Summary of Articles from the Journal of the American Geriatrics Society: September 2010, Volume 58

Reviewed, prepared, and submitted by Thomas T. Yoshikawa, MD, Editor-in-Chief, Journal of the American Geriatrics Society Title: Greater Prevalence and Incidence of Dementia in Older Veterans with Posttraumatic Stress Disorder Authors: Qureshi SU, Kimbrell T, Pyne JM, et al Summary: Posttraumatic stress disorder (PTSD) has been reported to occur in 15-25 percent of U.S. veterans of various wars. Some disorders associated with PTSD are also associated with higher rates of dementia. This study explored the association of PTSD and dementia in older veterans. Veterans aged 65 and older were studied in 4 groups: those with PTSD and no Purple Heart (PH), PTSD and PH, no PTSD and PH, and no PTSD and no PH. Veterans with PTSD with or without PH had twice the prevalence of dementia diagnosis than veterans without PTSD with or without PH. These findings suggest that veterans with PTSD should be screened more closely for dementia. Comments: An accompanying editorial by Dr. Soo Borson provided additional insights on potential pathogenetic mechanisms of this association. Although many veterans use Veterans Affairs (VA) hospitals for their care, some veterans may receive healthcare by non-VA providers. Hence, practitioners should be aware of this potential association if they are caring for a veteran patient. Moreover, PTSD occurs in non-veteran persons exposed to traumatizing experiences with lifelong effects. Hence, the association of PTSD and dementia could become an increasing personal and public health problem as we continue to see a growing number of older adults with dementing illnesses. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society. ______________________________________________________________________ Title: Effect of Zoster Vaccine on Herpes Zoster-Related Interference with Functional Status and Health-Related Quality-of-Life Measures in Older Adults Authors: Schmader KE, Johnson GR, Saddier P, et al Summary: This study was part of the Shingles Prevention Study, a randomized, double-blind, placebo-controlled trial of live attenuated zoster vaccine in 38,546 adults aged 60 and older at 22 U.S. study sites. This particular study investigated the efficacy of the zoster vaccine on herpes zoster-related interference with functional status and quality-of-life measures. The findings indicated that the zoster vaccine reduced the burden of zoster-related interference of activities of daily living in those vaccinated and those vaccinated who developed herpes zoster. The vaccine also reduced the effect of herpes zoster health-related quality of life measures in vaccinated persons but not in those vaccinated who developed herpes zoster. An accompanying editorial by Dr. Roy Fried indicated that the risk-to-benefit ratio is not favorable for zoster vaccine in persons aged 80 and older. Comments: Although not all may be impressed with the positive impact of the zoster vaccine, it is this editor’s opinion that benefit of immunization against herpes zoster outweighs the morbidity and complications of shingles in older adults. I have seen many older adults including physicians afflicted with post-herpetic neuralgia and its long-term painful and emotionally draining impact. Thus, I believe the potential prevention of the disease or its complications through vaccination is worth the risk. I have received the vaccine. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society. ______________________________________________________________________ Title: Relationship Between Quality of Care of Hospitalized Vulnerable Elders and Postdischarge Mortality Authors: Arora VM, Fish M, Basu A, et al Summary: This study examined the relationship between the quality of care delivered in a hospital, using the Assessing Care of Vulnerable Elders (ACOVE) quality indicators, and mortality of elderly hospitalized patients after discharge. Among 1,856 hospitalized vulnerable older patients at one medical center, the mean quality-of-care score was 59.5 +/-19.2% and 495 patients (26.7%) died with 1 year. For each 10% increase in quality score, there was a 7% less likelihood for patients to die. Thus, adherence to quality-of-care indicators appears to be warranted for vulnerable older hospitalized patients. Comments: Although these findings are reassuring that better care leads to better outcomes (in this case fewer mortalities), there are many unclear issues in terms of implementing standards of practice related to quality. What type of measures or metrics should be used to measure quality of care in an inpatient setting? Which practice guidelines should be mandatory or optional? With the very old and frail hospitalized patients who have multiple disorders and comorbidities, there will be competing priorities in terms of which disease or disorder should take precedence for implementation of interventions to improve quality of care, when some interventions for one disease may adversely affect another coexisting condition? An accompanying editorial by Dr. Robert Palmer expands on many of these important issues. The opinions expressed are solely those of the reviewer and do not necessarily reflect those of the American Geriatrics Society or Journal of the American Geriatrics Society.