Recommendations for the conduct of economic evaluations in osteoporosis: outcomes of an experts' consensus meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the US branch of the International Osteoporosis Foundation

Economic evaluations are increasingly used to assess the value of health interventions, but variable quality and heterogeneity limit the use of these evaluations by decision-makers. These recommendations provide guidance for the design, conduct, and reporting of economic evaluations in osteoporosis to improve their transparency, comparability, and methodologic standards.

INTRODUCTION

This paper aims to provide recommendations for the conduct of economic evaluations in osteoporosis in order to improve their transparency, comparability, and methodologic standards.

METHODS

A working group was convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis to make recommendations for the design, conduct, and reporting of economic evaluations in osteoporosis, to define an osteoporosis-specific reference case to serve a minimum standard for all economic analyses in osteoporosis, to discuss methodologic challenges and initiate a call for research. A literature review, a face-to-face meeting in New York City (including 11 experts), and a review/approval by a larger group of experts worldwide (including 23 experts in total) were conducted.

RESULTS

Recommendations on the type of economic evaluation, methods for economic evaluation, modeling aspects, base-case analysis and population, excess mortality, fracture costs and disutility, treatment characteristics, and model validation were provided. Recommendations for reporting economic evaluations in osteoporosis were also made and an osteoporosis-specific checklist was designed that includes items to report when performing an economic evaluation in osteoporosis. Further, 12 minimum criteria for economic evaluations in osteoporosis were identified and 12 methodologic challenges and need for further research were discussed.

CONCLUSION

While the working group acknowledges challenges and the need for further research, these recommendations are intended to supplement general and national guidelines for economic evaluations, improve transparency, quality, and comparability of economic evaluations in osteoporosis, and maintain methodologic standards to increase their use by decision-makers.

Persistence at 24 months with denosumab among postmenopausal women with osteoporosis: results of a prospective cohort study

Persistence with prescribed medications for chronic diseases is important; however, persistence with osteoporosis treatments is historically poor. In this prospective cohort study of postmenopausal women treated for osteoporosis in real-world clinical practice settings in the USA and Canada, 24-month persistence with denosumab was 58%.

PURPOSE

Patients who persist with their prescribed osteoporosis treatment have increased bone mineral density (BMD) and reduced risk of fracture. Twelve-month persistence with denosumab in routine clinical practice is as high as 95%, but there are limited data on longer-term persistence with denosumab in this setting.

METHODS

This single-arm, prospective, cohort study evaluated 24-month persistence with denosumab administered every 6 months in postmenopausal women receiving treatment for osteoporosis in real-world clinical practice in the USA and Canada. Endpoints and analyses included the percentage of patients who persist with denosumab at 24 months (greater than or equal to four injections with a gap between injections of no more than 6 months plus 8 weeks), the total number of injections received by each patient, changes in BMD in persistent patients, and the incidence of serious adverse events (SAEs) and fractures.

RESULTS

Among 935 enrolled patients, 24-month persistence was 58% (50% in US patients and 75% in Canadian patients). A majority of patients received at least four injections over the observation period (62% of US patients and 81% of Canadian patients). Among patients who were persistent at 24 months and who had a baseline, 12-month, and 24-month DXA scan, mean BMD increased from baseline to 24 months by 7.8% at the lumbar spine and 2.1% at the femoral neck. SAEs and fractures were reported for 122 (13.0%) patients and 54 (5.8%) patients, respectively.

CONCLUSIONS

Persistence with denosumab for 24 months yields improvement in BMD among postmenopausal women with osteoporosis treated in routine clinical practice in the USA and Canada.

The importance of physical function to people with osteoporosis

There is increasing need to understand patient outcomes in osteoporosis. This article discusses that fracture in osteoporosis can lead to a cycle of impairment, driven by complex psychosocial factors, having a profound impact on physical function/activity which accumulates over time. More information is required on how treatments impact physical function.

INTRODUCTION

There is increasing need to understand patient-centred outcomes in osteoporosis (OP) clinical research and management. This multi-method paper provides insight on the effect of OP on patients' physical function and everyday activity.

METHODS

Data were collected from three sources: (1) targeted literature review on OP and physical function, conducted in MEDLINE, Embase and PsycINFO; (2) secondary thematic analysis of transcripts from patient interviews, conducted to develop a patient-reported outcome instrument. Transcripts were re-coded to focus on OP impact on daily activities and physical function for those with and without fracture history; and (3) discussions of the literature review and secondary qualitative analysis results with three clinical experts to review and interpret the importance and implications of the findings.

RESULTS

Results suggest that OP, particularly with fracture, can have profound impacts on physical function/activity. These impacts accumulate over time through a cycle of impairment, as fracture leads to longer term detriments in physical function, including loss of muscle, activity avoidance and reduced physical capacity, which in turn leads to greater risk of fracture and potential for further physical restrictions. The cycle of impairment is complex, as other physical, psychosocial and treatment-related factors, such as comorbidities, fears and beliefs about physical activity and fracture risk influence physical function and everyday activity.

CONCLUSION

More information on how treatments impact physical function would benefit healthcare professionals and persons with OP in making treatment decisions and improving treatment compliance/persistence, as these impacts may be more salient to patients than fracture incidence.

International Osteoporosis Foundation and European Calcified Tissue Society Working Group. Recommendations for the screening of adherence to oral bisphosphonates

Adherence to oral bisphosphonates is low. A screening strategy is proposed based on the response of biochemical markers of bone turnover after 3 months of therapy. If no change is observed, the clinician should reassess the adherence to the treatment and also other potential issues with the drug.

INTRODUCTION

Low adherence to oral bisphosphonates is a common problem that jeopardizes the efficacy of treatment of osteoporosis. No clear screening strategy for the assessment of compliance is widely accepted in these patients.

METHODS

The International Osteoporosis Foundation and the European Calcified Tissue Society have convened a working group to propose a screening strategy to detect a lack of adherence to these drugs. The question to answer was whether the bone turnover markers (BTMs) PINP and CTX can be used to identify low adherence in patients with postmenopausal osteoporosis initiating oral bisphosphonates for osteoporosis. The findings of the TRIO study specifically address this question and were used as the basis for testing the hypothesis.

RESULTS

Based on the findings of the TRIO study, specifically addressing this question, the working group recommends measuring PINP and CTX at baseline and 3 months after starting therapy to check for a decrease above the least significant change (decrease of more than 38% for PINP and 56% for CTX). Detection rate for the measurement of PINP is 84%, for CTX 87% and, if variation in at least one is considered when measuring both, the level of detection is 94.5%.

CONCLUSIONS

If a significant decrease is observed, the treatment can continue, but if no decrease occurs, the clinician should reassess to identify problems with the treatment, mainly low adherence.

Persistence at 12 months with denosumab in postmenopausal women with osteoporosis: interim results from a prospective observational study

To determine persistence with subcutaneous denosumab every 6 months in women being treated for osteoporosis, we conducted a single-arm prospective, observational study in the United States and Canada. Among 935 patients enrolled, 12-month persistence was 82%, with 66 patients (7%) reporting serious adverse events and 19 patients (2%) reporting fractures.

INTRODUCTION

Increased persistence with osteoporosis therapy is associated with reduced fracture risk. Denosumab reduced fracture risk in clinical trials; persistence in community settings is undetermined. This study evaluates persistence with denosumab in community practice in the United States (US) and Canada.

METHODS

In a 24-month multicenter, prospective, single-arm, observational study, women being treated for osteoporosis were enrolled ≤4 weeks after the first subcutaneous injection of denosumab. For this 12-month prespecified interim analysis, endpoints include persistence (one injection at study entry and another within 6 months + 8 weeks), attributes associated with persistence (univariate analysis), and serious adverse events (SAEs).

RESULTS

Among 935 patients (mean age 71 years), mean baseline T-scores were -2.18 (femoral neck) and -2.00 (lumbar spine); 50% of patients had experienced osteoporotic fracture(s). At 12 months, 82 % of patients were persistent with denosumab. Baseline factors significantly (p < 0.05) associated with higher persistence included use of osteoporosis medications >5 years previously, lumbar spine T-score > -2.5, and treatment by female physicians (US). Lower persistence was associated (p < 0.05) with psychiatric diagnoses including depression, southern US residence, being divorced, separated, or widowed (US), and prior hip fracture (Canada). SAEs were reported in 66 patients (7%); no SAEs of osteonecrosis of the jaw, atypical femoral fracture, fracture healing complications, hypocalcemia, eczema, or hypersensitivity were reported. Nineteen patients (2%) reported osteoporotic fractures.

CONCLUSIONS

The 12-month persistence observed in this single-arm open-label study of US and Canadian community practice extends the evidence regarding denosumab's potential role in reducing fracture risk in postmenopausal women with osteoporosis.

Osteoporosis Assessment Questionnaire-Physical Function (OPAQ-PF): a psychometrically validated osteoporosis-targeted patient reported outcome measure of daily activities of physical function

The purpose of this study was to evaluate the measurement properties of the Osteoporosis Assessment Questionnaire-Physical Functioning (OPAQ-PF). Based on this study, the OPAQ-PF has confirmed unidimensionality and acceptable reliability, construct validity, and sensitivity to change in a recent fracture/no recent fracture osteoporosis sample.

METHODS

Dimensionality was established through exploratory and confirmatory factor analysis. Patients completed three patient reported outcome (PRO) measures and four performance-based measures (PBMs) at baseline to enable an evaluation of construct validity. Patients without a recent fracture completed the OPAQ-PF 2 weeks after baseline to enable an evaluation of test-retest reliability. Ability to detect change and interpretation of change were investigated following completion of the OPAQ-PF 12 and 24 weeks postbaseline by patients with a recent fracture.

RESULTS

A prospective psychometric validation study in 144 postmenopausal women, with moderate to severe osteoporosis, 37 of whom had experienced a recent fragility fracture (<6 weeks). Unidimensionality was established for the OPAQ-PF by factor analysis. The OPAQ-PF had good internal consistency (α = 0.974) and test-retest reliability (mean intraclass correlation coefficient (ICC) 0.993. The OPAQ-PF differentiated between patients with/without recent fracture, and by severity of osteoarthritis; it correlated strongly with hypothesized-related scales and PBMs (r > 0.3, p < 0.001). Ability to detect change was established with high correlations between changes in OPAQ-PF score and changes in global concept scores in recent fracture patients (r ≥ 0.6, 24-week change). Effect size of change on OPAQ-PF score increased by level of global change (p < 0.001). Anchor-based methods identified an OPAQ-PF change of 10 at an individual patient level and 20 at a group level as meaningful to patients.

CONCLUSIONS

The OPAQ-PF has confirmed unidimensionality and acceptable reliability, construct validity, and sensitivity to change in a recent fracture/no recent fracture osteoporosis sample.

Development of the Osteoporosis Assessment Questionnaire--physical Function (OPAQ-PF): an osteoporosis-targeted, patient-reported outcomes (PRO) measure of physical function

We have developed a short, patient-reported outcome questionnaire--the Osteoporosis Assessment Questionnaire--Physical Function (OPAQ-PF)--that assesses the impact of osteoporosis on physical function. OPAQ-PF contains 15 items in three domains (mobility, physical positions, and transfers) and has content validity in osteoporosis patients with and without a history of fracture.

INTRODUCTION

This paper describes the development of the Osteoporosis Assessment Questionnaire--Physical Function (OPAQ-PF), a patient-reported outcome (PRO) questionnaire based on OPAQ v.2.0 (60 items, 14 domains) that assesses the impact of osteoporosis on physical function.

METHODS

OPAQ v.2.0 was administered to patients with osteoporosis. Item response theory methodology and clinical judgment were used to retain/eliminate items. The resulting instrument was modified during two sets of concept elicitation and cognitive debriefing interviews with osteoporosis patients.

RESULTS

Item response theory-based analysis of OPAQ v.2.0 (n = 1,478) coupled with clinician input resulted in the generation of a 21-item, six-domain instrument with a frequency response format. Interview data from 32 participants were used to modify this version and led to generation of the final instrument, OPAQ-PF. This final version has a severity response format and contains 15 items in three domains (mobility, physical positions, and transfers) that group together to provide an overall assessment of physical function in patients with osteoporosis. Twenty-two of the 32 interview participants (69 %) had previously sustained a fracture. Symptoms occurred primarily in these patients.

CONCLUSIONS

OPAQ-PF represents a brief, focused, PRO instrument that assesses physical function in patients with osteoporosis, specifically related to mobility, physical positions, and transfers. This questionnaire has content validity in osteoporosis patients who have, and have not, sustained a prior fracture.

Primary non-adherence to bisphosphonates in an integrated healthcare setting

We estimated primary non-adherence to oral bisphosphonate medication and examined the factors associated with primary non-adherence. Nearly 30% of women did not pick up their new bisphosphonate within 60 days. Identifying barriers and developing interventions that address patients' needs and concerns at the time a new medication is prescribed are warranted.

INTRODUCTION

To estimate primary non-adherence to oral bisphosphonate medications using electronic medical record data in a large, integrated healthcare delivery system and to describe patient and prescribing provider factors associated with primary non-adherence.

METHODS

Women aged 55 years and older enrolled in Kaiser Permanente Southern California (KPSC) with a new prescription for oral bisphosphonates between December 1, 2009 and March 31, 2011 were identified. Primary non-adherence was defined as failure to pick up the new prescription within 60 days of the order date. Multivariable logistic regression models were used to investigate patient factors (demographics, healthcare utilization, and health conditions) and prescribing provider characteristics (demographics, years in practice, and specialty) associated with primary non-adherence.

RESULTS

We identified 8,454 eligible women with a new bisphosphonate order. Among these women, 2,497 (29.5%) did not pick up their bisphosphonate prescription within 60 days of the order date. In multivariable analyses, older age and emergency department utilization were associated with increased odds of primary non-adherence while prescription medication use and hospitalizations were associated with lower odds of primary non-adherence. Prescribing providers practicing 10 or more years had lower odds of primary non-adherent patients compared with providers practicing less than 10 years. Internal medicine and rheumatology providers had lower odds of primary non-adherent patients than primary care providers.

CONCLUSION

This study found that nearly one in three women failed to pick up their new bisphosphonate prescription within 60 days. Identifying barriers and developing interventions aimed at reducing the number of primary non-adherent patients to bisphosphonate prescriptions are warranted.

Patient weighting of osteoporosis medication attributes across racial and ethnic groups: a study of osteoporosis medication preferences using conjoint analysis

We studied the ranking of osteoporosis (OP) medication attributes in a convenience sample of four different racial/ethnic groups in the United States. Our study showed that postmenopausal women differ in the ranking of OP medication attributes based on age, educational level, income, and prior fracture history.

INTRODUCTION

Decision making about OP medication-related behavior relies heavily on patient preferences about specific medication attributes. Patients may decide to initiate, change, or stop therapies based on ranking of perceived attributes of the therapy and their personal attitudes toward those attributes. We used MaxDiff, a form of conjoint analysis (Ryan and Farrar 2000), to explore patient weighting of attributes across four racial/ethnic groups at two sites in the United States and defined four critical attributes that influence such decisions (safety, efficacy, cost, and convenience) from qualitative interviews.

METHODS

We recruited a sample of 367 Postmenopausal (PM) women at risk of OP fractures from four racial/ethnic groups: Caucasian (n = 100), African American (n = 100), Asian American (n = 82), and Hispanic American (n = 85). Respondents completed a laptop-based questionnaire that included demographic items, several short scales on medical care preference and OP patient perceptions, and a MaxDiff procedure that determines comparative ranking of attributes either as least important or most important to their decisions.

RESULTS

MaxDiff analyses were done to evaluate the relative weight of specific statements for each participant and to determine whether racial/ethnic groups differed across dimensions. Overall, participants in all four groups rated efficacy > safety > cost > convenience.

CONCLUSIONS

Although there were no significant differences among the racial/ethnic groups on overall ranking of attributes, subgroup analyses revealed significant impact of age, education, income, and prior fracture on these decisions. The findings from this study suggest that postmenopausal women differ in their ranking of OP medication attributes, and healthcare providers must account for personal preferences in their communication about and selection of OP medications.

Oral bisphosphonates reduce the risk of clinical fractures in glucocorticoid-induced osteoporosis in clinical practice

This study aims to estimate bisphosphonate effectiveness by comparing fracture incidence over time on therapy in glucocorticoid-induced osteoporosis (GIO). From this observational study, alendronate and risedronate decreased clinical vertebral and nonvertebral fractures over time. The effectiveness of each bisphosphonate is consistent with their efficacies demonstrated on surrogate markers in randomized controlled trials (RCTs).

INTRODUCTION

This study aims to estimate bisphosphonate effectiveness by comparing fracture incidence over time on therapy with fracture incidence during a short period after starting a therapy.

METHODS

The study population was a subgroup of a larger cohort study comprising two cohorts of women aged ≥65 years, prescribed with alendronate or risedronate. Within the two study cohorts, 11,007 women were identified as having received glucocorticoids. Within each cohort, the baseline incidence of clinical fractures at nonvertebral and vertebral sites was defined by the initial 3-month period after starting therapy. Relative to these baseline data, we then compared the fracture incidence during the subsequent 12 months on therapy.

RESULTS

The baseline incidence of clinical nonvertebral and vertebral fractures was similar in the alendronate cohort (5.22 and 5.79/100 person-years, respectively) and in the risedronate cohort (5.51 and 5.68/100 person-years, respectively). Relative to the baseline incidence, fracture incidence was significantly lower in the subsequent 12 months in both cohorts of alendronate (33 % lower at nonvertebral sites and 59 % at vertebral sites) and risedronate (28 % lower at nonvertebral sites and 54 % at vertebral sites).

CONCLUSION

From this observational study not designed to compare drugs, both alendronate and risedronate decreased clinical vertebral and nonvertebral fractures over time. The reductions observed in fracture incidence, within each cohort, suggest that the effectiveness of each bisphosphonate in clinical practice is consistent with their efficacies demonstrated on surrogate markers in randomized controlled trials.

Measuring health-related quality of life (HRQOL) in osteoporotic males using the Male OPAQ

The Male Osteoporosis Assessment Questionnaire (OPAQ™) is a health-related quality of life (HRQOL) instrument that can differentiate between men with and without fracture. The Male OPAQ™ is a reliable and validated instrument that may be utilized in clinical trials seeking to include male populations.

INTRODUCTION

Men with osteoporosis (OP) experience poorer clinical outcomes than do women with the disorder, but little is known about the impact of OP on men's HRQOL. This study aimed to test the validity, reliability, and ability to differentiate between men with and without fracture of an HRQOL for men with osteoporosis, the Male OPAQ™.

METHODS

The OPAQ and OPAQ-SV were tested for face validity in interviews with male OP patients, and a revised, male-specific instrument was developed. Thirty-seven men ages 50+ completed the Male OPAQ™ and SF-12 at baseline and a two-week retest of the Male OPAQ™. To analyze both the domain and dimension scores, a normalization procedure was performed on the data to determine health status scores from 0 to 100. Descriptive statistics were calculated for each item and site. Reliability and validity of the Male OPAQ™ were assessed using Pearson's r.

RESULTS

The Male OPAQ™ can discriminate between men with and without fracture, and men who have more fractures have poorer scores. Instrument domains correspond to those of the SF-12.

CONCLUSIONS

The Male OPAQ(TM) is a brief and sensitive tool for measuring HRQOL in men with OP. Further testing in a more diverse and large sample is warranted.

Oral bisphosphonate compliance and persistence: a matter of choice?

Compliance to oral bisphosphonates is suboptimal, with negative consequences of increased healthcare utilization and less effective fracture risk reduction. Extending dose interval increased adherence only moderately. We used literature derived from multiple chronic conditions to examine the problem of noncompliance with osteoporosis medication. We reviewed the literature on adherence to osteoporosis medication as well as that across multiple chronic conditions to understand what is known about the cause of the poor adherence. Poor compliance to oral medications is due mostly, not to forgetfulness, but to deliberate choice. Gender differences and style of healthcare management also play a role. Preliminary data suggest psychobehavioral interventions may help to improve motivation. We need to understand better reasons for poor compliance before effective interventions can be developed. Forgetfulness is only a small part of poor compliance. Patient preferences must be considered in medication decision making.

Longitudinal change in clinical fracture incidence after initiation of bisphosphonates

SUMMARY

There are differences in the risk profile of patients prescribed alendronate, risedronate, or ibandronate. Observed reductions in fracture incidence over time suggest that the effectiveness of each bisphosphonate in clinical practice has been consistent with their efficacies demonstrated in randomized controlled trials.

INTRODUCTION

Observational studies of bisphosphonate effectiveness for fracture prevention are subject to bias from unknown characteristics of baseline fracture risk at the start of therapy. The fracture incidence during the short period after starting a bisphosphonate and before any expected clinical benefit likely reflects baseline fracture risk. Bisphosphonate effectiveness may then be estimated by measuring the change in fracture incidence over time on therapy.

METHODS

Administrative billing data were used to follow three cohorts of women aged 65 and older (total n = 210,144) after starting therapy either on alendronate, risedronate, or ibandronate in the USA between market introduction and 2006. Within each cohort, the baseline incidence of clinical fractures at the hip, vertebral, and nonvertebral sites was defined by the initial 3-month period after starting therapy. Relative to these baselines, we then compared the fracture incidence during the subsequent 12 months on therapy.

RESULTS

At the start of therapy, the ibandronate cohort was younger and had fewer prior fractures than either the risedronate or alendronate cohorts. Accordingly, the baseline incidence of hip fractures was higher in the risedronate cohort (0.90 per 100 person-years) and in the alendronate cohort (0.77) than in the ibandronate cohort (0.64). Relative to the baseline incidence, fracture incidence was significantly lower in the subsequent 12 months in both cohorts of alendronate (18% lower at hip, 28% at nonvertebral sites, and 57% at vertebral sites) and risedronate (27% lower at hip, 21% at nonvertebral sites, and 54% at vertebral sites). In the ibandronate cohort, the fracture incidence was lower (31%) only at vertebral sites.

CONCLUSIONS

Differences in the baseline fracture incidence among the cohorts may reflect differences in the risk profile of patients prescribed each bisphosphonate. The reductions observed in fracture incidence over time within each cohort suggest that the effectiveness of each bisphosphonate in clinical practice has been consistent with their efficacies demonstrated in randomized controlled trials.

Preference and satisfaction with a 6-month subcutaneous injection versus a weekly tablet for treatment of low bone mass

The Preference and Satisfaction Questionnaire (PSQ) compares patient preference and satisfaction between a 6-month subcutaneous injection and weekly oral tablet for treatment of bone loss. Patients preferred and were more satisfied with a treatment that was administered less frequently, suggesting the acceptability of the 6-month injection for treatment of bone loss.

INTRODUCTION

The PSQ compares patient preference and satisfaction between a 6-month subcutaneous injection and a weekly oral tablet for treatment of bone loss.

METHODS

Postmenopausal women with low bone mass who enrolled in two separate randomized phase 3 double-blind, double-dummy studies received a 6-month subcutaneous denosumab injection (60 mg) plus a weekly oral placebo or a weekly alendronate tablet (70 mg) plus a 6-month subcutaneous placebo injection. After 12 months, patients completed the PSQ to rate their preference, satisfaction, and degree of bother with each regimen.

RESULTS

Most enrolled patients (1,583 out of 1,693; 93.5%) answered >or=1 item of the PSQ. Significantly more patients preferred and were more satisfied with the 6-month injection versus the weekly tablet (P < 0.001). More patients reported no bother with the 6-month injection (90%) than the weekly tablet (62%).

CONCLUSION

Patients preferred, were more satisfied, and less bothered with a 6-month injection regimen for osteoporosis.

A systematic review of persistence and compliance with bisphosphonates for osteoporosis

Fourteen reports utilizing data from de-identified administrative databases were reviewed. Studies contained at least one measure of patient persistence or compliance with bisphosphonates or bisphosphonates and other anti-osteoporosis medications. These studies confirm that women with osteoporosis have suboptimal persistence and compliance rates with bisphosphonate therapy.

INTRODUCTION

This review summarizes patient persistence and compliance with bisphosphonates for the treatment of osteoporosis.

METHODS

We conducted a MEDLINE search for the period from January 1998 to May 2006, using a detailed list of terms related to persistence and compliance with anti-osteoporosis medications. Studies were included if they contained at least one measure of persistence or compliance derived from de-identified administrative databases containing patient demographics and prescription information.

RESULTS

We reviewed 14 reports, which described 14 databases. The percentage of patients persisting with therapy for 1 year ranged from 17.9% to 78.0%. Compliance, assessed as mean medication possession ratio (MPR), ranged from 0.59 to 0.81. When comparing compliance with weekly and daily bisphosphonates, the mean MPR was consistently higher for weekly versus daily therapy (0.58 to 0.76 versus 0.46 to 0.64 for patients receiving weekly and daily bisphosphonate therapy respectively). Persistence was also improved in patients receiving weekly bisphosphonates, assessed by both length of persistence (194 to 269 days [weekly] and 134 to 208 days [daily]) and percentage of persistent patients at the end of the follow-up period (35.7% to 69.7% [weekly] and 26.1% to 55.7% [daily]).

CONCLUSION

Although patients using weekly bisphosphonate medication follow their prescribed dosing regimens better than those using daily therapy, overall compliance and persistence rates were suboptimal.

Disability as a function of social networks and support in elderly African Americans and Whites: the Duke EPESE 1986--1992

OBJECTIVES

We examined the association of structural and functional aspects of social relationships with change in disability, and the degree to which race modifies these associations.

METHODS

Data are from a population-based sample of 4,136 African Americans and Whites aged > or = 65 living in North CAROLINA: Disability data were collected during seven consecutive yearly interviews and summarized in two outcome measures. Measures of social relationships included five measures representing network size, extent of social interaction, and specific type of relationships, as well as instrumental and emotional support. Weighted proportional odds models were fitted to model disability as a function of baseline social network and support variables, and the interaction of each variable with follow-up time.

RESULTS

Network size and social interaction showed significant negative associations with disability risks, which did not vary by race, or as a function of time. Social interaction with friends was associated with a reduced risk for disability, but social interaction with children or relatives was not related to disability. Instrumental support was associated with a significantly increased disability risk, with a greater adverse effect among Whites than African AMERICANS: Emotional support was not associated with disability, but a protective effect for ADL disability was found after controlling for its intercorrelation with instrumental support.

DISCUSSION

The findings provide further evidence for the role of social relationships in the disablement process, although not all types of social relationships may be equally beneficial. Furthermore, these associations may be more complex than simple causal effects. There were few racial differences in the association of social relationships with disability, with the possible exception of instrumental support, which may allude to possible sociocultural differences in the experience of instrumental support exchanges.

The nonskeletal consequences of osteoporotic fractures. Psychologic and social outcomes

The prevalence of osteoporosis is rising as the population of the United States and other developed countries ages. These increasing numbers of people have motivated pharmaceutical companies to develop and market several antiresorptive medications that can slow down the bone loss associated with osteoporosis. Although these are not cures for this disease, they are an important first step in a vital ongoing public health effort to prevent osteoporosis in the future and to manage osteoporosis now. We cannot expect to remediate the problems caused by this disease if we attend only to its skeletal implications. Like any other chronic disease, osteoporosis has significant psychologic and social consequences. From anxiety and depression to social withdrawal and isolation, if these problems are left unresolved, they can have a significant negative impact not only on health issues but also on overall quality of life. No quick fixes exist for the numerous ways in which osteoporosis can transform an autonomous person into a dependent and hopeless patient. In part, responsibility for helping this patient rests with the medical community. Referrals to appropriate providers can improve a patient's physical and emotional well-being. Physician specialists can help the patient manage comorbid conditions. Physical and occupational therapists can teach exercises, home safety, and safe movement. Social workers can provide a framework for coping that enables individuals to improve their interpersonal interactions and minimize stress in their lives. Nutritionists, pharmacists, nurses, and other health care professionals can make major contributions to the quality of life of people with osteoporosis and should be encouraged to do so. Unfortunately, managed care has set policies that deprive patients with osteoporosis of the kinds of care that would be most useful to them. As we have advocated for the last 15 years, a multidisciplinary approach offers patients the most positive overall way to manage osteoporosis. Therefore, new alternatives need to be examined, alternatives that provide both low-cost and high-quality care. In the long run, patients who practice self-management, that is, those who take responsibility for their own calcium and vitamin D intake, are compliant with medications, exercise, and practice home safety, and who have a healthy outlook, can control their osteoporosis. The most effective intervention for the future may be to teach individuals how to use self-management strategies so that they can take charge of their osteoporosis and positively influence their quality of life.

Correlates and consequences of chronic pain in older adults

Chronic pain is a frequent challenge to older adults' coping skills. Despite the widespread occurrence of chronic geriatric pain, no comprehensive body of literature on this topic exists. Instead, research on chronic pain is scattered across disciplines and is perceived as inaccessible by scientists. We completed a comprehensive review and qualitative analysis of the geriatric chronic pain literature since 1990 and found 314 articles on this topic that reported. North American research. Physical, social, and psychologic variables associated with chronic pain and the elderly were mentioned in just over half (53%) of the articles. However, both psychosocial causes and consequences of chronic pain were understudied. Only 16% of the articles had social variables (gender, race, and age) as their primary interest; 27% focused on psychologic or psychiatric issues, with half including depression as the variable of interest. An analysis of the articles' content suggests that research on chronic pain in later life would be substantially improved if a more structured and comprehensive approach were used that combined the study of psychosocial issues with that of physical pain. Researchers and clinicians with a global understanding of chronic pain might help improve quality of life for older adults.

Racial differences in use of cancer prevention services among older Americans

CONTEXT

Racial differences in receipt of cancer prevention services may be related to poorer outcomes for minorities. Understanding reasons for such differences could help target appropriate interventions.

OBJECTIVES

To determine if racial differences exist in the use of cancer prevention services among older blacks and whites and to explore explanatory factors.

DESIGN

Sixth follow-up survey of probability sample, four-stage stratified household design with 4,162 at baseline in 1986-1987 and 2,846 surveyed in 1992-1993.

SETTING

The Piedmont area of North Carolina.

PARTICIPANTS

At time of follow-up survey in 1992-1993 there were 1,486 women and 726 men age >70 years, of whom 1,246 were black and 966 were white.

MEASUREMENTS

Self-reported use of Papanicolou (pap) testing, clinical breast examination, mammography, rectal examination, and fecal occult blood testing on a regular basis within the last two years.

RESULTS

Compared with older whites, older black persons are less likely to receive pap test (48.1% black vs 56.6% white, P < .001), clinical breast examination (64.6% black vs 69.2% white, P < .007), mammography (30.2% black vs 40.5% white, P < .001), rectal examination (50.2% black vs 62.4% white, P < .001), and fecal occult blood testing (37.5% black vs 46.2% white, P < .001). Effect of race on receipt of cancer prevention services was not significant when levels of education, income, and insurance coverage were considered.

CONCLUSION

Racial differences exist in the use of cancer prevention services among older Americans. However, these differences are related to educational, income, and insurance differences between blacks and whites.

Timed loaded standing: a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis

Chronic back tiredness or fatigue is a common complaint of people who have a history of osteoporotic vertebral fracture. Trunk muscle endurance has not been studied in people with vertebral osteoporosis, partly due to the lack of assessment tools. We developed a measure of combined trunk and arm endurance suitable for people with vertebral osteoporosis, timed loaded standing (TLS). TLS measures the time a person can stand while holding a two-pound dumbbell in each hand with the arms at 90 degrees of shoulder flexion and the elbows extended. Intraclass correlation coefficients (ICCs) for same day inter-trial and six to ten day test-retest reliability were 0.89 (lower bound 95% confidence interval [LB 95% CI] 0.79) and 0.84 (LB 95% CI 0.68), respectively, in a sample of 21 older women with no known osteoporosis. In 127 women with vertebral fractures, the ICC for same day inter-trial reliability was 0.81 (LB 95% CI 0.75). In a sub-sample of 30 of these women with vertebral fractures, the six to ten day test-retest reliability was 0.85 (LB 95% CI 0.75). Moderately strong and statistically significant (p < or = 0.05) correlations were found between TLS and sixteen of eighteen measures of physical impairment and function. Functional reach distance, gait velocity, MOS-36 Physical Function Subscale, shoulder flexion strength, and six minute walk distance were most strongly associated with TLS time. Women with vertebral fractures who endorsed having back tiredness when standing and working with the arms in front of the body, sitting to rest because of back tiredness or pain, and planning rest periods because of back tiredness or pain had significantly lower TLS times. TLS is a simple, safe physical performance measure of combined trunk and arm endurance that demonstrates acceptable reliability (inter-trial and test- retest) and concurrent validity.

Effects of educational materials concerning osteoporosis on women's knowledge, beliefs, and behavior

PURPOSE

This study examined the effects of brief written educational materials on osteoporosis-related knowledge, beliefs, and behaviors. The study also examined whether observed effects varied as a function of one's stage in the precaution adoption process.

DESIGN

The study used an experimental research design.

SETTING

Participants were identified from North Carolina driver's license records.

SUBJECTS

Of the 1476 women in the initial sample, 536 (36.3%) enrolled in the study and 307 completed all follow-up assessments.

INTERVENTION

Participants were randomly assigned to one of four groups. One group received an information packet containing general information about osteoporosis. One group received an action plan packet containing instructions on how to increase one's level of exercise and calcium intake. One group received both packets. The final group received neither packet.

MEASURES

Primary study variables were beliefs related to osteoporosis, calcium, and exercise; osteoporosis knowledge; calcium and exercise stage; calcium intake; and exercise level.

RESULTS

Overall, receipt of the information packet was associated with changes in knowledge and beliefs (F[18,283] = 2.11, p < .01) irrespective of participants' stage of change. No effects on behavior were observed.

CONCLUSIONS

These findings suggest that brief written educational materials can facilitate knowledge and belief change but that they do not promote behavior change. The generalizability of these findings is limited by the low study response rate.

Factors associated with self-rated health in patients with Paget's disease of bone

Multiple studies show that poor self-rated health (SRH) increases the risk of mortality up to 5-fold when compared to excellent SRH. This powerful association remains even with objective health status and risk factors controlled. However, few studies have examined the determinants of SRH, especially as they relate to specific chronic diseases. Here we identify personal characteristics and disease-related attributes that are strongly associated with SRH in a sample of patients with Paget's disease of bone to determine whether any factors can be modified. Two thousand people randomly selected from the Paget Foundation mailing list received a survey asking for information on demographics, general health and functioning, and the impact of Paget's disease. Nine hundred and fifty-eight PD patients returned the completed survey and answered the question, "How would you rate your overall health?" Answers ranged from excellent (1) to poor (5). Ordinary least squares regression was used, with SRH as the dependent variable, to identify those variables significantly associated with SRH. The overall regression model was significant (p = 0.0001; R2 = 0.44). Age (p = 0. 005), satisfaction with family help (p = 0.0001), number of comorbid conditions (p = 0.0001), functional limitations (p = 0.0003), disease impact (p = 0.0002), health compared to 5 years ago (p = 0. 0001), and depressive symptoms (p = 0.012) were significant predictors. Of these, satisfaction with family help, functional limitations, disease impact, and depressive symptoms are potentially modifiable with appropriate interventions. Future longitudinal studies should examine the effectiveness of such interventions in improving SRH.

Spinal deformity and mobility self-confidence among women with osteoporosis and vertebral fractures

This study evaluated the direct and indirect effects of spinal deformity on confidence in mobility among 185 older women with osteoporosis and vertebral fractures. We administered multidimensional tests of physical and psychosocial impairment and function to female residents of continuing care retirement communities, and used path analytic regression methods to delineate relationships between spinal deformity, pain, function and mobility self-confidence. No direct effect of spinal deformity on confidence in mobility was observed. However, important indirect paths mediated by functional limitations were confirmed. A pattern of indirect effects was observed for a broad array of impairment-level constructs. These results support current models of the disablement process that propose functional limitations as the major pathway to disability. However, they also suggest that the impact of impairment-level constructs might be overlooked unless we evaluate indirect, as well as direct effects, on disability.

Association of race and other potential risk factors with nonvertebral fractures in community-dwelling elderly women

This study determined potential associations of sociodemographic, lifestyle, health, and drug use factors known to affect bone metabolism with incident nonvertebral fractures. The baseline sample consisted of 2,590 female, nonproxy subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly, which focuses on five adjacent counties in the Piedmont area of North Carolina. Information about potential risk factors was collected during a baseline in-home interview during 1986-1987. Subsequent nonvertebral fractures were reported at follow-up interviews during the annual follow-up periods (1988-1993). The authors used multivariate analyses in which weighted data were adjusted for sampling design. After controlling for other potential confounding sociodemographic, lifestyle, health, and drug use factors, they found that African American race (adjusted odds ratio (OR) = 0.43, 95% confidence interval (CI) 0.31-0.58), age (adjusted OR = 1.04, 95% CI 1.01-1.06), alcohol consumption (adjusted OR = 1.61, 95% CI 1.01-2.57), being underweight (adjusted OR = 1.63, 95% CI 1.13-2.34), cognitive impairment (adjusted OR = 1.67, 95% CI 1.12-2.48), impaired mobility (adjusted OR = 1.15, 95% CI 1.03-1.29), and phenytoin use (adjusted OR = 2.93, 95% CI 1.04-8.30) were associated with first fracture occurrence. Similar findings were observed for nonhip, nonvertebral fractures. African Americans were less likely than Whites to have nonvertebral fractures, and these differences were not related to lifestyle or health factors examined in this study.

Reliability of physical performance tests in four different randomized clinical trials

OBJECTIVES

(1) To assess the test-retest reliability of physical performance tests in subject groups with different levels of impairment and disability, and (2) to assess the stability of these tests over different time intervals.

DESIGN

Test-retest, repeated measures reliability design.

SETTING

(1) A university's center for aging and research center, (2) a continuing care retirement community, and (3) an extended care and rehabilitation center at a Veterans Affairs medical center.

SUBJECTS

Twenty-four community-dwelling elders, 15 community-dwelling elders with Parkinson disease, 12 older women with vertebral osteoporosis and compression fractures, and 14 elderly nursing home residents.

MEASURES

Lower extremity isometric strength (ankle dorsiflexion, hip abduction), spinal configuration (thoracic kyphosis, lumbar lordosis), lumbosacral motion (flexion, extension), and timed measures of the ability to get in and to get out of bed at a usual pace.

RESULTS

Most of the within-group intraclass correlation coefficients (ICCs) were good to excellent (.70 to .97). Overall, ICCs for all groups combined were between .70 and .96, and no decrement in reliability was noted after controlling for group membership. In addition, no decrement in the ICC was observed for short (1 day) vs. longer (1 week) intervals of testing.

CONCLUSIONS

These performance-based measures may be used reliably across a wider range of testing environments and elderly populations than has been reported.

Quality of life and Parkinson's disease

BACKGROUND

People with Parkinson's disease (PD) have a progressive loss of function eventually leading to severe disability. Although PD would be expected to have a profound impact on an individual's psychosocial health, there is relatively limited research on its psychosocial effect. The purposes of this study were (a) to examine the relationships between physical disability, depression, and control beliefs and quality of life in people with PD and (b) to characterize how these psychosocial variables differ by stage of disease.

METHODS

Eighty-six individuals from five stages based on clinical disability, ages 51-87, were interviewed. Established instruments were used to measure physical disability, depression, and control beliefs. Quality of life (QOL) was rated on a 5-point Likert scale.

RESULTS

A multivariable regression model including physical disability, stage of disease, depression, mastery, and health locus of control predicted QOL (R2 = 0.48), with mastery as the only significant predictor (p = .0001). There were significant differences by PD stage for all variables (p < .05).

CONCLUSIONS

Mastery predicted quality of life in individuals with PD even when depression and physical disability were included in the model. Differences in psychosocial variables by stage of PD suggest that the psychosocial profile of PD patients may change as the disease progresses.

Using a short food frequency questionnaire to estimate dietary calcium consumption: a tool for patient education

OBJECTIVE

To develop a short food frequency questionnaire (FFQ) assessing calcium intake and a prediction equation for estimating total calcium intake from the short FFQ.

METHODS

Data were collected from 536 women via mailed questionnaires at 3 time points. Stepwise regression analyses were used to identify those foods and beverages included in the Black Health Habits and History Questionnaire (HHHQ) that explained the most variance in participants' dietary calcium intake. A prediction equation was developed to estimate total calcium intake based only on information from the foods/beverages identified.

RESULTS

Calcium obtained from 15 foods/beverages explained 97.2% of the variance in total calcium intake. The mean absolute difference between total calcium intake estimated from the 15 foods/beverages and the full HHHQ was less than 50 mg at each time point.

CONCLUSION

Findings suggest that a short FFQ can provide estimates of total dietary calcium consumption comparable to the full Block HHHQ.

Private health insurance coverage and disability among older Americans

OBJECTIVES

This study examines the relationship between the lack of private supplemental health insurance coverage and the development of disability among adults aged 65 and older.

METHODS

Data are from the baseline and six follow-up waves of the Duke Established Populations for Epidemiologic Studies of the Elderly survey (N = 4,000). Discrete-time hazard models were used to estimate the impact of insurance coverage and other risk factors on the incidence of disability among those unimpaired at baseline.

RESULTS

Controlling for education, income, and other potential confounders, the odds of developing disability were 35-49% higher among those without private coverage. Insurance coverage also statistically explained part of the increased risk of disability among low-income persons.

DISCUSSION

The results indicate that changes in health insurance coverage as well as in individual behaviors may be needed to reduce disability generally and disability among the socioeconomically disadvantaged, in particular.

Managing patients with complications of osteoporosis

This article reviews the impact of osteoporosis on quality of life. It defines specific impairments and suggests how best to minimize the impact of osteoporosis on patients' daily lives. Specific issues such as a spinal deformity, limitations on activities of daily living, pain, functionality, social impairment, self esteem, and depression also are addressed. Finally, a multidisciplinary team approach to osteoporosis is advocated.

Peyronie's disease is associated with Paget's disease of bone

Peyronie's disease is an idiopathic disorder in which an inflammatory fibrosis occurs in the tunica albuginea of the corpora cavernosa which causes the erect penis to become deformed. Peyronie's disease has a prevalence of 1% in men over age 50 years. Paget's disease of bone is a chronic skeletal disease with areas of increased bone turnover leading to pain, deformity, and in some cases arthritis. Because of a high rate of Peyronie's disease in subjects in a Paget's disease industry-sponsored drug trial, we asked whether there was an association between Peyronie's disease and Paget's disease of bone. We evaluated 61 men with Paget's disease attending our clinic for metabolic bone disease in a tertiary referral hospital, reviewed hospital records of all men discharged from our three hospitals with the diagnosis of Peyronie's disease, and mailed a validated questionnaire about shape of the erect penis to 1500 male members of the Paget Foundation. In the clinic population of men with Paget's disease of bone, 51 of 61 (83.6%) reported having normal erections; 10 patients (16.4%) were impotent. Sixteen of the 51 men (31.4%) had developed a bend or deformity in their erect penis which was confirmed by a urologist's examination to be Peyronie's disease. When the men with Paget's disease with and without Peyronie's disease were compared, there was no difference in their ages, years with Paget's disease, or serum alkaline phosphatase level. Upon medical record review, 1 patient of 262 (0.4%) with Peyronie's disease was found to have Paget's disease of bone. The men with Paget's disease returned their questionnaires for a response rate of 44.8% and reported Peyronie's disease with a prevalence of 14.5%. We suggest that Peyronie's disease is associated with Paget's disease of bone. Furthermore, we suggest that Peyronie's disease may be a previously unrecognized complication of Paget's disease of bone.

Memory complaint as a predictor of cognitive decline: a comparison of African American and White elders

Of a representative, racially mixed community sample of older adults in North Carolina, 59% of Whites and 49% of African Americans reported worsening memory. The complaint about memory was positively correlated with age, depressive symptomatology, and physical function but not with level of cognitive function as measured by the Short Portable Mental Status Questionnaire (SPMSQ) at baseline. In a controlled analysis of longitudinal data, initial SPMSQ score, age, African American race, lower education, depressive symptomatology, and physical deficits at baseline, but not memory complaint, predicted a decline in cognitive function as measured by the SPMSQ 3 years later. Whereas African Americans were less likely to complain of deterioration in memory, actual decline as measured by the SPMSQ was greater for African Americans than for Whites.

Paget's disease of bone and quality of life

Little is known about how Paget's disease of bone affects quality of life. To better understand the relative impact of factors on quality of life, we mailed a brief survey to 2000 people randomly selected from the Paget's Foundation mailing list. The sample was geographically stratified to examine the effects of specialist availability. Nine hundred and fifty-eight persons responded to the questionnaire (53% response rate after adjustment for death, incorrect addresses, and nondeliverable mailings). The sample had equal proportions of males and females, with a mean age of 74 years (SD = 9.0). Most (97%) were white, with high levels of education (mean 13 years; SD 3.7) and income (60% earned more than $20,000 annually). They reported pagetic bone in the skull (34%), spine (35%), pelvis (49%), and leg (48%). The most frequently mentioned complications were hearing loss (37%) and bowed limbs (31%). Comorbidity included arthritis (64%), hypertension (32%), and heart problems (28%). Nearly half (47%) reported feelings of depression, and 42% said that their health was fair or poor. Only 21% reported that quality of life was very good or excellent. In multiple partial F-test regression analyses, variables were divided into four domains (social, psychological, care, and biomedical). The psychological domain explained 19% of the variance beyond that explained by all other variables; the social domain explained 3%, the biomedical domain explained 3% and the care domain explained 1%. The importance of the psychological aspects of Paget's disease suggests that treatment protocols should include psychological intervention to improve quality of life.

Global self-ratings of health and mortality: hazard in the North Carolina Piedmont

We analyzed the first 5 years of surveillance data from the Established Population for the Epidemiologic Studies of the Elderly (EPESE) in the Piedmont of North Carolina (n = 4162) to estimate the effect of a global self-rating of health on survival. Covariates used in Cox proportional hazard models included sociodemographic factors, chronic medical conditions, activities of daily living, use of health services, health risk behaviors, cognitive function, affective mood, and negative life events. Adjusted risk of mortality associated with poor (compared to excellent) self-ratings of health was significantly elevated among urban men only. Confounders of the association between survival and overall health assessment varied widely by subgroup. Pooled estimates from heterogeneous populations may mask significant subgroup differences both in the pattern of variables that mediate crude risk and also in the magnitude of residual risk of global self-ratings of health.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Do racial differences in hypertension persist in successful agers? Findings from the MacArthur Study of Successful Aging

The objective of this study was to determine whether racial differences in hypertension in a random sample of community-dwelling older adults also remained significant in a sample of successful agers. Data for the random sample of community-dwelling older adults came from the Duke University Established Populations for Epidemiologic Studies of the Elderly (4,162 community-dwelling adults age 65 and older) and showed strong racial differences in hypertension. Data for successful agers came from the Duke MacArthur (428 of EPESE respondents in the top 30% in terms of physical, cognitive, and psychosocial performance). The mean of two sitting blood pressure measurements was the dependent variable for both sets of analyses. Independent variables included demographics and health factors. Using logistic regression, odds ratios in the Duke EPESE and Duke MacArthur samples for race were similar (Duke EPESE odds ratio = 1.30; Duke MacArthur odds ratio = 1.29). Sample size differences affected statistical significance. However, race differences in hypertension in older adults appear to be unexplained by socioeconomic status or other usual explanatory variables. Even among successful agers, racial differences in hypertension persist.

The clinical impact of vertebral fractures: quality of life in women with osteoporosis

Osteoporosis has obvious physical and functional consequences such as kyphosis, restricted range of motion, and pain. What are not so obvious are the psychosocial sequelae that result from this metabolic bone disease. Many patients in the initial phases of the disease express substantial anxiety, especially about the possibility of future fractures and physical deformity. As the disease progresses, depression can become profound for those who experience hip or multiple vertebral fractures. The effects of the chronicity of osteoporosis, its disabling and disfiguring aspects, and the chronic postural pain that develops as time passes challenge even the most stable individuals. In addition, osteoporosis has substantial impact on interpersonal relationships and social roles. The dependency created by this disease affects close relationships, because the patient with osteoporosis cannot reciprocate in social support. Today's older women find the restrictions of the disease socially devastating. These women, unlikely to work in the labor force, took pride in their roles of housekeeper and cook. Unfortunately, severe osteoporosis can force women to relinquish even these social roles, leaving them with no source of self-esteem or accomplishment. In all, osteoporosis is devastating both psychologically and socially.

Osteoporosis prevention in premenopausal women: using a stage model approach to examine the predictors of behavior

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weight-bearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. Information requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis.

Black-white and urban-rural differences in stability of household composition among elderly persons

The dynamic nature of household composition in a population of elderly persons, with particular focus on Black-White and urban-rural differences, is described in this study. The Duke EPESE is a stratified, random household sample (N = 4,162) of elderly persons in a five-county mixed urban-rural area of North Carolina with respondents contacted annually to report on health and social factors. Between 1986 and 1990, 35 percent of the households underwent some change in composition, with 14 percent contracting and/or expanding more than once. Where elders lived alone and where married elders lived with the spouse and/or others, Black elders were significantly more likely to experience a net expansion of their household than were White elders of the same age, gender, socioeconomic, and functional status. Elderly residents of rural areas who lived alone were slightly more likely to add one or more persons to their households than were comparable elderly urban residents. No additional risk of household instability was noted in sociodemographic or health-related subgroups by race or residence. Future analyses should examine the outcomes of instability.

Functional and mobility impairments associated with Paget's disease of bone

OBJECTIVE

To determine if patients with Paget's disease of bone involving the tibia, femur, and/or acetabular portion of the ilium had more impairments in function and mobility than age- and sex-matched control subjects.

PATIENTS AND METHODS

A case control study with Paget's disease patients selected from a center for bone disease at a tertiary medical center; control subjects were volunteers from the Duke University Aging Center subject registry. Demographic characteristics, physical examination and serum alkaline phosphatase levels were obtained. Radiographs of the pelvis and lower extremities were evaluated by a radiologist. All participants completed a Functional Status Questionnaire (FSQ). Mobility measures included mobility skills protocol, 10-foot walk time, 360-degree turn left (number of steps), and 6-minute walk distance.

RESULTS

The 12 Paget's disease patients were no different in age (70.7 +/- 6.2 years) than the 12 control subjects (69.5 +/- 6.2 years). Serum alkaline phosphatase levels were elevated in Paget's patients (539 +/- 530 IU/L), and normal in control subjects (85 +/- 17 IU/L). In addition to Paget's disease, radiographs showed joint space loss in joints proximate to the diseased bone. On the FSQ scales Paget's disease patients had significantly lower scores in basic activities of daily living (P < .05), instrumental activities of daily living (P < .001), and social activity than control subjects (P < .05). There was no difference between the groups on scales measuring mental health and quality of social interaction. On mobility measurements, Paget's disease patients showed significant impairments when compared with control subjects: mobility skills protocol score (22.5 +/- 2.5 vs 25.6 +/- 0.7, P < .001); 10-foot walk (3.96 +/- 1.3 vs 2.55 +/- 0.5 seconds, P < .001); 360 degree turn left (8.0 +/- 1.0 vs 5.9 +/- 0.6 steps, P < .001); and 6-minute walk (342.0 +/- 108.5 vs 519.4 +/- 100 meters, P < .001).

CONCLUSION

When compared with control subjects, patients who have Paget's disease of bone involving the tibia, femur, or acetabular portion of the ilium have clinically and statistically significant functional and mobility impairments compared to age- and gender-matched controls.

Self-rated health and mortality in the high-functioning elderly--a closer look at healthy individuals: MacArthur field study of successful aging

BACKGROUND

This study tested the predictive value of self-rated health on 3-year mortality, with attention focused on healthy, high-functioning elders.

METHODS

Data from the MacArthur Field Study of Successful Aging were utilized. Subjects were 70-79-year-old (at baseline) residents of the communities of East Boston, MA, New Haven, CT, and a five-county area in and around Durham County, NC (N = 1192) which comprise three sites of the Established Populations for Epidemiologic Studies of the Elderly (EPESE). In-home interviews were conducted in 1988 and 1991. Logistic regression was performed to create odds ratios adjusted for age, sex, race, marital status, education, alcohol consumption, cigarette smoking, chronic diseases, past hospitalizations, and cognitive function. The sample was then divided into healthy and less healthy cohorts based on number of chronic diseases, and the analyses were repeated.

RESULTS

The adjusted odds ratios for self-rated health (poor/bad ratings compared to excellent ratings) in relation to mortality were 19.56 in the general sample, 93.51 in the healthy cohort, and 2.75 in the less healthy cohort.

CONCLUSION

Self-rated health is predictive of mortality in controlled analyses, with the greatest impact seen in healthy individuals. Health care professionals should be sensitive to the significance of poor self-rated health in apparently healthy patients.

Recurrent syncope as a chronic disease: preliminary validation of a disease-specific measure of functional impairment

BACKGROUND

A disease-specific measure of functional health in syncope would provide an important outcome measure for use either in clinical trials or in the clinical management of patients with recurrent syncope.

METHODS AND MEASUREMENTS

In a previous study the authors used formal functional status measures to determine physical and psychosocial impairment in recurrent syncope. This study provides a preliminary assessment of a disease-specific measure of function. The measure was pilot tested on 84 subjects, and validated in a separate cohort of 49 patients. The measure consists of 1) an 11-question matrix of yes/no questions, assessing the ways that syncope interferes with a patient's life (the result is expressed as a proportion of the total number of ways that syncope might interfere and is called the Impairment Score), and 2) three Likert-scale questions that assess the patient's fear and worry about syncope. Correlations were obtained between scores on the disease-specific measure and other measures of functional health.

RESULTS

Among the 49 patients in the test cohort, final scores on the disease-specific measure correlated with both physical and psychosocial dimension scores on a measure of functional status, the Sickness Impact Profile (r = 0.35-0.36, p = 0.01), and with five of ten subscale scores on a measure of psychological distress, the Symptom Checklist 90-R (r = 0.30-0.43, p = 0.004-0.02).

CONCLUSIONS

This new disease-specific quality-of-life measure in syncope measures both physical and psychosocial components of impairment and could be a valuable adjunct in measuring outcomes in syncope patients.

Association of osteoporotic vertebral compression fractures with impaired functional status

PURPOSE

To determine if vertebral compression fractures in elderly women were associated with impairments in physical, functional, and psychosocial performance.

SUBJECTS AND METHODS

Ten white women with confirmed vertebral compression fractures were age- and race-matched with 10 control subjects without fractures in a case-control design. All subjects invited to participate in this study were patients of the Geriatrics Division of the Department of Medicine at Duke University Medical Center. All study participants lived either in the community or in the independent-living sections of local retirement communities in and around Durham, NC. Subjects with fractures (mean age = 81.9 years, SD = 5.9 years) had two or more vertebral compression fractures in their medical records, whereas control subjects (mean age = 79.6 years, SD = 6.5 years) had no history of vertebral fractures. Spinal radiographs of all women confirmed group assignment. Physical, functional, and psychosocial performances were evaluated. Physical performance was assessed by measurements of maximal trunk extension torque and thoracic and lumbar spinal motion in the sagittal plane, functional reach, mobility skills, 10-ft timed walk, and 6-minute walk test. Thoracic and lumbar spinal configurations were also determined. Functional performance was assessed using the Functional Status Index. Psychosocial performance was assessed with the following scales: Hopkins Symptom Checklist 90 Revised, Rosenberg Self-Esteem Scale, West Haven-Yale Pain Inventory, Beck Depression Inventory, and single-item health-belief questions.

RESULTS

Control subjects were not significantly different from patients with fractures in age, weight, number of current illnesses, number of prescribed medications, number of pain medications, ratings of lumbar spine degenerative disc disease, or lumbar spine facet joint arthritis. Activity levels and exercise participation were similar in both groups. Control subjects had no vertebral fractures, whereas fracture subjects had 4.2 +/- 2.6 fractures (range: 2 to 10). Thoracic kyphosis was increased and lumbar lordosis was reduced in fracture subjects. Fracture subjects had reduced maximal trunk extension torque, thoracic and lumbar spine sagittal plane motion, functional reach, mobility skills, and 6-minute walk test. The Functional Status Index showed reduced levels of functional performance in fracture subjects compared with controls with increased levels of assistance, pain with activity, and difficulty in activities. Psychosocial performance was limited in fracture subjects with increased psychiatric symptoms, increased pain, and greater perception of problems caused by health.

CONCLUSION

Vertebral compression fractures are associated with significant performance impairments in physical, functional, and psychosocial domains in older women.

Expenditures in caring for patients with dementia who live at home

OBJECTIVES

Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home.

METHODS

Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures.

RESULTS

Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal ($6986) and informal ($786) services. Out-of-pocket expenditures were high (e.g., in-home companion or sitter, adult day care, visiting nurse). Multivariable analyses indicated that patients with more severe symptoms of dementia and families with higher incomes reported significantly higher expenditures.

CONCLUSIONS

The expense of caring for patients with progressive dementia living at home may be higher than previously estimated and frequently involves expenses paid directly by patients and their families.

Social service interventions for caregivers of patients with dementia: impact on health care utilization and expenditures

OBJECTIVES

An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short-term (ie, 6-month) health services utilization and expenditures.

DESIGN

Randomized controlled trial.

SETTING

University-based memory disorders clinic.

PARTICIPANTS

Caregivers of patients with progressive memory disorders.

MAIN OUTCOME MEASURES

Service utilization and expenditures.

RESULTS

The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline.

CONCLUSIONS

Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.

Physician-related barriers to breast cancer screening in older women

Despite evidence that annual mammographic screening in women 50 years and older reduces mortality, surveys of physicians and patients have repeatedly demonstrated that annual screening mammography is not performed. The fundamental question addressed in this chapter is: If the assumption is made that the scientific evidence supports the use of mammography, what, then, are physician-related barriers to mammographic screening of elderly women? Using a model that classifies barriers to implementing prevention protocols into three categories (predisposing, enabling, and reinforcing factors), literature is reviewed to help identify reasons for low mammographic screening rates, especially in elderly women. This article concludes with a discussion of strategies that may help overcome barriers to mammographic screening in elderly women.

Special care units: a typology of care settings for memory-impaired older adults

After rating 55 nursing homes in five states, we created a typology of care settings that included eight distinct types of units designed to care for memory-impaired older adults. SCUs appeared to be associated with higher quality care than were traditional units, although quality of SCU care was not uniformly outstanding. This typology provides guidelines that can be used in preresidential analysis of prospective care units for demented older adults.

Osteoporosis in late life: does health locus of control affect psychosocial adaptation?

Osteoporosis, a metabolic bone disease most prevalent in older adults, is a major public health problem. Although management of osteoporosis through diet, exercise, and medication has improved, little is known about the psychosocial consequences of this disabling disease. In an attempt to identify patient characteristics that would provide physicians with insight into appropriate management styles for older osteoporotics, we assessed 103 patients with osteoporosis for their health locus of control (HLOC) orientation. We examined the relationship between HLOC and patient outcomes after participation in the Duke University Preventive and Therapeutic Program for Osteoporosis (DUPATPO) to determine whether HLOC was associated with functioning after program participation. More specifically, we asked whether internal or external HLOC was associated with decreases in depression, psychiatric symptoms, and stress symptoms, or with increases in self-esteem, exercise, and disease knowledge. We have shown in our earlier work (Gold et al, J Am Geriatr Soc 1989; 37:417) that program participation is associated with improved functioning in older adults. We now asked whether knowledge of a patient's HLOC would help predict these improvements. A comparison group (ie, older osteoporotics who did not participate in DUPATPO) was also assessed for HLOC to examine the possible association between HLOC and health behaviors regardless of the DUPATPO intervention. Our findings indicate that HLOC provided little useful information regarding patient outcomes. Although improvements were seen in the mental health of program participants, no association between these improvements and HLOC could be found.