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High Prevalence of Chronic Kidney Disease, Anemia, and Falls in an Urban Long-Term Care Facility: Relationship or Coincidence?
withdrawing potentially helpful treatment on the basis of number of medications is not a logical solution to polypharmacy. Innovative methods to replace medications with nonpharmacologic interventions or reducing med passes seem much more logical. All of us are embarrassed at times when we reconcile our longer medication lists. We often wonder whether our elderly patients are better because of treatments we provide or if they are better because of serendipity. We look forward to when we will know the precise annual risk of bleeding in a high-risk stroke patient with atrial fibrillation being treated with warfarin. For now, we have to hope that by mitigating risk, we will assure a reasonable risk-benefit ratio. Cohn reminds us that we must practice without such knowledge because guidelines are based on flawed and imprecise data, and that randomized trials for elderly outliers can never be conducted quickly or cheaply enough.4 Stevenson credits Jan Tillish, a proponent of tailored therapy, as saying that if we had all the knowledge needed to tailor care that treatments could be prescribed by algorithm and by techinicians.5 If Cohn is correct, Dr Morley’s discussions of phronesis are crucial to the education of long-term care practitioners. Introducing this strange new term invites us to review what the great philosophers have concluded about uncertainty.1,6 Can we learn from them? Could framing our ideas and frustrations in terms used by Aristotle, Plato, or Socrates be less an affront when we debate our differing points of view with opinionated colleagues? Although oversimplified, it might be said that Socrates’ contribution to this conversation was his method of challenging conventional wisdom. Similarly, Plato, his student, noted that much of what a physician thinks or believes is based on an illusion and that, under more careful scrutiny, there is more to be considered than we typically consider. He is credited with defining a realm bordered by what we already know and what we don’t yet know as the Platonic fold.7 Eventually, Aristotle, Plato’s student, pondered the concept of tailoring medical care for individual patients.8 He must have developed this remarkable insight from his father, Nicomacheus, who was a physician. It is beyond time that we study and value these salient insights that are centuries old. That is the beauty of Dr Morley’s challenge. Aristotle describes phronesis in Nicomachean Ethics.9 Most agree that it means the ability to achieve a desired end that enhances the quality of life. Some contend that phronesis requires the physician to determine a desired end. Others would contend that the desired end is a given. Regardless, Aristotle believed that it requires maturation for a person to combine experience (situational factors) with knowledge (scientific evidence). He believed that the young acquire knowledge quickly, but that acquiring experience and wisdom requires time. Wharam and Sulmasy’s quote of Aristotle on the value of experience is worth repeating: The doctor does not treat ‘man’ except accidentally; he treats Callius or Socrates or someone else described in this way, who is accidentally ‘man.’ So, if someone has grasped the principles of the subject without having any experience, and thus knows the universal LETTERS TO THE EDITOR
without knowing the individuals contained in it, he will often fail in his treatment; for it is the individual who has to be treated.8
Does this notion, in fact, speak for a specialty in long-term care?10 Nursing home practice occurs largely in the Platonic fold and our patients are, indeed, the black swans and zebras of the medical community. The observations of both Cohn and Morley are correct and they confirm that nursing home practitioners are not likely to develop a skill more useful than phronesis. Honing this skill is rewarding and, typically, occurs late in the career of many practitioners. This process begins after years of encountering difficulty and uncertainty that in time leads a practitioner to discover his or her own fallibility. Although centuries apart, there is a principle upon which Aristotle and Gladwell could agree: years of practice are typically required to acquire expertise.11 We should ask ourselves how we can facilitate this time-consuming process for our younger colleagues. Richard W. Miles, MD Medical Director of 6 long-term care facilities in Benton and Washington Counties, AR
REFERENCES 1. Morley JE. Polypharmacy in the nursing home. J Am Med Dir Assoc 2009;10:289–291. 2. Gurwitz JH. Polypharmacy: A new paradigm for quality drug therapy in the elderly. Arch Intern Med 2004;164:1957–1958. 3. Tangalos ED, Zarowitz BJ. Combination drug therapy. J Am Med Dir Assoc 2005;8:406–409. 4. Cohn JN. The fallacy of the mean. J Card Fail 2001;7:103–104. 5. Stevenson L. Challenges for the basis of practice in heart failure. Circ Heart Fail 2008;1:81–83. 6. Morley JE. Phronesis and the medical director. J Am Med Dir Assoc 2009;10:149–152. 7. Taleb N. The Black Swan: The Impact of the Highly Improbable. New York: Random House; 2007. 8. Wharam JS, Sulmasy D. Improving the quality of health care: Who is responsible for what? JAMA 2009;301:215–217. 9. Aristotle IT. Nichomachean Ethics. Indianapolis, IN: Hackett Publishing Company; 1999. 10. Katz P, Jurgisn K, Intrator O, Mor V. Nursing home physician specialists: A response to the workforce crisis in long-term care. Ann Intern Med 2009;150:411–413. 11. Gladwell M. Outliers: The Story of Success. New York: Little Brown and Company; 2008.
High Prevalence of Chronic Kidney Disease, Anemia, and Falls in an Urban Long-Term Care Facility: Relationship or Coincidence? To the Editor: Although it is known that comorbidity is the norm in the typical long-term care (LTC) resident,1 our observations on the prevalence of chronic kidney disease in an urban 350-bed Bronx LTC facility surprised us. Presented in brief are our findings, which may have implications in the management of residents in LTC. Evaluation of kidney function and prevalence of chronic kidney disease (CKD) in the LTC setting 297
has received attention in a recent publication.2 Renal function influences the dosing of medications primarily metabolized or removed by the kidney, and is directly linked to evaluation and management in several situations (eg, anemia, electrolyte imbalance, dietary prescription, cognition, affect, planning for dialysis). With knowledge of kidney function of the residents, we additionally looked at the prevalence of anemia and falls in this population. We observed that the prevalence of all 3 conditions (CKD, anemia, and falls) was high. METHODS Data on demographics were retrospectively collected over a 1-year period (January through December 2008) on the entire resident population of the LTC facility. Data included resident age, sex, race (required to determine glomerular filtration rate [GFR] using Modification of Diet in Renal disease [MDRD] formula to determine CKD stages 1–5), serum creatinine, hemoglobin (Hb), and hematocrit levels as well as falls history, falls frequency, and falls outcome in 323 LTCF residents. World Health Organization criteria defined anemia as less than 12.0 g/dL in females and less than 13.0 g/dL in males (as reported in the WHO/INICEF/UNU Consultation. Geneva, Switzerland. December 1993). The National Kidney Foundation staging for CKD was used (GFR .90, 60–89, 30– 59, 15–29, and \15 5 stage 1, 2, 3, 4, and 5, respectively).3 RESULTS Data from 323 LTCF residents were examined (mean age 5 83.4 10.9 [SD] years; 78.3% female; 10.8% African American) consistent with typical LTC resident age and gender patterns. In December 2008, CKD stages 1, 2, 3, 4, and 5 were present, respectively, in 26.9%, 45.2%, 25.1%, 1.9%, and 0.9% of the residents. At this time, 61.6% of the residents were anemic. Most of the residents (76.8%) with anemia had low hemoglobin throughout the entire year of data collection. Table 1 describes the distribution of CKD staging by resident age and sex; regression analysis determined a decline of 0.5 mL GFR for every 1-year increase in age (P 5 .003) in these 323 residents, whereas resident sex was found to be unrelated to changes in GFR (P 5 .587). Interestingly, this decline in GFR in older residents is consistent with a physiological decline in renal function believed to occur with aging. Table 2 describes falls outcome and shows that 25% of falls resulted in some injury, whereas 2.4% resulted in serious injury requiring Table 1.
hospitalization. Figure 1 presents the distribution of Hb levels across all 323 residents as of December 2008. Regression analyses were also used to explore the data described in Table 2 and Figure 1. These analyses determined that males experienced 1.13 more falls during 12 months compared with females (P 5 .004) and, independently, residents with anemia at the time of their fall experienced 1.28 more falls than residents who were not anemic (P 5 .001). Age (P 5 .356) and GFR (P 5 .912) were determined not to be related to falls. Additional analyses determined that males were 3.1-fold more likely to be anemic than females (P 5 .001) and, independently, that individuals with worsening CKD (stages 3–5) were 2-fold more likely to be anemic than residents with CKD stages 1 or 2 (P 5 .014). DISCUSSION A recent report on 794 residents in LTC across the United States (mean age 83 years) suggests a prevalence of 50% CKD (stages 3–5),2 consistent with another estimate.4 Our report, which included CKD stages 2 to 5, showed a prevalence of 73.1%. We observed that besides CKD, anemia (61.6%) and falls (in 42.7%) were exceedingly common in this LTC setting. It is well known that CKD in worsening stages beyond stage 3 is associated with anemia. In our retrospective study, anemia was present in three fifths of residents but an evaluation to determine the etiology was not evident in most. Anemia was mild (10–12 g/dL) in 69% of cases and more severe (\10 g/dL) in 24%. Our sample of LTC residents had a high prevalence of both CKD and anemia and we identified a cause-and-effect relationship between worsening CKD and anemia; this relationship has been recognized by others.2 Falls are also known to occur in the LTC setting. The Joint Commission and societies such as the American Geriatrics Society and American Medical Directors Association require that older adults be assessed for falls risk, and have issued guidelines. In our sample, 454 falls or 1.4 falls per resident (454/323) had occurred during 12 months. Most falls resulted in no injury (75% of cases); however, 25% of falls caused some injury and a small number (2.4%) were serious enough to require hospitalization. Anemia is common in older adults in the LTC setting. The NHANES III data noted that a third of all anemias in adults older than 65 are nutritional in origin and a third result from chronic disease including CKD.5 In addition, we have
CKD Stages by Age and Sex
CKD Staging Age, % \ 70 y 70–79 y 80–89 y .89 y Sex ratio, % Males Females
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
P Value
15.2 24.0 40.8 20.0
7.0 16.4 40.8 35.8
3.4 20.2 44.5 31.9
16.7 0.0 50.0 33.3
33.3 33.3 33.3 0.0
.015*
34.4 65.6
17.9 82.1
19.3 80.7
83.3 16.7
33.3 66.7
.003*
CKD, chronic kidney disease. Data are percentages observed by CKD stage. * Chi-square analysis was used. 298
JAMDA – May 2010
Table 2.
Falls Outcome (January through December 2008)
Injury Type
Percentage of Total Falls
No injury Minor injury* Major injury†
75% 22.6% 2.4%
Injury Examples
speculate that the high prevalence of anemia, CKD, and falls in this LTC site may be related rather than a coincidence. T.S. Dharmarajan, MD, FACP, AGSF Montefiore Medical Center North Division, Bronx, New York New York Medical College Valhalla, New York
Soft tissue injuries Fractured wrist Lacerations to forehead Lacerations to arm Lacerations to chest
Prabir Banik, MD Montefiore Medical Center North Division, Bronx, New York
* Hospitalization not necessary. † Hospitalization required.
reported that anemia in community and long-term care patients increases the risk for falls and falls frequency6,7 and, more recently, that anemia and declining renal function in the elderly were both independently associated with an increased risk of falls and falls frequency.8 The literature also suggests that falls are more common in dialysis patients9 and that medications and comorbidity increase the risk of falls in hospitalized patients with CKD.10 The high prevalence of falls in residents of LTC with CKD and anemia should thus not come as a surprise and appear not to have occurred by chance. Still, falls do not result solely from anemia or CKD. In most cases, falls in residents of LTC are multifactorial with a variable and complex interplay of intrinsic and extrinsic factors.11,12 Our study has shortcomings. It is retrospective and our data, available through review of medical records, are far from complete. One cannot rule out the impact of other factors (impaired vision, cognition, acute illness, medications, and so forth), and so it is very likely that a number of factors contributed to our observed falls. Nevertheless, we present an interesting combination of findings on the high prevalence of anemia, CKD, and falls in a single facility. Although falls draw provider and caregiver attention, anemia and CKD may not receive the same importance in LTC. Unlike falls, both anemia and CKD are ‘‘quiet’’ disorders and may simply be viewed as associated with aging, prompting fewer interventions. Patients with worsening stages of CKD tend to be anemic; these patients usually suffer comorbidity and are on multiple medications that may border on polypharmacy. The potential benefits of addressing these issues in LTC residents appear worth exploring. It is tempting to
M. Kanagala, MD Montefiore Medical Center North Division, Bronx, New York Joseph Scarpa, MD, CMD Schervier Nursing Care Center Bronx, New York Edward P. Norkus, PhD, FACN Montefiore Medical Center North Division, Bronx, New York New York Medical College Valhalla, New York REFERENCES 1. Messinger-Rapport BJ, Tomas DR, Gammack JK, Morley JE. Clinical update on nursing home medicine. J Am Med Dir Assoc 2009;10:530–553. 2. McClellan WM, Resnick B, Bradbury BD, et al. Prevalence and severity of chronic kidney disease and anemia in the nursing home population. J Am Med Dir Assoc 2010;11:33–41. 3. K/DOQI clinical practice guidelines for chronic kidney disease. Evaluation, classification and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39:S1–246. 4. Garg AX, Papaioannou A, Ferko N, et al. Estimating the prevalence of renal insufficiency in seniors requiring long term care. Kidney Intl 2004;65: 649–653. 5. Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in United States: Evidence for a high rate of unexplained anemia. Blood 2004;104:2263–2268. 6. Dharmarajan TS, Norkus EP. Mild anemia and the risk of falls in older adults from nursing homes and the community. J Am Med Dir Assoc 2004;5:395–400. 7. Dharmarajan TS, Avula S, Norkus EP. Anemia increases the risk for falls in hospitalized older adults: An evaluation of falls in 362 hospitalized, ambulatory, long-term care and community patients. J Am Med Dir Assoc 2006;7:287–293. 8. Dharmarajan TS, Yeddu M, Ambati R, et al. Falls in hospitalized older adults from community and nursing homes. Impact of chronic kidney disease and anemia. J Am Geriatr Soc 2009;57:S28. 9. Cook WL, Tomlinson G, Donaldson M, et al. Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol 2006;1:1197–1204. 10. Angalakuditia MV, Gomes J, Coley KC. Impact of drug use and comorbdities in in-hospital falls in patients with chronic kidney disease. Ann Pharmacother 2007;41:1638–1643. 11. Morley JE. Falls and fractures. J Am Med Dir Assoc 2007;8:276–278. 12. Albert SM. Behavioral interventions to reduce risk of falls in nursing home residents. J Am Med Dir Assoc 2009;10:593–594.
DOI:10.1016/j.jamda.2010.02.014 Fig. 1. Hemoglobin levels in 323 residents. LETTERS TO THE EDITOR
299
without knowing the individuals contained in it, he will often fail in his treatment; for it is the individual who has to be treated.8
Does this notion, in fact, speak for a specialty in long-term care?10 Nursing home practice occurs largely in the Platonic fold and our patients are, indeed, the black swans and zebras of the medical community. The observations of both Cohn and Morley are correct and they confirm that nursing home practitioners are not likely to develop a skill more useful than phronesis. Honing this skill is rewarding and, typically, occurs late in the career of many practitioners. This process begins after years of encountering difficulty and uncertainty that in time leads a practitioner to discover his or her own fallibility. Although centuries apart, there is a principle upon which Aristotle and Gladwell could agree: years of practice are typically required to acquire expertise.11 We should ask ourselves how we can facilitate this time-consuming process for our younger colleagues. Richard W. Miles, MD Medical Director of 6 long-term care facilities in Benton and Washington Counties, AR
REFERENCES 1. Morley JE. Polypharmacy in the nursing home. J Am Med Dir Assoc 2009;10:289–291. 2. Gurwitz JH. Polypharmacy: A new paradigm for quality drug therapy in the elderly. Arch Intern Med 2004;164:1957–1958. 3. Tangalos ED, Zarowitz BJ. Combination drug therapy. J Am Med Dir Assoc 2005;8:406–409. 4. Cohn JN. The fallacy of the mean. J Card Fail 2001;7:103–104. 5. Stevenson L. Challenges for the basis of practice in heart failure. Circ Heart Fail 2008;1:81–83. 6. Morley JE. Phronesis and the medical director. J Am Med Dir Assoc 2009;10:149–152. 7. Taleb N. The Black Swan: The Impact of the Highly Improbable. New York: Random House; 2007. 8. Wharam JS, Sulmasy D. Improving the quality of health care: Who is responsible for what? JAMA 2009;301:215–217. 9. Aristotle IT. Nichomachean Ethics. Indianapolis, IN: Hackett Publishing Company; 1999. 10. Katz P, Jurgisn K, Intrator O, Mor V. Nursing home physician specialists: A response to the workforce crisis in long-term care. Ann Intern Med 2009;150:411–413. 11. Gladwell M. Outliers: The Story of Success. New York: Little Brown and Company; 2008.
High Prevalence of Chronic Kidney Disease, Anemia, and Falls in an Urban Long-Term Care Facility: Relationship or Coincidence? To the Editor: Although it is known that comorbidity is the norm in the typical long-term care (LTC) resident,1 our observations on the prevalence of chronic kidney disease in an urban 350-bed Bronx LTC facility surprised us. Presented in brief are our findings, which may have implications in the management of residents in LTC. Evaluation of kidney function and prevalence of chronic kidney disease (CKD) in the LTC setting 297
has received attention in a recent publication.2 Renal function influences the dosing of medications primarily metabolized or removed by the kidney, and is directly linked to evaluation and management in several situations (eg, anemia, electrolyte imbalance, dietary prescription, cognition, affect, planning for dialysis). With knowledge of kidney function of the residents, we additionally looked at the prevalence of anemia and falls in this population. We observed that the prevalence of all 3 conditions (CKD, anemia, and falls) was high. METHODS Data on demographics were retrospectively collected over a 1-year period (January through December 2008) on the entire resident population of the LTC facility. Data included resident age, sex, race (required to determine glomerular filtration rate [GFR] using Modification of Diet in Renal disease [MDRD] formula to determine CKD stages 1–5), serum creatinine, hemoglobin (Hb), and hematocrit levels as well as falls history, falls frequency, and falls outcome in 323 LTCF residents. World Health Organization criteria defined anemia as less than 12.0 g/dL in females and less than 13.0 g/dL in males (as reported in the WHO/INICEF/UNU Consultation. Geneva, Switzerland. December 1993). The National Kidney Foundation staging for CKD was used (GFR .90, 60–89, 30– 59, 15–29, and \15 5 stage 1, 2, 3, 4, and 5, respectively).3 RESULTS Data from 323 LTCF residents were examined (mean age 5 83.4 10.9 [SD] years; 78.3% female; 10.8% African American) consistent with typical LTC resident age and gender patterns. In December 2008, CKD stages 1, 2, 3, 4, and 5 were present, respectively, in 26.9%, 45.2%, 25.1%, 1.9%, and 0.9% of the residents. At this time, 61.6% of the residents were anemic. Most of the residents (76.8%) with anemia had low hemoglobin throughout the entire year of data collection. Table 1 describes the distribution of CKD staging by resident age and sex; regression analysis determined a decline of 0.5 mL GFR for every 1-year increase in age (P 5 .003) in these 323 residents, whereas resident sex was found to be unrelated to changes in GFR (P 5 .587). Interestingly, this decline in GFR in older residents is consistent with a physiological decline in renal function believed to occur with aging. Table 2 describes falls outcome and shows that 25% of falls resulted in some injury, whereas 2.4% resulted in serious injury requiring Table 1.
hospitalization. Figure 1 presents the distribution of Hb levels across all 323 residents as of December 2008. Regression analyses were also used to explore the data described in Table 2 and Figure 1. These analyses determined that males experienced 1.13 more falls during 12 months compared with females (P 5 .004) and, independently, residents with anemia at the time of their fall experienced 1.28 more falls than residents who were not anemic (P 5 .001). Age (P 5 .356) and GFR (P 5 .912) were determined not to be related to falls. Additional analyses determined that males were 3.1-fold more likely to be anemic than females (P 5 .001) and, independently, that individuals with worsening CKD (stages 3–5) were 2-fold more likely to be anemic than residents with CKD stages 1 or 2 (P 5 .014). DISCUSSION A recent report on 794 residents in LTC across the United States (mean age 83 years) suggests a prevalence of 50% CKD (stages 3–5),2 consistent with another estimate.4 Our report, which included CKD stages 2 to 5, showed a prevalence of 73.1%. We observed that besides CKD, anemia (61.6%) and falls (in 42.7%) were exceedingly common in this LTC setting. It is well known that CKD in worsening stages beyond stage 3 is associated with anemia. In our retrospective study, anemia was present in three fifths of residents but an evaluation to determine the etiology was not evident in most. Anemia was mild (10–12 g/dL) in 69% of cases and more severe (\10 g/dL) in 24%. Our sample of LTC residents had a high prevalence of both CKD and anemia and we identified a cause-and-effect relationship between worsening CKD and anemia; this relationship has been recognized by others.2 Falls are also known to occur in the LTC setting. The Joint Commission and societies such as the American Geriatrics Society and American Medical Directors Association require that older adults be assessed for falls risk, and have issued guidelines. In our sample, 454 falls or 1.4 falls per resident (454/323) had occurred during 12 months. Most falls resulted in no injury (75% of cases); however, 25% of falls caused some injury and a small number (2.4%) were serious enough to require hospitalization. Anemia is common in older adults in the LTC setting. The NHANES III data noted that a third of all anemias in adults older than 65 are nutritional in origin and a third result from chronic disease including CKD.5 In addition, we have
CKD Stages by Age and Sex
CKD Staging Age, % \ 70 y 70–79 y 80–89 y .89 y Sex ratio, % Males Females
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
P Value
15.2 24.0 40.8 20.0
7.0 16.4 40.8 35.8
3.4 20.2 44.5 31.9
16.7 0.0 50.0 33.3
33.3 33.3 33.3 0.0
.015*
34.4 65.6
17.9 82.1
19.3 80.7
83.3 16.7
33.3 66.7
.003*
CKD, chronic kidney disease. Data are percentages observed by CKD stage. * Chi-square analysis was used. 298
JAMDA – May 2010
Table 2.
Falls Outcome (January through December 2008)
Injury Type
Percentage of Total Falls
No injury Minor injury* Major injury†
75% 22.6% 2.4%
Injury Examples
speculate that the high prevalence of anemia, CKD, and falls in this LTC site may be related rather than a coincidence. T.S. Dharmarajan, MD, FACP, AGSF Montefiore Medical Center North Division, Bronx, New York New York Medical College Valhalla, New York
Soft tissue injuries Fractured wrist Lacerations to forehead Lacerations to arm Lacerations to chest
Prabir Banik, MD Montefiore Medical Center North Division, Bronx, New York
* Hospitalization not necessary. † Hospitalization required.
reported that anemia in community and long-term care patients increases the risk for falls and falls frequency6,7 and, more recently, that anemia and declining renal function in the elderly were both independently associated with an increased risk of falls and falls frequency.8 The literature also suggests that falls are more common in dialysis patients9 and that medications and comorbidity increase the risk of falls in hospitalized patients with CKD.10 The high prevalence of falls in residents of LTC with CKD and anemia should thus not come as a surprise and appear not to have occurred by chance. Still, falls do not result solely from anemia or CKD. In most cases, falls in residents of LTC are multifactorial with a variable and complex interplay of intrinsic and extrinsic factors.11,12 Our study has shortcomings. It is retrospective and our data, available through review of medical records, are far from complete. One cannot rule out the impact of other factors (impaired vision, cognition, acute illness, medications, and so forth), and so it is very likely that a number of factors contributed to our observed falls. Nevertheless, we present an interesting combination of findings on the high prevalence of anemia, CKD, and falls in a single facility. Although falls draw provider and caregiver attention, anemia and CKD may not receive the same importance in LTC. Unlike falls, both anemia and CKD are ‘‘quiet’’ disorders and may simply be viewed as associated with aging, prompting fewer interventions. Patients with worsening stages of CKD tend to be anemic; these patients usually suffer comorbidity and are on multiple medications that may border on polypharmacy. The potential benefits of addressing these issues in LTC residents appear worth exploring. It is tempting to
M. Kanagala, MD Montefiore Medical Center North Division, Bronx, New York Joseph Scarpa, MD, CMD Schervier Nursing Care Center Bronx, New York Edward P. Norkus, PhD, FACN Montefiore Medical Center North Division, Bronx, New York New York Medical College Valhalla, New York REFERENCES 1. Messinger-Rapport BJ, Tomas DR, Gammack JK, Morley JE. Clinical update on nursing home medicine. J Am Med Dir Assoc 2009;10:530–553. 2. McClellan WM, Resnick B, Bradbury BD, et al. Prevalence and severity of chronic kidney disease and anemia in the nursing home population. J Am Med Dir Assoc 2010;11:33–41. 3. K/DOQI clinical practice guidelines for chronic kidney disease. Evaluation, classification and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002;39:S1–246. 4. Garg AX, Papaioannou A, Ferko N, et al. Estimating the prevalence of renal insufficiency in seniors requiring long term care. Kidney Intl 2004;65: 649–653. 5. Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in United States: Evidence for a high rate of unexplained anemia. Blood 2004;104:2263–2268. 6. Dharmarajan TS, Norkus EP. Mild anemia and the risk of falls in older adults from nursing homes and the community. J Am Med Dir Assoc 2004;5:395–400. 7. Dharmarajan TS, Avula S, Norkus EP. Anemia increases the risk for falls in hospitalized older adults: An evaluation of falls in 362 hospitalized, ambulatory, long-term care and community patients. J Am Med Dir Assoc 2006;7:287–293. 8. Dharmarajan TS, Yeddu M, Ambati R, et al. Falls in hospitalized older adults from community and nursing homes. Impact of chronic kidney disease and anemia. J Am Geriatr Soc 2009;57:S28. 9. Cook WL, Tomlinson G, Donaldson M, et al. Falls and fall-related injuries in older dialysis patients. Clin J Am Soc Nephrol 2006;1:1197–1204. 10. Angalakuditia MV, Gomes J, Coley KC. Impact of drug use and comorbdities in in-hospital falls in patients with chronic kidney disease. Ann Pharmacother 2007;41:1638–1643. 11. Morley JE. Falls and fractures. J Am Med Dir Assoc 2007;8:276–278. 12. Albert SM. Behavioral interventions to reduce risk of falls in nursing home residents. J Am Med Dir Assoc 2009;10:593–594.
DOI:10.1016/j.jamda.2010.02.014 Fig. 1. Hemoglobin levels in 323 residents. LETTERS TO THE EDITOR
299