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Am Fam Physician. 2002 Aug 1;66(3):515-517.

HHS Report on Physical Activity for Older Americans

The U.S. Department of Health and Human Services (HHS) has released a new report finding that frail health often associated with aging is in large part related to physical inactivity, but that it is never too late to benefit from becoming physically active. The report, “Physical Activity and Older Americans: Benefits and Strategies,” is available at www.ahrq.gov/ppip/activity.htm.

According to the report, frequent and intense activity, and even moderate levels of activity such as raking leaves can produce substantial benefits, which can be even more pronounced in older adults. These benefits can include preventing or delaying chronic diseases such as heart disease, diabetes, and high blood pressure, as well as reducing the risk of colon cancer and improving the ability to function for people with arthritis and lung disease.

Recent research has identified a number of strategies that are effective in promoting regular physical activity in older adults. Persons are encouraged to find activities that are enjoyable and to make the activities a daily part of life, setting specific activity goals that gradually increase. Physicians are encouraged to work closely with their patients to assess levels of physical activity and how to overcome barriers to increasing those activity levels.

Few older adults achieve the minimum recommended 30 or more minutes of physical activity on five or more days a week. About 28 to 34 percent of adults 65 to 74 years of age, and 35 to 44 percent of adults age 75 and older are inactive, meaning they report no leisure-time moderate activity. Lack of physical activity and poor diets are the major causes of an epidemic of obesity that is affecting the elderly as well as younger populations.

By 2030, the number of older Americans is expected to double from 35 million to 70 million. Almost one third of the current U.S. health care expenditures is for older adults. Given this aging trend, the impact of a lack of physical activity on medical care costs is likely to grow as a result of an aging population, unless trends in physical activity change.

The National Institute on Aging at the National Institutes of Health has published the booklet “Exercise: A Guide from the National Institute on Aging” with information for older Americans on beginning an exercise routine. It is available at www.nia.nih.gov/exercisebook/intro.htm.

USPSTF Breast Cancer Recommendations

The U.S. Preventive Services Task Force (USPSTF) has released two recommendations on the chemoprevention of breast cancer. Family physicians should discuss the potential benefits and risks of taking prescription medicines such as tamoxifen to reduce the risk of breast cancer with their female patients who are at high risk for the disease. The USPSTF also recommends against the use of these drugs by women at low or average risk for breast cancer. The new recommendations appear in the July 2 issue of Annals of Internal Medicine.

The USPSTF reviewed three randomized controlled trials that studied the use of the drug tamoxifen and one study on the off-label use of the drug raloxifene to reduce the risk of breast cancer. Tamoxifen is the only medication currently approved by the U.S. Food and Drug Administration (FDA) to reduce the incidence of breast cancer in women at high risk for the disease. Raloxifene currently is approved by the FDA for the prevention and treatment of osteoporosis, but some physicians prescribe it off-label to reduce the risk of breast cancer. The Study of Tamoxifen and Raloxifene (STAR) Trial, an ongoing trial by the National Cancer Institute (NCI), is recruiting postmenopausal women at increased risk for breast cancer to compare the safety and efficacy of the two drugs in reducing the risk of the disease. Information about the trial is available at www.cancer.gov/star.

Women are considered at high risk for breast cancer if they are older than 40 years of age and have a family history of breast cancer in a mother, sister, or daughter, or have a history of atypical cells on a breast biopsy. A risk assessment instrument, developed by NCI ( www.cancer.gov/bcrisktool) can help estimate cancer risk based on age, family history, and other risk factors.

For women who are not at high risk for developing breast cancer, the USPSTF recommended against the routine use of tamoxifen or raloxifene to reduce the risk of breast cancer because the potential side effects may outweigh the potential benefits. Those side effects can include hot flushes and increased risk for blood clots in the legs or lungs. Tamoxifen also has been found to increase the risk for endometrial cancer.

In general, the USPSTF found that the balance of benefits and harms of chemoprevention is more favorable for women in their 40s who are at high risk for breast cancer and have no predisposition toward blood clots, and for women in their 50s who are at high risk for breast cancer, who have no predisposition to blood clots, and who do not have a uterus. However, each woman needs to talk with her physician about whether the potential benefits of reducing her risk of breast cancer are worth the potential risks of taking the medications.

AAP Childhood OSAS Screening Guidelines

The American Academy of Pediatrics (AAP) has released new guidelines on screening children for obstructive sleep apnea syndrome (OSAS). The guidelines appear in the April 2002 issue ofPediatrics, and are available online at www.aap.org.

OSAS is a common childhood condition that often includes habitual nighttime snoring. OSAS causes breathing problems during sleep and can lead to sleep disturbances and problems with learning and behavior.

The guidelines state that physicians should screen all children for snoring, because chronic snoring is often a symptom of OSAS.

According to the AAP, the diagnostic test of choice for OSAS is “nocturnal polysomnography”—a nighttime sleep study. Other diagnostic techniques can also be useful in specific circumstances.

Adenotonsillectomy, or removal of tonsils and adenoids, is considered by the AAP to be the first line of treatment for most children with OSAS. Patients should be reevaluated postoperatively to determine if additional treatment is required. Continuous positive airway pressure is an option for those who are not candidates for surgery or who do not respond to surgery.

FDA Approval of Alosetron Reintroduction

The U.S. Food and Drug Administration (FDA) approved the re-introduction of alosetron hydrochloride (Lotronex) under restricted conditions of use.

According to the manufacturer, alosetron will be indicated specifically for use in women with severe diarrhea-predominant irritable bowel syndrome (IBS) who have failed to respond to conventional therapy, whose IBS symptoms are chronic, and who have had other gastrointestinal medical conditions that could explain their symptoms ruled out. Symptoms that make diarrhea-predominant IBS severe are frequent and serious abdominal pain, fecal incontinence or the uncontrolled urge to have a bowel movement, or curtailment of daily activities because of IBS.

Serious gastrointestinal events, specifically ischemic colitis and complications of constipation, have been reported in association with the use of alosetron. These events have resulted in hospitalization, blood transfusion, surgery, and some fatalities. In clinical trials, about three women in 1,000 developed ischemic colitis over six months.

The manufacturer is finalizing details of how the risk management plan, which must be approved by the FDA, will be implemented. The risk management plan will include updated warnings in product labeling, a medication guide for patients that explains what to do if they get constipated or have signs of ischemic colitis, a lower starting dose than previously approved, a prescribing program for physicians to be enrolled into based on self-attestation of qualifications and acceptance of certain responsibilities in prescribing the medicine, an agreement for patients to sign attesting that they are informed about risks and benefits of therapy, and directions to prescribers for active follow-up and management of patients.


Copyright © 2002 by the American Academy of Family Physicians.
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