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In This Issue of Archives of Internal Medicine
May 23, 2011

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2011;171(10):879. doi:10.1001/archinternmed.2011.177
Efficacy of Brief Behavioral Treatment for Chronic Insomnia in Older Adults

Cognitive behavioral therapy is efficacious for chronic insomnia, but it is not feasible in most practice settings because it is provided by highly trained therapists over 6 to 8 weekly sessions. This study tested the efficacy of a 2-session brief behavioral treatment for insomnia (BBTI) vs an information control (IC) condition, both delivered by a nurse practitioner, in 79 older adults with chronic insomnia. Treatment response (66.7% vs 25.0%; χ2 = 13.8, P < .001) and the proportion of participants without insomnia after 4 weeks (55.3% vs 12.8%; χ2 = 15.5, P < .001) were significantly higher for BBTI than IC. The number needed to treat was 2.4 for each outcome, and improvements were maintained at 6 months. For chronic insomnia in older adults, BBTI is a simple, efficacious, and durable intervention that has the potential for dissemination across medical settings.

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Electronic Health Records and Clinical Decision Support Systems

Electronic health record (EHR) systems are promoted as an effective way to improve care quality in outpatient practices. Electronic health records could improve clinical care via clinical decision support (CDS), electronic guideline-based reminders, and alerts. Romano and Stafford investigated the association between EHR use, CDS use, and care quality using a retrospective, cross-sectional analysis of outpatient physician survey data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 2005 through 2007. The authors assessed quality using a previously developed set of 20 visit-based quality indicators and found no consistent association between either EHR use or CDS use and care quality. These results raise doubts about the ability of EHR, in isolation, to fundamentally alter outpatient care quality.

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Inhaled Anticholinergic Drug Therapy and the Risk of Acute Urinary Retention in Chronic Obstructive Pulmonary Disease

Inhaled anticholinergic medications are widely used treatments for chronic obstructive pulmonary disease (COPD); however, their systemic effects have not been widely studied. Using linked administrative health care data from Ontario, Canada, this population-based nested case-control study sought to determine the risk of acute urinary retention (AUR) in seniors with COPD prescribed inhaled anticholinergic medications. Of 565 073 individuals with COPD, Stephenson et al identified 11 238 cases of AUR. Compared with matched controls, men who were new users of inhaled anticholinergic therapy had a more than 40% greater odds of developing AUR compared with nonusers after adjusting for multiple covariates. This risk increased further in men with benign prostatic hyperplasia (odds ratio, 1.81; 95% confidence interval, 1.46-2.24). When prescribed both a short- and long-acting inhaled anticholinergic medication, men had a significantly higher risk of AUR compared with nonusers (odds ratio, 2.69; 95% confidence interval, 1.93-3.76). The risk of AUR in women was not statistically significant.

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Translating Weight Loss and Physical Activity Programs Into the Community to Preserve Mobility in Older, Obese Adults in Poor Cardiovascular Health

This study examined the effect of an 18-month, translational, randomized controlled trial of physical activity (PA) and weight loss (WL) on mobility in overweight or obese older adults with cardiovascular disease (CVD) or at risk for CVD. Participants were randomized to PA, WL + PA, or a successful aging (SA) education control arm. The primary outcome was time to complete a 400-m walk in seconds (400MWT), with secondary measures including change in physical activity and weight loss. A significant treatment effect and follow-up testing revealed that the WL+PA group improved their 400MWT compared with both PA and SA groups. The WL + PA and PA groups experienced a significant increase in physical activity compared with the SA group, whereas the WL + PA group lost more weight that either the PA or SA group. Participants with poorer mobility at baseline benefited the most in improved 400MWT. These data illustrate that existing community infrastructures can be effective in delivering lifestyle interventions to enhance mobility in older adults in poor cardiovascular health with deficits in mobility; attention should be given to intervening on both weight and sedentary behavior because weight loss is critical to long-term improvement in mobility.

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