COILS BEAT CLIPPING FOR SUBARACHNOID ANEURYSM

Patients with a ruptured intracranial aneurysm have a better chance of surviving without disability if they undergo endovascular coiling rather than neurosurgical clipping, according to results from the International Subarachnoid Aneurysm Trial. The primary objective of the trial was to determine whether endovascular treatment, when compared with conventional neurosurgical treatment, would reduce the proportion of patients who became disabled or died by 25% one year after the procedure. The study was published in the October 26 Lancet.

Researchers enrolled 2,143 patients with ruptured intracranial aneurysms who met rigorous criteria. The patients were randomly assigned to undergo either neurosurgery, in which a metal clip is placed across the neck of the ruptured aneurysm, or endovascular treatment, which uses a catheter to place a detachable platinum coil inside the aneurysm. Clinical outcomes were assessed at two months and at one year with interim ascertainment of rebleeds or death. The investigators determined the primary outcome using a modified Rankin scale to rank functional outcome from zero (no symptoms) to six (dead).

One-year follow-up data were available for 1,594 patients. Overall, after one year, 27.2% of patients scored a three (significant restriction in lifestyle) or higher on the Rankin scale—30.6% of patients in the neurosurgery arm and 23.7% of patients in the endovascular arm, representing a 22.6% relative risk reduction and a 6.9% absolute risk reduction in the endovascular arm. The overall mortality rates were similar between the two groups, at 10.1% in the neurosurgical group and 8.1% in the endovascular group. Researchers emphasized that “the results of this trial should not be interpreted as indicating that neurosurgery for aneurysms should cease,” as endovascular treatment could be unsuitable for some patients.

International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360:1267-1274.

TRAINING IMPROVES ABILITIES OF OLDER ADULTS

Training sessions for two hours a week for five weeks improved the memory, concentration, and problem solving skills of healthy, independent adults age 65 and older, according to research published in the November 13 JAMA. Investigators attempted to determine whether three cognitive training interventions improve mental abilities and daily functioning in older, independent-living adults. They found that the training not only improved participants’ cognitive abilities, but the improvement persisted for two years after the training.

Researchers recruited 2,802 volunteers to attend 10 sessions of 60 to 75 minutes of training for five to six weeks. The participants were divided into four groups—three groups that received either memory training, reasoning training, or speed of processing training, and a control group receiving no training. Researchers chose these types of interventions because they were pertinent to tasks of daily living, such as telephone use, shopping, transportation, medication use, and personal finances. Volunteers in the memory-training group were taught strategies for remembering word lists and sequences of items. Those in the reasoning group learned how to solve problems that followed patterns, and participants in the speed of processing group focused on the ability to identify and locate visual information quickly.

Volunteers were assessed prior to training, immediately after training, and at one and two year follow-ups. Their performance was measured using standardized tests and simulations of everyday tasks. Researchers found large immediate gains in cognitive outcomes; following the five-week training period, 87% of participants in speed training, 74% of participants in reasoning training, and 26% of participants in memory training demonstrated reliable improvement in their respective cognitive ability. These effects continued through 24 months, although at lower levels.

Ball K, Berch DB, Helmers KF, et al. Effects of cognitive training interventions with older adults: a randomized controlled trial. JAMA. 2002;288:2271-2281.

CNS-ACTIVE MEDICATIONS INCREASE FALLING RISK IN ELDERLY WOMEN

Elderly women taking central nervous system-active medications, such as benzodiazepines, antidepressants, and anticonvulsants, are at an increased risk for frequent falls, reported an article in the October Journal of the American Geriatrics Society. Investigators also determined that taking selective serotonin-reuptake inhibitors (SSRIs) instead of tricyclic antidepressants may increase the risk of falling, and substituting short-acting benzodiazepines for longer-acting ones only marginally decreased the risk. They asserted that “the increase in fall risk was most evident in older women with a prior fall history taking benzodiazepines or anticonvulsants.”

Researchers recruited 8,127 women age 65 and older for the study. At the fourth examination, the women completed a questionnaire including a medication history and were interviewed about health, physical activity, and falls. The researchers classified the central nervous system-active medications into four mutually exclusive categories: benzodiazepines, antidepressants, anticonvulsants, and narcotics.

Benzodiazepines were further classified as long-acting or short-acting, and antidepressants were further categorized as tricyclics, SSRIs, and serotonin antagonist and reuptake inhibitors. After the fourth examination, the participants were contacted every four months for a year with regard to incident falls.