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Stewart et al conducted a randomized controlled trial of 6 months of combined aerobic and resistance exercise training in men and women, aged 55 to 75 years, with untreated baseline systolic blood pressure (BP) between 130 and 159 mm Hg or diastolic BP between 85 and 99 mm Hg. Blood pressure fell by 5.3/3.7 mm Hg among exercisers and by 4.5/1.5 mm Hg among controls (all P<.01). Only the reduction in diastolic BP was significantly greater among exercisers vs controls, thereby precluding attribution of the systolic BP reduction among exercisers solely to training. Reductions in body fat and increases in leanness were associated with BP reductions more so than improvement in fitness, suggesting that improved body composition may be a pathway by which exercise improves cardiovascular health.
Cholinesterase inhibitors are commonly used to manage the symptoms of dementia. These drugs can precipitate urge urinary incontinence. Anticholinergic drugs are used to treat urge incontinence, but their use among patients with dementia is generally discouraged because they can worsen cognitive impairment. In a population-based cohort study, Gill and colleagues document a prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Their results suggest that clinicians may be misattributing some cases of drug-related urinary incontinence to the underlying dementia. The coprescribing of cholinesterase inhibitors and anticholinergic drugs to patients with dementia should be avoided.
To estimate the bleeding risk associated with these combinations in medical practice, Buresly et al conducted a population-based observational cohort study using linked administrative databases. The authors studied 21 443 elderly survivors of acute myocardial infarction between 1996 and 2000 and examined hospitalizations related to bleeding complications. Of the patients, 7% had a bleeding event during follow-up. The adjusted odds ratio for bleeding in the antiplatelet combination and in the aspirin plus warfarin combination was almost twice that in the aspirin alone group. In practice, the combination of aspirin with warfarin or thienopyridine leads to a modest increase in the bleeding risk in the elderly, but the overall risk is small.
For psychotropic drugs, conservative initial dosing is recommended by both geriatricians and the Food and Drug Administration. Peterson et al present the results of a clinical trial evaluating a guided geriatric prescribing application within a computerized physician order entry system. Doses and frequencies of psychotropic drugs were suggested to ordering physicians, and substitutions were recommended for higher risk drugs. During the intervention period when the guided application was active, the initial drug dose chosen by physicians was lower and fewer nonrecommended medications were ordered compared with a control period. Fewer falls also occurred during the intervention period. These data suggest that adverse drug events can be prevented by providing decision support when psychotropic medications are prescribed in the elderly.
Although disability is thought to be primarily a consequence of clinical disease episodes, there is some suggestion that it may also be present prior to clinically overt disease. There is little systematic information on the exact temporal relationship between clinical disease episodes and disability. Mendes de Leon et al examined changes in disability before and after acute myocardial infarction (MI) in a cohort study of 2812 adults 65 years and older, using yearly data on 3 disability outcomes for the 279 subjects who had an MI during follow-up. Compared with the period before MI, they found no evidence for greater disability increases after MI for 2 of the 3 disability outcomes. There was a greater increase after MI in disability in basic tasks requiring mobility and strength, but an exploratory analysis suggested that this increase started about 1 year prior to MI, rather than after the clinical event. Changes in disability after MI may form a continuation of changes that occur before the event. Increases in disability before MI may be related to progression of subclinical disease or age-related decline in other physiological processes.
Predicted change in disability before and after acute MI.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2005;165(7):718. doi:10.1001/archinte.165.7.718