Summary of Articles From the Journal of the American Geriatrics Society: February 2011, Volume 59

Reviewed, prepared, and submitted by Joseph G. Ouslander, MD, Executive Editor, Journal of the American Geriatrics Society Title: Strength Training, Walking, and Social Activity Improve Sleep in Nursing Home and Assisted Living Residents: Randomized Controlled Trial Authors: Richards KC, Lambert C, Beck CK, et al Summary: The objectives of this study were to compare the effects of physical resistance strength training and walking, individualized social activity, and a combination of both with a usual care control group on total nighttime sleep time in nursing home and assisted living residents. The exercise intervention included high-intensity physical resistance strength training 3 days a week and on 2 days walked for up to 45 minutes, and the social activity intervention included social activity 1 hour daily 5 days a week. Total nighttime sleep time was measured using 2 nights of polysomnography before and 2 nights of polysomnography after the intervention. Sleep efficiency (SE), non–rapid eye movement (NREM) sleep, rapid eye movement sleep, and sleep onset latency were also analyzed. The investigators used a pretest–posttest experimental design with random assignment to 1 of the 4 groups for 7 weeks recruited from 10 nursing homes and 3 assisted living facilities. One hundred ninety-three residents were randomly assigned and 165 completed the study. The results showed that total nocturnal sleep time was significantly greater in the combined group than in the control group (adjusted means 364.2 minutes vs 328.9 minutes), as was SE and NREM sleep. The authors conclude that a combination of high-intensity physical resistance strength training and walking with social activity significantly improved sleep in nursing home and assisted living residents, but the interventions by themselves did not have significant effects on sleep in this population. Comment: This is probably the most rigorous clinical trial of nonpharmacologic treatments for sleep in the nursing home and assisted living population ever performed. To conduct repeated polysomnography in this patient population poses enormous challenges. The results are important and are consistent with data from intervention trials for other geriatric conditions: interventions can be effective in this patient population, but usually require a multifaceted approach because of the heterogeneity of the population and the multifactorial nature of many geriatric conditions. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society. ______________________________________________________________________ Title: Histamine-2 Receptor Antagonist Use and Incident Dementia in an Older Cohort Authors: Gray SL, Walker R, Dublin S, et al Summary: The objectives of this study were to examine whether histamine-2 receptor antagonist medications (H2RAs) are associated with a lower incidence of all-cause dementia or Alzheimer’s disease (AD), as some studies have suggested. This was a prospective population-based cohort study carried out at Group Health, an integrated health maintenance organization, in Seattle, Washington. Two thousand nine hundred twenty-three participants aged 65 and older without dementia at baseline, with initial recruitment between 1994 and 1996 were studied. Follow-up occurred every 2 years to identify incident dementia and AD using standard criteria. Exposure to H2RAs was determined based on automated pharmacy data. Three aspects of exposure (time-varying) were examined based on standard daily dose (SDD): cumulative use, intensity of use (highest SDD in any prior 2-year window), and cumulative use stratified according to timing of use (1–3 years vs >3 years before). Over a mean follow-up of 6.7 years, 585 subjects developed dementia (453 developed AD). Total cumulative exposure was not associated with dementia (P=.35; omnibus test) or AD (P=.23). The adjusted hazard ratios for the highest exposure category (>1,080 SDDs) compared with light or no use were 1.28 (95% confidence interval [CI] = 0.95–1.72) for dementia and 1.41 (95% CI = 1.00–1.97) for AD. Intensity of use was not associated with dementia (P=.39) or AD (P=.63). Examining exposure according to recent and distant cumulative use also showed no association with dementia (P=.11) or AD (P=.30). Thus, in this large prospective study, no association was found between H2RA use and risk of all-cause dementia or AD using more-detailed and extensive information about past H2RA use than any prior study. Comment: H2RAs have been repeatedly implicated in causing cognitive impairment as well as possibly dementia with chronic use. This carefully done prospective study was not able to demonstrate a relationship between using these agents and incident dementia. The data are reassuring given the over-the-counter availability of H2RAs and the frequency of use in the older population. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society. ______________________________________________________________________ Title: Improvement in Memory with Plasticity-Based Adaptive Cognitive Training: Results of the 3-Month Follow-Up Authors: Zelinski EM, Spina LM, Yaffe K et al Summary: The objectives of this study were to investigate maintenance of training effects of a novel brain plasticity–based computerized cognitive training program in older adults after a 3-month no-contact period. The study was conducted as a multi-site, randomized, controlled, double-blind trial with 2 treatment groups. Four hundred eighty-seven community-dwelling adults aged 65 and older without diagnosis of clinically significant cognitive impairment were recruited from communities in northern and southern California and Minnesota. Participants were randomly assigned into a broadly available brain plasticity–based computerized cognitive training program experimental group or a novelty- and intensity-matched cognitive stimulation active control. Assessments were done at baseline, after training, and at 3 months and included a primary outcome of a composite of auditory subtests of the Repeatable Battery for the Assessment of Neuropsychological Status. Secondary measures included trained task performance, standardized neuropsychological assessments of overall memory and attention, and participant-reported outcomes (PROs). The results showed a significant difference in improvement from baseline to 3-month follow-up in the experimental training and control groups on the secondary composite of overall memory and attention, (P=.01, d=0.25), the trained processing-speed measure (P<.001 d="0.80)," word="" list="" total="" recall="" letter="" sequencing="" and="" the="" cognitive="" subscale="" of="" pro="" previously="" significant="" improvements="" became="" non-significant="" at="" follow-up="" for="" primary="" outcome="" secondary="" measures="" attention="" memory="" several="" pros.="" narrative="" continued="" to="" show="" no="" advantage="" experimental="" group.="" effect="" sizes="" from="" baseline="" were="" generally="" smaller="" than="" post-training.="" authors="" conclude="" that="" training="" effects="" this="" computerized="" program="" maintained="" but="" waned="" over="" no-contact="" period.="">Comment: Many older adults are starting to look for, find, and use various computerized cognitive training programs. This study makes 2 important points about them. These programs can have short-term beneficial effects on various aspects of cognitive function in the older population. But, the effects are not maintained over a short time of 3 months if they are not used. How often these computer-based interventions need to be used to achieve improved cognition and maintain it over time needs to be further studied. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or the Journal of the American Geriatrics Society.