JAGS
JANUARY 2015–VOL. 63, NO. 1
Author Contributions: Clark, Vandermorris, Heisz: study concept and design, preparation of manuscript. Clark, Heisz: acquisition of subjects and data, analysis and interpretation of data. Sponsor’s Role: None.
REFERENCES 1. Alzheimer’s Association. 2013 Alzheimer’s disease facts and figures. Alzheimers Dementia 2013;9:208. 2. Voss MW, Vivar C, Kramer AF et al. Bridging animal and human models of exercise-induced brain plasticity. Trends Cogn Sci 2013;17:525–544. 3. Erickson KI, Prakash RS, Voss MW et al. Aerobic fitness is associated with hippocampal volume in elderly humans. Hippocampus 2009;19:1030–1039. 4. Ruscheweyh R, Willemer C, Kruger K et al. Physical activity and memory functions: An interventional study. Neurobiol Aging 2011;32:1304–1319. 5. Heisz JJ, Vandermorris S, Wu J et al. Age differences in the association of physical activity, sociocognitive engagement, and TV viewing on face memory. Health Psychol 2014. [Epub ahead of print.] 6. Wirth M, Haase CM, Villeneuve S et al. Neuroprotective pathways: Lifestyle activity, brain pathology, and cognition in cognitively normal older adults. Neurobiol Aging 2014;35:1873–1882. 7. Stuckey MI, Knight E, Petrella RJ. The step test and exercise prescription tool in primary care: A critical review. Crit Rev Phys Rehabil Med 2012;24:109–123. 8. Cahalin LP, Mathier MA, Semigran MJ et al. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest 1996;110:325–332. 9. Colcombe S, Kramer AF. Fitness effects on the cognitive function of older adults: A meta-analytic study. Psychol Sci 2003;14:125–130. 10. Jopp DS, Hertzog C. Assessing adult leisure activities: An extension of a self-report activity questionnaire. Psychol Assess 2010;22:108–120.
PROTON PUMP INHIBITORS AND HYPOMAGNESEMIA IN POLYMORBID ELDERLY ADULTS To the Editor: The use of proton pump inhibitors (PPIs) has risen in the last decade, but according to several studies, their prescription is inappropriate in 40% to 80% of individuals.1,2 Although PPIs are safe, they can cause adverse drug effects such as nausea, abdominal pain, constipation, and diarrhea. In March 2011, the Food and Drug Administration stated that PPIs may cause low serum magnesium levels if taken for prolonged periods of time and that healthcare professionals should consider obtaining serum magnesium levels before initiation of PPI treatment in individuals expected to be taking these drugs for long periods of time.3 Nevertheless, no conclusive evidence has been found on the association between long-term therapy with PPIs and hypomagnesemia.4,5 The main aim of the current study was to assess the prevalence of hypomagnesemia in a hospitalized elderly population. Secondary aims were to find whether there is a relationship between hypomagnesemia and long-term PPI therapy. Participants were individuals aged 65 and older consecutively admitted to a geriatric unit (N = 260). Exclusion criteria were diagnosis of acute pathology of the gastrointestinal tract and presence of severe dysphagia. Written informed consent was obtained from all participants. Information was gathered about socioeconomic status, clinical and drug history, comorbidities, functional
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179
assessment, cognitive status, and blood tests at baseline. Hypomagnesemia is defined as levels lower than 1.7 mg/ dL (0.70 mmol/L). The mean age of participants was 82.2 69.8, and 56.2% were women. Fifty-nine (22.7%) were dependent in all six activities of daily living. The Short Portable Mental Status Questionnaire indicated severe intellectual impairment in 32.3% (n = 84) of participants. The mean Cumulative Illness Rating Scale (CIRS) severity index was 1.69 0.29, and the mean CIRS comorbidity index was 3.07 1.51. The most-frequent comorbidities detected were diabetes mellitus (27.7%, n = 72) and heart failure (23.1%, n = 60). The prevalence of hypomagnesemia in this study was 16.5% (95% confidence interval = 12.2–21.6%, n = 43). In participants who had been using PPIs for at least 6 months (n = 146), the prevalence of hypomagnesemia was slightly higher (19.9%, n = 29), but this difference was not statistically significant (P = .10). Serum magnesium levels were not correlated with long-term therapy with PPIs (P = .25) or with age, sex, comorbidities (CIRS-s), potassium and magnesium supplementation, serum potassium, serum creatinine, or use of diuretics. Conversely, magnesemia was associated with serum albumin (P = .001). PPI users had greater CIRS-c (3.34, vs 2.72 in PPI nonusers; P < .001) and CIRS-s (1.75, vs 1.61 in PPI nonusers; P < .001). No difference was detected between the two groups in serum magnesium level (P = .20). The majority of participants with hypomagnesemia (n = 43) were women (67.4%, vs 32.6% of men; P = .10). The prevalence of PPI use was higher (67.4%, n = 29) in these patients than in the total population, although the difference was not statistically significant. Use of diuretics did not have any effect on the association between long-term therapy with PPI and hypomagnesemia (P = .39). No association was found between serum magnesium levels and diabetes mellitus (P = .13) or heart failure (P = .82). Study participants had severe functional impairment, which is not surprising because participants were hospitalized elderly adults, who are at risk of functional decline before6 and during hospitalization.7 Among other factors, low albumin level and large number of drugs prescribed are associated with functional decline.7 The observed prevalence of hypomagnesemia in hospitalized elderly adults was similar to what has been found in previous studies.8,9 This study suggests that many factors affect serum magnesium levels, although only serum albumin levels were significantly associated with hypomagnesemia. Long-term PPI users had serum magnesium levels (1.95 mg/dL) similar to those of PPI nonusers (2.00 mg/ dL; P = .20). A large percentage of elderly adults have been prescribed PPIs.10 Because PPIs, even though generally considered to be safe, have some adverse effects, their prescription must always be motivated by and based on scientific evidence. A large prevalence of hypomagnesemia in hospitalized older adults was found, and there is not a statistically significant relationship between PPI and hypomagnesemia. Future randomized prospective studies performed on a larger number of individuals analyzing serum magnesium levels before and after PPI therapy could add more knowledge to this topic. Hypomagnesemia cannot be considered a contraindication to the initiation of long-term PPI therapy.
180
LETTERS TO THE EDITOR
Alessandra Pastorino, MD Francesca Greppi, MD Daniele Bergamo, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy Elisabetta Versino, MD Epidemiology, Department of Clinical and Biological Sciences, AOU San Luigi, University of Turin, Orbassano, Turin, Italy Mario Bo, MD Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, Orbassano, Turin, Italy Maria S. Pezzilli, MD Elisabetta Furno, MD Sokol Rrodhe, MD Gianluca Isaia, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pastorino, Greppi, Bergamo: preparation of manuscript, acquisition of subjects and data. Versino: analysis and interpretation of data. Bo: study concept and design. Pezzilli, Furno, Rrodhe: acquisition of subjects and data. Isaia: study concept and design, preparation of manuscript. Sponsor’s Role: None.
JANUARY 2015–VOL. 63, NO. 1
JAGS
10. Jarchow-MacDonald AA, Mangoni AA. Prescribing patterns of proton pump inhibitors in older hospitalized patients in a Scottish health board. Geriatr Gerontol Int 2013;13:1002–1009.
INSIGHT INTO ELDER ABUSE AMONG URBAN POOR OF KUALA LUMPUR, MALAYSIA—A MIDDLE-INCOME DEVELOPING COUNTRY To the Editor: Malaysia’s population is aging rapidly because of rising life expectancy, a lower crude death rate, and a falling birth rate.1 Sensitivity regarding the problems of elderly adults is necessary. Social problems such as elder abuse and neglect must be identified now to ensure that vulnerable older adults are protected and that Malaysia progresses as an aging society. Well-established child protective services serve as an example of how to do so.2 Research in developed countries is now focusing on a vulnerability index to identify such individuals within the community.3 Because these social problems have multiple contributing factors, a proper screening method and a broad multidisciplinary intervention approach are required.4 In Malaysia, the National Policy for the Elderly 20115 outlines six strategies centered on promotion and advocacy, safety and protection, and intergenerational involvement, among others. It emphasizes that elderly adults should be able to live with respect and self-worth, to be safe and free from oppression and abuse, and to continue living with their family within society as long as possible. This is a common attitude in Asian cultures, where filial piety toward elderly adults and preserving the integrity of family structure is valued, and institutionalization of elderly adults is frowned upon.
METHODS REFERENCES 1. Batuwitage BT, Kingham JG, Morgan NE et al. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 2007;83: 66–68. 2. Ahrens D, Behrens G, Himmel W et al. Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care. Int J Clin Pract 2012;66:767–773. 3. FDA Drug Safety Communication. Low Magnesium Levels Can Be Associated with Long Term Use of Proton Pump Inhibitor Drugs (PPIs). Washington, DC: U.S. Food and Drug Administration, 2011. 4. Gau JT, Yang YX, Chen R et al. Uses of proton pump inhibitors and hypomagnesemia. Pharmacoepidemiol Drug Saf 2012;21:553–559. 5. Danziger J, William JH, Scott DJ et al. Proton-pump inhibitor use is associated with low serum magnesium concentrations. Kidney Int 2013;83: 692–699. 6. Isaia G, Bo M, Aimonino N et al. Functional decline two weeks before hospitalization in an elderly population. Aging Clin Exp Res 2010;22: 352–355. 7. Isaia G, Maero B, Gatti A et al. Risk factors of functional decline during hospitalization in the oldest old. Aging Clin Exp Res 2009;21: 453–457. 8. Martin BJ, Black J, McLelland AS. Hypomagnesaemia in elderly hospital admissions: A study of clinical significance. Q J Med 1991;78: 177–184. 9. Arinzon Z, Peisakh A, Schrire S et al. Prevalence of hypomagnesemia (HM) in a geriatric long-term care (LTC) setting. Arch Gerontol Geriatr 2010;51:36–40.
A pilot study among the urban poor in the capital city of Kuala Lumpur was conducted in December 2012. The researcher and trained enumerators interviewed 291 individuals aged 60 and older living in low-cost government subsidized flats face-to-face using an instrument developed based on recent work in a national Irish elder abuse and neglect prevalence survey.6 This instrument was first validated locally in an expert panel of social workers and public health experts in the field of violence and geriatrics and subsequently tested in a small subset of elderly adults. Sufficient content validity and face validity was declared before interviews were conducted on this sample of 291 elderly adults.
RESULTS Of 291 elderly persons interviewed, 28 (9.6%) reported experiencing some form of abuse or neglect in the preceding 12 months. Abuse refers to overall abuse, which may be a combination of one of more of its subtypes (physical, financial, psychological, sexual, neglect). Financial abuse was most common (6.2%), followed by psychological
JANUARY 2015–VOL. 63, NO. 1
Author Contributions: Clark, Vandermorris, Heisz: study concept and design, preparation of manuscript. Clark, Heisz: acquisition of subjects and data, analysis and interpretation of data. Sponsor’s Role: None.
REFERENCES 1. Alzheimer’s Association. 2013 Alzheimer’s disease facts and figures. Alzheimers Dementia 2013;9:208. 2. Voss MW, Vivar C, Kramer AF et al. Bridging animal and human models of exercise-induced brain plasticity. Trends Cogn Sci 2013;17:525–544. 3. Erickson KI, Prakash RS, Voss MW et al. Aerobic fitness is associated with hippocampal volume in elderly humans. Hippocampus 2009;19:1030–1039. 4. Ruscheweyh R, Willemer C, Kruger K et al. Physical activity and memory functions: An interventional study. Neurobiol Aging 2011;32:1304–1319. 5. Heisz JJ, Vandermorris S, Wu J et al. Age differences in the association of physical activity, sociocognitive engagement, and TV viewing on face memory. Health Psychol 2014. [Epub ahead of print.] 6. Wirth M, Haase CM, Villeneuve S et al. Neuroprotective pathways: Lifestyle activity, brain pathology, and cognition in cognitively normal older adults. Neurobiol Aging 2014;35:1873–1882. 7. Stuckey MI, Knight E, Petrella RJ. The step test and exercise prescription tool in primary care: A critical review. Crit Rev Phys Rehabil Med 2012;24:109–123. 8. Cahalin LP, Mathier MA, Semigran MJ et al. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest 1996;110:325–332. 9. Colcombe S, Kramer AF. Fitness effects on the cognitive function of older adults: A meta-analytic study. Psychol Sci 2003;14:125–130. 10. Jopp DS, Hertzog C. Assessing adult leisure activities: An extension of a self-report activity questionnaire. Psychol Assess 2010;22:108–120.
PROTON PUMP INHIBITORS AND HYPOMAGNESEMIA IN POLYMORBID ELDERLY ADULTS To the Editor: The use of proton pump inhibitors (PPIs) has risen in the last decade, but according to several studies, their prescription is inappropriate in 40% to 80% of individuals.1,2 Although PPIs are safe, they can cause adverse drug effects such as nausea, abdominal pain, constipation, and diarrhea. In March 2011, the Food and Drug Administration stated that PPIs may cause low serum magnesium levels if taken for prolonged periods of time and that healthcare professionals should consider obtaining serum magnesium levels before initiation of PPI treatment in individuals expected to be taking these drugs for long periods of time.3 Nevertheless, no conclusive evidence has been found on the association between long-term therapy with PPIs and hypomagnesemia.4,5 The main aim of the current study was to assess the prevalence of hypomagnesemia in a hospitalized elderly population. Secondary aims were to find whether there is a relationship between hypomagnesemia and long-term PPI therapy. Participants were individuals aged 65 and older consecutively admitted to a geriatric unit (N = 260). Exclusion criteria were diagnosis of acute pathology of the gastrointestinal tract and presence of severe dysphagia. Written informed consent was obtained from all participants. Information was gathered about socioeconomic status, clinical and drug history, comorbidities, functional
LETTERS TO THE EDITOR
179
assessment, cognitive status, and blood tests at baseline. Hypomagnesemia is defined as levels lower than 1.7 mg/ dL (0.70 mmol/L). The mean age of participants was 82.2 69.8, and 56.2% were women. Fifty-nine (22.7%) were dependent in all six activities of daily living. The Short Portable Mental Status Questionnaire indicated severe intellectual impairment in 32.3% (n = 84) of participants. The mean Cumulative Illness Rating Scale (CIRS) severity index was 1.69 0.29, and the mean CIRS comorbidity index was 3.07 1.51. The most-frequent comorbidities detected were diabetes mellitus (27.7%, n = 72) and heart failure (23.1%, n = 60). The prevalence of hypomagnesemia in this study was 16.5% (95% confidence interval = 12.2–21.6%, n = 43). In participants who had been using PPIs for at least 6 months (n = 146), the prevalence of hypomagnesemia was slightly higher (19.9%, n = 29), but this difference was not statistically significant (P = .10). Serum magnesium levels were not correlated with long-term therapy with PPIs (P = .25) or with age, sex, comorbidities (CIRS-s), potassium and magnesium supplementation, serum potassium, serum creatinine, or use of diuretics. Conversely, magnesemia was associated with serum albumin (P = .001). PPI users had greater CIRS-c (3.34, vs 2.72 in PPI nonusers; P < .001) and CIRS-s (1.75, vs 1.61 in PPI nonusers; P < .001). No difference was detected between the two groups in serum magnesium level (P = .20). The majority of participants with hypomagnesemia (n = 43) were women (67.4%, vs 32.6% of men; P = .10). The prevalence of PPI use was higher (67.4%, n = 29) in these patients than in the total population, although the difference was not statistically significant. Use of diuretics did not have any effect on the association between long-term therapy with PPI and hypomagnesemia (P = .39). No association was found between serum magnesium levels and diabetes mellitus (P = .13) or heart failure (P = .82). Study participants had severe functional impairment, which is not surprising because participants were hospitalized elderly adults, who are at risk of functional decline before6 and during hospitalization.7 Among other factors, low albumin level and large number of drugs prescribed are associated with functional decline.7 The observed prevalence of hypomagnesemia in hospitalized elderly adults was similar to what has been found in previous studies.8,9 This study suggests that many factors affect serum magnesium levels, although only serum albumin levels were significantly associated with hypomagnesemia. Long-term PPI users had serum magnesium levels (1.95 mg/dL) similar to those of PPI nonusers (2.00 mg/ dL; P = .20). A large percentage of elderly adults have been prescribed PPIs.10 Because PPIs, even though generally considered to be safe, have some adverse effects, their prescription must always be motivated by and based on scientific evidence. A large prevalence of hypomagnesemia in hospitalized older adults was found, and there is not a statistically significant relationship between PPI and hypomagnesemia. Future randomized prospective studies performed on a larger number of individuals analyzing serum magnesium levels before and after PPI therapy could add more knowledge to this topic. Hypomagnesemia cannot be considered a contraindication to the initiation of long-term PPI therapy.
180
LETTERS TO THE EDITOR
Alessandra Pastorino, MD Francesca Greppi, MD Daniele Bergamo, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy Elisabetta Versino, MD Epidemiology, Department of Clinical and Biological Sciences, AOU San Luigi, University of Turin, Orbassano, Turin, Italy Mario Bo, MD Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, Orbassano, Turin, Italy Maria S. Pezzilli, MD Elisabetta Furno, MD Sokol Rrodhe, MD Gianluca Isaia, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pastorino, Greppi, Bergamo: preparation of manuscript, acquisition of subjects and data. Versino: analysis and interpretation of data. Bo: study concept and design. Pezzilli, Furno, Rrodhe: acquisition of subjects and data. Isaia: study concept and design, preparation of manuscript. Sponsor’s Role: None.
JANUARY 2015–VOL. 63, NO. 1
JAGS
10. Jarchow-MacDonald AA, Mangoni AA. Prescribing patterns of proton pump inhibitors in older hospitalized patients in a Scottish health board. Geriatr Gerontol Int 2013;13:1002–1009.
INSIGHT INTO ELDER ABUSE AMONG URBAN POOR OF KUALA LUMPUR, MALAYSIA—A MIDDLE-INCOME DEVELOPING COUNTRY To the Editor: Malaysia’s population is aging rapidly because of rising life expectancy, a lower crude death rate, and a falling birth rate.1 Sensitivity regarding the problems of elderly adults is necessary. Social problems such as elder abuse and neglect must be identified now to ensure that vulnerable older adults are protected and that Malaysia progresses as an aging society. Well-established child protective services serve as an example of how to do so.2 Research in developed countries is now focusing on a vulnerability index to identify such individuals within the community.3 Because these social problems have multiple contributing factors, a proper screening method and a broad multidisciplinary intervention approach are required.4 In Malaysia, the National Policy for the Elderly 20115 outlines six strategies centered on promotion and advocacy, safety and protection, and intergenerational involvement, among others. It emphasizes that elderly adults should be able to live with respect and self-worth, to be safe and free from oppression and abuse, and to continue living with their family within society as long as possible. This is a common attitude in Asian cultures, where filial piety toward elderly adults and preserving the integrity of family structure is valued, and institutionalization of elderly adults is frowned upon.
METHODS REFERENCES 1. Batuwitage BT, Kingham JG, Morgan NE et al. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 2007;83: 66–68. 2. Ahrens D, Behrens G, Himmel W et al. Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care. Int J Clin Pract 2012;66:767–773. 3. FDA Drug Safety Communication. Low Magnesium Levels Can Be Associated with Long Term Use of Proton Pump Inhibitor Drugs (PPIs). Washington, DC: U.S. Food and Drug Administration, 2011. 4. Gau JT, Yang YX, Chen R et al. Uses of proton pump inhibitors and hypomagnesemia. Pharmacoepidemiol Drug Saf 2012;21:553–559. 5. Danziger J, William JH, Scott DJ et al. Proton-pump inhibitor use is associated with low serum magnesium concentrations. Kidney Int 2013;83: 692–699. 6. Isaia G, Bo M, Aimonino N et al. Functional decline two weeks before hospitalization in an elderly population. Aging Clin Exp Res 2010;22: 352–355. 7. Isaia G, Maero B, Gatti A et al. Risk factors of functional decline during hospitalization in the oldest old. Aging Clin Exp Res 2009;21: 453–457. 8. Martin BJ, Black J, McLelland AS. Hypomagnesaemia in elderly hospital admissions: A study of clinical significance. Q J Med 1991;78: 177–184. 9. Arinzon Z, Peisakh A, Schrire S et al. Prevalence of hypomagnesemia (HM) in a geriatric long-term care (LTC) setting. Arch Gerontol Geriatr 2010;51:36–40.
A pilot study among the urban poor in the capital city of Kuala Lumpur was conducted in December 2012. The researcher and trained enumerators interviewed 291 individuals aged 60 and older living in low-cost government subsidized flats face-to-face using an instrument developed based on recent work in a national Irish elder abuse and neglect prevalence survey.6 This instrument was first validated locally in an expert panel of social workers and public health experts in the field of violence and geriatrics and subsequently tested in a small subset of elderly adults. Sufficient content validity and face validity was declared before interviews were conducted on this sample of 291 elderly adults.
RESULTS Of 291 elderly persons interviewed, 28 (9.6%) reported experiencing some form of abuse or neglect in the preceding 12 months. Abuse refers to overall abuse, which may be a combination of one of more of its subtypes (physical, financial, psychological, sexual, neglect). Financial abuse was most common (6.2%), followed by psychological
