The efficacy of risedronate, both in improving bone mineral density and decreasing the risk for fracture, is similar to that of alendronate, but the former drug may have a better safety profile. Protection is obvious within the first year of treatment. If the reduction in nonvertebral fractures is confirmed, risedronate will have the status of a therapeutic milestone. Numerous future generations of bisphosphonates can be anticipated. It seems likely that bisphosphonates will prevent new spinal fractures in patients already affected and, very possibly, long-bone fractures as well. Although prevention of hip fractures is much more speculative, we are clearly moving in the right direction. At this juncture, the questions are whether it is ethical not to treat any elderly postmenopausal woman with low bone density and a history of spinal fracture and whether placebo-controlled trials are still permissible.
Raloxifene, Given for 3 Years, Preserved Bone Mineral Density and Reduced New and Recurrent Vertebral Fractures in Postmenopausal Women with Osteoporosis
The Multiple Outcomes of Raloxifene Evaluation study, a multicenter effort, randomly assigned 7705 women 31 to 80 years of age who had osteoporosis and had been postmenopausal for 2 years or longer to receive raloxifene in a daily dose of 60 or 120 mg, or placebo, and followed them for up to 3 years. All the women received calcium and cholecalciferol supplements as well. After 3 years, when 6828 women remained in the trial, one or more new vertebral fractures had occurred in 10% of placebo recipients, 6.6% of those given the lower dose of raloxifene, and 5.4% of women receiving the higher raloxifene dose. The higher dose was clearly more effective in women with a history of previous bone fractures. When comparing the active treatment group receiving the 120-mg dose to placebo recipients, the relative risk for new vertebral fracture was 0.5 (CI, 0.4 to 0.8; number needed to treat for benefit, 46). The relative risk for nonvertebral fracture after 3-year follow-up was 0.9 (CI, 0.8 to 1.1) in the pooled raloxifene groups. Bone mineral density in the spine and femoral neck increased from 2% to 3% in raloxifene-treated women. The only serious side effect that probably was causally related to raloxifene therapy was venous thromboembolism, for which the pooled drug-related risk was 3.1 (CI, 1.5 to 6.2). Breast cancer was less frequent in women given raloxifene, and no vaginal bleeding or breast tenderness was encountered.
This trial provides the first large-scale evidence that a selective estrogen receptor modulator reduces the risk for osteoporotic fracture, at least in women at high risk because of severe osteoporosis or previous fractures. Raloxifene, though highly effective, is not yet a clear alternative to estrogen. First-line management remains based on exercise, avoiding falls, and taking supplemental calcium and vitamin D. Women at high risk, however, should almost always receive some form of antiresorptive therapy. The risk for venous thromboembolism, including pulmonary embolism, is a real one, but its absolute clinical magnitude—at least to date—is very modest. Unlike with risedronate, it is not yet possible to conclude that raloxifene will definitely prevent long bone fractures.
Predicting Disability in Old Age
Nothing can potentially benefit older persons more than for their physicians to encourage them to become, and remain, physically active. The decline in muscle strength that accompanies aging correlates with functional limitation (slower walking is an example), and it is important to retain at least a minimal level of strength to perform essential daily tasks. Those who possess a reserve of muscle strength are less likely to become limited after deconditioning or inactivity occasioned by acute illness, surgery, or other reasons.
Hand-Grip Strength in Middle-Aged Men Was Highly Predictive of Functional Status after 25 Years
Can a simple office procedure, such as testing maximum hand-grip strength, when first done in healthy middle-aged persons, predict functional limitation and disability in old age? A study designed to answer this question enrolled 6089 men who were 45 to 68 years of age and initially were in good health. Participants were followed prospectively for 25 years. The major end points were slow walking speed, inability to rise from a seated position without using the arms, and self-reported problems related to limb strength. Final disability assessment was possible in 3218 surviving participants. After adjustment for possible confounding factors, the risk for functional limitation increased as baseline hand-grip strength (measured with a hand-held dynamometer) decreased. Compared with participants with the highest grip strength, the odds ratio for slow walking (≤ 0.4 meter/s) was 2.87 (CI, 1.76 to 4.67) in those in the lowest tertile of grip strength and 1.79 (CI, 1.14 to 2.81) for those in the middle tertile. The corresponding figures for inability to rise from a chair were 2.90 (CI, 1.26 to 6.68) and 2.84 (CI, 1.34 to 6.02). Participants with the weakest grip at baseline were more than twice as likely to report problems in self-care or activities, which included such items as walking up stairs, lifting, doing heavy household work, dressing, bathing, eating, and toileting. The risk for functional limitation declined moderately after adjustment for chronic conditions present at final follow-up but in most cases remained statistically significant.
These findings present strong evidence that testing maximum hand-grip strength in middle-aged men is a valid predictor of disability 25 years later. Those who had greater grip strength during midlife remained stronger than others in old age. The implication is that good muscle strength at midlife may protect against aging-related disability by providing a greater margin of functional safety, although cause and effect cannot be established on the basis of this population study. Simple and inexpensive tests such as this might well be made part of yearly screening in primary care offices and the basis for recommending appropriate exercises. Many studies have found that regular physical exercise can substantially augment muscle strength at any age. This may be as close as we can get to the “fountain of youth.”
2000-2001 Series: Update Sessions from ACP-ASIM's 2000 Annual Session
Margaret Ring Gillock, Editor; David Cramer, MD, Co-Editor; and Paul T. Kefalides, MD, Co-Editor
Article and Author Information
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Requests for Single Reprints: William J. Hall, MD, Department of Medicine, University of Rochester School of Medicine, 601 Elmwood Avenue, Box MED/GMU, Rochester, NY 14642; e-mail, william_hall@urmc.rochester.edu.
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Current Author Addresses: Dr. Hall: Department of Medicine, University of Rochester School of Medicine, 601 Elmwood Avenue, Box MED/GMU, Rochester, NY 14642.
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Dr. Leipzig: Geriatric Research Education and Clinical Center, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1070, New York, NY 10029-6574.
- Copyright ©2004 by the American College of Physicians
