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LETTERS TO THE EDITOR

Kalpana P. Padala, MD, MS Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas Courtney Ghormley, PhD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Dennis H. Sullivan, MD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas

ACKNOWLEDGMENTS Conflict of Interest: There are no financial or personal conflict of interest relevant to the submitted manuscript for any authors. Office of Rural Health, Department of Veterans Affairs P00493 (PI: Padala PR); Patient Centered Alternatives to Institutional Extended Care, VA Central Office Office of Geriatrics and Extended Care, Department of Veterans Affairs G598–4 (PI: Padala PR). Author Contributions: PRP: concept, recruiting and conducting study, manuscript preparation. LN: recruiting and conducting study, critical review of manuscript. KPP: concept, critical review of manuscript. CG, DHS: critical review of manuscript. Sponsor’s Role: The sponsor had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of paper.

REFERENCES 1. Royall DR, Cordes JA, Polk M. CLOX: An executive clock drawing task. J Neurol Neurosurg Psychiatry 1998;64:588–594. 2. Parikh M, Grosch MC, Graham LL et al. Consumer acceptability of brief video conference-based neuropsychological assessment in older individuals with and without cognitive impairment. Clin Neuropsychol 2013;27:808– 817. 3. Turner T, Horner M, VanKirk K et al. A pilot trial of neuropsychological evaluations conducted via telemedicine in the Veterans Health Administration. Telemed J E Health 2012;18:662–667. 4. Timpano F, Pirrotta F, Bonanno L et al. Videoconference-based Mini-Mental State Examination: A validation study. Telemed J E Health 2013;19: 931–937. 5. Barton C, Morris R, Rothlind J et al. Video-telemedicine in a memory disorders clinic: Evaluation and management of rural elders with cognitive impairment. Telemed J E Health 2011;17:789–793.

TESTOSTERONE LEVELS AND BONE MINERAL DENSITY IN HEALTHY ELDERLY MEN To the Editor: We read with interest the letter by Iucif and colleagues1 on the association between total testosterone

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(T) plasma levels and bone mineral density (BMD) in healthy elderly men. A study of the association between T plasma levels and several bone measurements in a larger cohort (n = 162) of healthy elderly men was recently published.2 Quantitative ultrasound (QUS) measurements at the calcaneous and the hand phalanges were made, as well as peripheral BMD (pBMD) in the hand phalanges. These techniques differ from central BMD measurements determined using dual-energy X-ray absorptiometry (DXA) that are considered the criterion standard for the diagnosis of osteoporosis but allow the assessment of bone tissue in populations that do not have access to central DXA. The results that Iucif and colleagues presented were obtained from a cohort of men aged 60 and older (similar to the second study cohort: mean age 74.2  5, range 65–88) with mean T plasma levels of 411  192 ng/dL (slightly higher than observed in the second study cohort: 365  171 ng/dL). Iucif and colleagues found a negative correlation between BMD and T levels in the proximal femur and lumbar spine. These results contradict a number of studies that have demonstrated positive associations between T levels and BMD measured centrally and that the authors did not discuss. In particular, a meta-analysis3 presented results from 1,083 subjects with a mean age of 64.5 and demonstrated that T improved BMD at least in the lumbar spine. The results of the current study also indicate that higher values of os calcis, phalangeal QUS, and pBMD at the phalanges were observed in healthy elderly adults with higher T plasma levels. There are studies that have not found a positive association between T levels and BMD,4,5 but these do not support the data that Iucif and colleagues present, and based on the data presented, there may have been some misinterpretations. First, care should be taken because results presented in Figure 1 of Iucif and colleagues are from a correlation study between T-score and T levels, but the authors conclude that these results represent a negative correlation between BMD and T levels. The T-score compares the individual’s BMD measured using central DXA with the average for young individuals and expresses the difference as a standard deviation score. Single T-score measurements should never be interpreted as indicating any magnitude of bone loss. Most of the subjects studied in the Iucif and colleagues cohort would be classified as clinically normal based on the equipment reference database. Crude BMD values correlated with T levels would more accurately support the conclusion presented in the letter. Second, the correlation study that Iucif and colleagues present seems not to be adjusted (bivariate correlation) using any confounding factor. In particular, because of the putative gradual decrease in T levels during aging, partial correlations should be adjusted at least for age to address a negative correlation between BMD and T levels in elderly adults. Other factors should also be included in the analysis (mainly adjustment by weight of the participants). Finally, because the authors are presenting data from T-scores obtained in men, they should recognize what reference database are they using to interpret their results correctly. The International Society for Clinical Densitometry Position Development Conference6 recently recommended the use of a uniform Caucasian (non-raceadjusted) female reference database to calculate T-scores for femoral neck; manufacturer databases could still be

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used to calculate T-scores for the spine. The use of local reference data should not be used to calculate T-scores. Jose M. Moran, PhD Jesus M. Lavado-Garcıa, RN, PhD Raul Roncero-Martin, RN, PhD Maria Pedrera-Canal, MD Vincente Vera, PhD Pilar Fernandez, RN, PhD Juan D. Pedrera-Zamorano, MD, PhD Metabolic Bone Diseases Research Group, University of Extremadura, C aceres, Spain

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: Moran, Pedrera-Zamorano: study concept, preparation of manuscript. Lavado-Garcia, RonceroMartin, Pedrera-Canal, Vera, Fernandez: study concept. Sponsor’s Role: None.

REFERENCES 1. Iucif N, Marchini JS, do Carmo Sitta M et al. Association between plasma testosterone level and bone mineral density in healthy elderly men. J Am Geriatr Soc 2014;62:981–982. 2. Moran JM, Roncero-Martin R, Pedrera-Canal M et al. Low testosterone levels are associated with poor peripheral bone mineral density and quantitative bone ultrasound at phalanges and calcaneous in healthy elderly men. Biol Res Nurs 2014. doi:10.1177/1099800414532710. 3. Isidori AM, Giannetta E, Greco EA et al. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: A meta-analysis. Clin Endocrinol 2005;63:280–293. 4. Gennari L, Merlotti D, Martini G et al. Longitudinal association between sex hormone levels, bone loss, and bone turnover in elderly men. J Clin Endocrinol Metab 2003;88:5327–5333. 5. Emmelot-Vonk MH, Verhaar HJ, Nakhai Pour HR et al. Effect of testosterone supplementation on sexual functioning in aging men: A 6-month randomized controlled trial. JAMA 2008;299:39–52. 6. Schousboe JT, Shepherd JA, Bilezikian JP et al. Executive summary of the 2013 International Society for Clinical Densitometry Position Development Conference on bone densitometry. J Clin Densitom 2013;16:455– 466.

ESTABLISHING CODE STATUS: ARE PEOPLE’S DECISIONS TRULY INFORMED? To the Editor: More people are completing advance directives before they die,1 and a recent study in Oregon indicates that those who document their wishes not to be hospitalized at the end of life have those wishes honored.2 However, it is still common to find frail elderly adults or terminally ill individuals who have not documented or discussed their end-of-life wishes or request full resuscitation efforts, and the numbers of hospitalized individuals undergoing cardiopulmonary resuscitation (CPR) before dying is increasing.3 In contrast, essays and surveys by physicians and other healthcare professionals show a clear preference for not being resuscitated in the face of poor health.4,5 This discrepancy suggests that

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there is something that physicians understand about the process and prognosis of resuscitation that is not being effectively communicated. Code status discussions frequently focus on the low success rate ( 1).6 Another study examining survivors of cardiac arrest found that 66.3% had moderate to severe neurological disability 6 months after discharge.9 These data provide a different framework for discussion of code status than does focusing on the 20% chance of survival. Furthermore, when people are asked about code status, they are being asked to give permission to withhold potential treatment. Resuscitation is the only medical procedure for which consent not to proceed is needed. Although life-sustaining procedures are not withheld in emergency situations, all other medical procedures require prior consent unless the situation is life threatening. For example, when individuals who have experienced a trauma come into the emergency department needing blood, they receive it without delay, but before elective surgery, informed consent is obtained in case transfusion is needed. CPR should be no different. Code status discussions should communicate to the individual that, although the procedure can be life saving, there are inherent risks and potential for a bad outcome associated with it as well. Shifting the focus to asking for permission to perform CPR, rather than asking an individual to sign a do-notresuscitate order, can provide a more-balanced consent process. Ultimately, more needs to be known about prognosis before it will be possible to obtain adequate informed consent for a procedure. The Cardiac Arrest Survival Post Resuscitation In-hospital prediction tool10 examines 11 variables to predict the quality of neurological survival of individuals who undergo CPR. This tool can be a resource to help individuals and their families develop realistic expectations and make decisions about further code status and medical care after an arrest. This is a first step toward having a prearrest prediction tool to help guide decisionmaking during code status discussions. Further research is needed in this area.

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Testosterone levels and bone mineral density in healthy elderly men.

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