bluuebunny/crossref_metadata_2025 huggingface dataset:
An Outbreak of Influenza A (H3N2) in a Well Immunized Nursing Home Population
Authors: Coles F. Bruce , Balzano Gregory J. , Morse Dale L.
Published: April 2015

Objective

To describe the epidemiologic features of an outbreak of influenza A that occurred in a skilled nursing home although over 90 percent of the resident population had previously received influenza vaccine.

Design

Retrospective cohort study.

Setting

Skilled nursing home facility in western New York State.

Patients

Nursing home residents and patient‐care staff.

Main Outcome Measure

Incidence of influenza‐like illness among vaccinated versus unvaccinated nursing home residents and staff.

Results

Thirty‐seven of 124 residents (attack rate = 30%) and 18 of 146 staff (attack rate = 12%) had an influenza‐like illness. Staff illness began 16 days prior to onset among residents. Six cases of pneumonia and three influenza‐related deaths occurred, all among the vaccinated residents. Ninety percent of the nursing home residents and 10% of the staff received the influenza vaccine prior to the outbreak. The calculated vaccine efficacies were minus 21% and plus 45% for residents and staff, respectively.

Conclusion

While antigenic drift of the circulating influenza virus was the major factor in the apparent vaccine failure, the observed poor staff immunization rate (10%) and absence of surveillance which precluded the use of amantadine chemoprophylaxis suggest that the use of these strategies may be of importance in controlling influenza outbreaks in nursing homes.
Prostate Cancer
Authors: Moon Timothy D.
Published: April 2015

Clinically, prostate cancer (prostatic adenocarcinoma) is now the most frequently diagnosed cancer in males and the second leading cause of mortality due to cancer in the United States. However, because 75% of histologic prostate cancers remain functionally benign (will not metastasize and kill the patient), mass screening of the male population for the disease has become a hotly debated issue among urologists. The real challenge in the upcoming decade for geriatricians, though, will be to diagnose earlier in their course the prostate cancers which, if not treated, will metastasize and kill the patient and thus allow this subgroup of patients the opportunity to be treated more effectively. This review briefly discusses the etiology of prostate cancer, ways the disease may present, current treatments, depending on disease stage, screening in the diagnosis of prostate cancer, and quality of life issues important to patients confronted with the disease.
Suicide Attempts in Elderly Psychiatric Inpatients
Authors: Lyness Jeffrey M. , Conwell Yeates , Nelson J. Craig
Published: April 2015

Objective

To describe the psychopathological characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit.

Design

Retrospective chart review.

Patients

All 168 patients age 60 years and over treated on the adult psychiatric inpatient unit of Yale‐New Haven Hospital from 1979 to 1984. Twenty‐five made a suicide attempt.

Main Outcome Measures

Presence and severity of suicide attempts were rated and compared with demographic, clinical, and functional data.

Results

(1) Eighty percent of the attempters had a major depressive syndrome; (2) among patients with affective disorders, presence of an attempt was significantly associated with a later age of onset; (3) patients who had made more severe attempts were more likely to be diagnosed as psychotic depression, although this trend was not significant; (4) substance abuse and dementia were uncommon diagnoses; (5) symptomatic and functional outcome of hospitalization was as favorable for the attempters as for the entire elderly cohort.

Conclusions

Affective illness, especially late‐onset major depression, was the major association with suicide attempts.
Postprandial Cholecystokinin Secretion in Elderly with Protein‐Energy Undernutrition
Authors: Berthélemy Philippe , Bouisson Michèle , Vellas Bruno , Moreau Jacques , Nicole‐Vaysse  , Albarede Jean Louis , Ribet André
Published: April 2015

Objective

Malnutrition is currently observed in aged people, and cholecystokinin is an important peripheral satiety signal. The aim of this study was to examine the effect of aging and protein‐energy malnutrition on postprandial cholecystokinin (CCK) release.

Design

Non‐randomized, cross‐sectional comparison by age group.

Setting

Gastroenterology section of a teaching hospital.

Participants

Twenty‐one human volunteers divided into three groups: young healthy subjects (Group 1: mean 29 years, n = 7), aged healthy subjects (Group 2, mean 80 years, n = 7), and aged subjects with an important degree of malnutrition (Group 3, mean 84.6 years, n = 7).

Intervention

Each subject ingested a standardized liquid meal after an overnight fast.

Main Outcome Measures

Plasma cholecystokinin was measured using a sensitive bioassay before and after the ingestion of the liquid meal.

Results

Basal cholecystokinin levels were similar (0.9 to 1 pm equivalent CCK‐8) in the three groups. Postprandial levels were significantly increased over basal (P < 0.05). The maximal cholecystokinin value was lower in Group 1 (3.5 ± 0.8 pm equivalent CCK‐8) and Group 2 (3.3 ± 0.77 pm equivalent CCK‐8) than in Group 3 (8.3 ± 2 pm equivalent CCK‐8) (P < 0.05). Integrated plasma cholecystokinin was also similar in Group 1 (171 ± 38 pm · 60 min), (P < 0.05).

Conclusion

The increase of postprandial maximal levels of cholecystokinin is more related to malnutrition than to aging.
Attitudes toward Discussing Life‐Sustaining Treatments in Extended Care Facility Patients
Authors: Lurie Nicole , Pheley Alfred M. , Miles Steven H. , Bannick‐Mohrland Susan
Published: April 2015

Objective: To determine nursing home residents' attitudes toward discussing life‐sustaining treatment plans with their physicians and the factors associated with these attitudes.

Objective: Random‐sample, interviewer‐administered survey.

Setting: Forty‐one nursing homes in which some residents were cared for by house‐staff physicians of the Hennepin County (Minnesota) Medical Center Extended Care Department.

Patients: Random sample of 150 nursing home residents receiving primary care from Extended Care Department physicians, 131 (87%) of whom completed the interview.

Results: Older individuals were less likely to have spoken with physicians and family members about treatment plans (P < 0.05), and to have felt that they had more say than necessary in their treatment (P < 0.05). Only 19 (14.5%) residents had formal treatment plan discussions about limiting life‐sustaining treatment. Although perceived current health status did not differ between residents with and without treatment plans, those residents who had discussions about advance directives were more likely to report health improvement over the past 6 months (P < 0.05). Residents with formal advance directives were, on average, 8.4 years younger than those without them (P < 0.05).

Conclusions: Younger patients are more likely to have had discussions about life‐sustaining treatment and are also more frequently involved in plan development. Preferences for level of involvement should be considered during advance directive planning, and it should be recognized that these preferences may vary with age. Future research should evaluate whether this age relationship is a true age or a cohort effect. J Am Geriatr Soc 40:1205–1208, 1992
A Prospective Evaluation of the Geriatric Depression Scale in an Outpatient Geriatric Assessment Center
Authors: Burke William J. , Nitcher Rodney L. , Roccaforte William H. , Wengel Steven P.
Published: April 2015

Objective: To prospectively evaluate the Geriatric Depression Scale (GDS) in cognitively intact and impaired patients undergoing outpatient geriatric assessment.

Subjects: One hundred ninety‐four geriatric patients evaluated in a 1‐year period.

Setting: The outpatient Geriatric Assessment Center of the University of Nebraska Medical Center.

Measurements: The 30‐item GDS was completed by all patients. The patients were then evaluated by one of three geriatric psychiatrists who were blind to the GDS results. The prospective clinical diagnosis of major depression was compared to the GDS results. Patients were categorized as cognitively impaired or intact on the basis of the Mini‐Mental State Examination. Data were analyzed using ROC curves. An optimal cutoff was identified which was the total score on the GDS with the highest combined sensitivity and specificity.

Results: ROC curve analyses showed good agreement between the clinical diagnosis and the GDS in both cognitively intact and impaired subjects. Cognitively intact, euthymic patients reported a mean of 8.4 symptoms, while cognitively impaired, euthymic patients, reported a mean of 8.7. Cognitively intact, depressed patients reported a mean of 14.7 symptoms, while cognitively impaired, depressed patients reported a mean of 15.0.

Conclusions: This study provides further evidence that the GDS is as accurate a screening test for depression in cognitively impaired as in intact patients. J Am Geriatr Soc 40:1227–1230, 1992
The Influence of Treatment Descriptions on Advance Medical Directive Decisions
Authors: Malloy Timothy R. , Wigton Robert S. , Meeske Jessica , Tape Thomas G.
Published: April 2015

Objective: To determine whether the wording of the descriptions of life‐sustaining interventions would affect the choices elderly patients make when completing advance directives.

Methods: Survey.

Setting: General community in Omaha, Nebraska.

Patients: Two hundred one community‐dwelling elderly were selected from a population‐based sample.

Main Outcome Measures: Subjects were asked whether they would accept or reject three life‐sustaining interventions: cardiopulmonary resuscitation, mechanical ventilation, or tube feeding in three separate hypothetical case scenarios. The three life‐sustaining interventions were each described positively, negatively, and exactly as they are worded in a widely used advance directive. Subjects reviewed each scenario three times with three different descriptions of the three interventions.

Results: For the three interventions presented in three scenarios, subjects opted for the intervention 12 percent of the time when it was presented negatively, 18 percent of the time when it was phrased as in an advance directive already in use and 30 percent of the time it was phrased positively. One hundred fifty‐five of the 201 subjects (77 percent) changed their minds at least once when given the same scenario but a different description of the intervention. Of these 155, 33 percent changed decisions one to three times, 33 percent changed decisions four to seven times, and another 34 percent changed decisions eight to seventeen times based solely on the description of the intervention.

Conclusion: The decisions patients make about whether to accept or reject life‐sustaining treatments are affected by the descriptions of the treatments. These findings emphasize the critical importance of doctor‐patient consultation when patients execute advance directives. J Am Geriatr Soc 40:1255–1260, 1992
Community‐Acquired Bacteremia in the Elderly: A Prospective Study of 121 Cases
Authors: Whitelaw David A. , Rayner Brian L. , Willcox Paul A.
Published: April 2015

Objective: To describe community‐acquired bacteremia in the elderly and correlate clinical and laboratory findings with outcome.

Design: Prospective study of consecutive cases.

Setting: Large community‐based teaching hospital.

Patients: One hundred and twenty‐one elderly patients aged 65 to 89 years, seen between February 1, 1986 and January 31, 1988.

Main Outcome Measures: Bacteriological cultures, symptoms and signs, laboratory findings, and mortality.

Results: Gram‐negative organisms accounted for 65 (54%) cases and Gram‐positive organisms for 47 (39%) cases, while nine (7%) cases were polymicrobial. E. coli (39%), Klebsiella sp. (8%), S. pneumoniae (14%), and S. aureus (12%) were the most commonly isolated organisms. The overall mortality was 38%. A poor prognosis was associated with confusion as a presenting symptom (P < 0.0003), hypotension (P < 0.0003), and inappropriate or delayed treatment (P < 0.02). A good prognosis was associated with E. coli as the pathogen (P < 0.0003) and prompt, appropriate antibiotic therapy.

Conclusion: Community‐acquired bacteremia in the elderly has a high mortality rate. Early recognition and prompt, appropriate treatment are critical in reducing the mortality. J Am Geriatr Soc 40:996–1000, 1992
Mammography and Papanicolaou Smear Use by Elderly Poor Black Women
Authors: Mandelblatt Jeanne , Traxler Maryann , Lakin Patricia , Kanetsky Peter , Kao Richard ,   Harlem Study Team
Published: April 2015

Objective: To describe factors related to the use of mammography and Papanicolaou smears in low‐income women aged 65 or more years to guide development of future interventions.

Design: A cross‐sectional survey.

Setting and Patients: Elderly Black women attending a public hospital medical clinic.

Measurements: Information obtained in a face‐to‐face interview of a random sample of patients.

Results: Four‐hundred and forty‐five women (94%) consented to be interviewed; 74% reported a mammogram, and 85% reported a Papanicolaou smear in the past, although these early‐detection tests were not obtained with any regularity after age 65. Concordance between self‐reported screening use and blind chart review was more than 90%. The major reasons for non‐use of both screening tests were that a physician hadn't recommended them or that the women didn't know they needed them. Levels of knowledge about breast and cervix cancer were low; 68% believed bumping or bruising the breast caused cancer, and only 25% knew that cancer risk increased with advancing age. In logistic regression models, health status, provider type, perceived benefit, life satisfaction, and knowledge of test intervals were each significantly associated with mammogram use. Age, health status, education, perceived susceptibility and benefit, life satisfaction, and knowledge of test intervals were independently related to Pap use (P < .05).

Conclusion: This study illustrates that elderly, poor, minority women who are regular health‐care users do use mammography and Pap smear screening services. Incorporating screening into routine primary care and physician and patient education could enhance the use of early cancer detection procedures in this age group. J Am Geriatr Soc 40:1001–1007, 1992
The Effect of Chlorothiazide on Bone‐Related Biochemical Variables in Normal Post‐Menopausal Women
Authors: Peh C. A. , Horowitz M. , Wishart J. M. , Need A. G. , Morris H. A. , Nordin B. E. C.
Published: April 2015

Objective

To evaluate the effects of short‐term administration of chlorothiazide on fasting urinary hydroxyproline, an index of bone resorption, and other bone‐related biochemical parameters in normal post‐menopausal women.

Design

Subjects served as their own control before and after chlorothiazide treatment.

Setting

Subjects were recruited by advertisement.

Participants

Thirteen healthy post‐menopausal women with a mean age of 65 years.

Intervention

Each subject was given chlorothiazide 500 mg bd po for 7 days. Fasting blood and urine samples were obtained immediately before the commencement of chlorothiazide (day 1) and 2 and 7 days after starting chlorothiazide.

Results

Chlorothiazide decreased the urinary calcium/creatinine (mean value day 1, 0.267; day 2, 0.143; day 7, 0.135; P < 0.001) and hydroxyproline/creatinine (day 1, 0.0192; day 2, 0.0145; day 7, 0.0139; P < 0.02) molar ratios.

Conclusion

Chlorothiazide decreases fasting urinary hydroxyproline, a marker of bone resorption in post‐menopausal women. This observation supports a potential role for thiazide diuretics in the prevention of osteoporosis. The observed fall in urinary hydroxyproline is of the same order as that seen after treatment with estrogen or calcium supplements.
Pain Complaints and Cognitive Status among Elderly Institution Residents
Authors: Parmelee Patricia A. , Smithy Buster , Katz Ira R.
Published: April 2015

Objective

To examine the association between self‐reported pain and cognitive impairment among frail elderly institution residents.

Design

A cross‐sectional correlational study.

Setting

A large urban nursing home and congregate apartment complex housing predominantly Jewish elderly.

Participants

Seven hundred fifty‐eight elderly institution residents (30% in the nursing home, 70% in congregate apartments). The sample was 70% female and averaged 83.3 years of age.

Measurements

Respondent self‐reports tapped pain intensity, number of localized pain complaints, cognitive status, and disability in performance of activities of daily living. Attending physicians or physician assistants rated respondents health status.

Main Results

Pain intensity and number of localized pain complaints bore small but significant negative relationships to cognitive impairment. Pain was positively associated with physician‐rated ill health and functional disability. The association between pain and cognitive status remained significant even when controlled statistically for effects of physical health and functional disability. Item‐by‐item examination of localized pain complaints indicated that markedly cognitively impaired individuals were less likely to report pain in the back and joints. However, examination of possible physical causes of reported pain revealed no differences between pain reports of cognitively impaired versus intact individuals in either the presence or the absence of a likely physical cause.

Conclusions

These data provide no evidence for the “masking” of pain complaints by cognitive impairment. They suggest instead that, although cognitively impaired elderly may slightly underreport experienced pain, their self‐reports are generally no less valid that those of cognitively intact individuals. Limitations of the research are acknowledged and implications for treatment of cognitively impaired institution residents are discussed.
Serum Albumin and Prealbumin As Predictors of Clinical Outcomes of Hospitalized Elderly Nursing Home Residents
Authors: Ferguson Robert P. , O'Connor Patrick , Crabtree Benjamin , Batchelor Allison , Mitchell Jeanne , Coppola Devin
Published: April 2015

Objective

To investigate the prevalence of hypoalburninemia and hypoprealbuminemia in hospitalized, elderly, skilled nursing facility residents and to correlate these findings with clinical outcomes.

Design

Prospective cohort study.

Setting

A 300‐bed community hospital.

Participants

Eighty‐one hospitalized, skilled nursing facility patients, average age 83.1 years.

Interventions

None.

Outcome Measures

Serum albumin and prealbumin (transthyretin) were measured at admission, mid‐week, 1 week, and 1 month. Patients were followed for 90 days for the outcomes of length of hospitalization and mortality.

Results

The prevalence of hypoalbuminemia was 99% and of hypoprealbuminemia, 79%. Both means dropped significantly from admission to midweek nadirs of 25 g/L for albumin and 14 mg/L for prealbumin. Severe hypoalbuminemia at mid‐week predicted mortality (RR = 4.1 95%, CI 2.0–8.5) and extended length of hospitalization (RR = 5.2 95%, CI 2.8–9.8). Severe hypoprealbuminemia predicted extended hospitalization (RR = 3.2, CI 1.5–6.7) but not mortality.

Conclusions

Hypoalbuminemia and hypoprealbuminemia are very common in this clinical setting and vary in parallel fashion over time. Severe hypoalbuminemia was a stronger predictor than hypoprealbuminemia of 90‐day mortality and extended length of stay. Serum albumin on admission was not as strong a predictor of outcomes as serum albumin at mid‐week.
Regulation of Energy Expenditure in Aging Humans
Authors: Poehlman Eric T.
Published: April 2015

The regulation of daily energy expenditure and its components in aging humans in considered in this review. Specifically, the effects of age on resting metabolic rate (RMR), the thermic effect of a meal, body composition, and the interaction of these variables with physical activity in both men and women are considered. The possible modulators of the age‐related decline in RMR are examined by exploring the influence of alterations in body composition, physical activity, and the sodium‐potassium pump. Thereafter, the status of energy .requirements in healthy and diseased individuals is examined. New information is presented regarding the use of the doubly‐labeled water technique to measure daily energy expenditure and its applicability to the determination of daily energy requirements in free‐living older persons.
The Critical Shortage of Geriatrics Faculty
Authors: Reuben David B. , Bradley Thomas B. , Zwanziger Jack , Fink Arlene , Vivell Susan , Hirsch Susan H. , Beck John C.
Published: April 2015

To estimate the adequacy of current and future supply of geriatrics faculty, we conducted a national survey to determine the current supply of geriatrics faculty in five specialties and compared these estimates to standards for optimal faculty supply in geriatrics. Finally, we generated a model to project future faculty supply based on both current training capacity and differing assumptions regarding future training capacity.

Our findings indicate that the current supply of geriatrics physician faculty is less than half the number needed in each specialty. (Existing numbers range from a high of 909 faculty in internal medicine to a low of 86 in physical medicine.) Moreover, given the current capacity for training, there will be a net loss of such faculty each year in each specialty.

We conclude that the number of geriatrics faculty currently available is insufficient to provide an appropriate “core” level of geriatrics training for all undergraduate medical students and residents in relevant residency programs. In addition, the current framing capacity for geriatrics faculty cannot even sustain the current level of faculty over the next 10 years. To correct the current and future deficit, substantial increases in both geriatrics fellowship positions and mid‐career training positions will be necessary.
“Lifecare”: A Viable Option for Long‐Term Care for the Elderly
Authors: Somers Anne R.
Published: April 2015

In the absence of any coherent US long‐term care policy, the “lifecare” or “continuing care” retirement community (CCRC) has emerged as one viable model, providing housing, health care, social supports, and long‐term care insurance to about 300,000 elderly Americans. Some CCRCs have also demonstrated the cost‐effectiveness of a health care philosophy targeted to the maximum functional independence (MFI) of residents. Broad dissemination of the CCRC model and the philosophy of MFI depend on development of new approaches to the role of government and private health insurance along with a new understanding of, and commitment to, risk management.
BOOK REVIEWS
Authors: Katz Paul R. , Barzel Uriel S.
Published: April 2015

Drug Information for the Health Care Professional, USP DI, 12th Edition. Rockville, MD, Pharmacopeial Convention, Inc., 1992. Volume I (2 books): 2,784 pages plus appendices and index. Hardcover, plus 12 monthly updates, $115.00.
Treadmill Walking in Old Age May Not Reproduce the Real Life Situation
Authors: Greig Carolyn , Butler Felicity , Skelton Dawn , Mahmud Siti , Young Archie
Published: April 2015

Objective: In a preliminary study in our laboratory, healthy elderly people had a higher heart rate during treadmill walking than during corridor walking at the same speed. The objective of this study was to determine whether this initial observation, (1) persisted after repeated testing, (2) was present in younger adults, (3) was due to wearing a mouthpiece during treadmill walking, or (4) was due to a change in gait.

Design: A study of elderly and young volunteers undergoing repeated testing, with comparison of treadmill walking with corridor walking.

Setting: The Royal Free Hospital School of Medicine.

Participants: Twelve healthy elderly (71–80 years) and 12 healthy young (21–37 years) volunteers.

Main Outcome Measures: Heart rate (beats/min) and step rate (steps/min) during comfortable self‐paced corridor walking and during treadmill walking at the same speed.

Main Results: The elderly subjects had higher heart rates during treadmill walking than during corridor walking at the same speed (mean difference = 6 beats/min, 95% Confidence Interval (CI) = 1 to 10). This difference increased (to a mean of 11 beats/min, 95% CI = 5 to 16) when a mouthpiece was worn on the treadmill. These differences persisted after repeated testing. The young subjects did not have higher heart rates on the treadmill, (with or without the mouthpiece). In both groups, step rate was lower (95% CI = ‐9 to ‐2, elderly; ‐5 to ‐2, young) during treadmill walking, corresponding to a 3% increase in stride length.

Conclusion: The heart rate response to treadmill walking in healthy elderly people may be less representative of the “real life” situation than in younger adults.
What Is Appropriate Health Care for End‐Stage Dementia?
Authors: Daniel J. Luchins MD  , Hanrahan Patricia
Published: April 2015

Objective: This study sought to determine the kind of health care that professional and family caregivers viewed as appropriate for end‐stage dementia patients.

Design: Survey.

Participants: All 819 physician members and 1,000 randomly selected non‐physician members of the Gerontological Society of America and 500 families of demented relatives from the Alzheimer's Association.

Measures: Respondents chose the appropriate level of care from five choices on a continuum from highly aggressive to palliative.

Results: The majority of physicians who cared for elders (61%), gerontologists from other professions (55%), and families (71%) chose palliative care only. Increased age of the respondent and experience with terminal care choices were associated with the choice of palliative care. The majority favored hospice care for patients with end‐stage dementia.

Conclusions: Professional and family members of demented individuals, especially if they have experience in terminal care decisions, strongly favor palliative care for end‐stage dementia. These findings may be helpful to professionals and families dealing with these choices.
Alleviation of Sleep Maintenance Insomnia with Timed Exposure to Bright Light
Authors: Campbell Scott S. , Dawson Drew , Anderson Michael W.
Published: April 2015

Objective: Half of the population over 65 suffers from chronic sleep disturbance. As a consequence, almost 40% of hypnotic medications are prescribed to people over age 60. Yet, hypnotics are often of little benefit in this population. As such, an effective non‐drug alternative could prove important in the management of age‐related sleep maintenance insomnia. The current study sought to evaluate the efficacy of bright light exposure in the treatment of sleep maintenance insomnia.

Design: Following baseline sleep and circadian rhythms assessment, subjects with sleep‐maintenance insomnia were treated with timed exposure to either bright white light or dim red light for 12 consecutive days. Sleep and circadian rhythms recordings were subsequently obtained and measures of sleep quality were compared to assess efficacy of the treatments.

Setting: Baseline and post‐treatment sleep and circadian rhythms assessments took place in the Laboratory of Human Chronobiology, Department of Psychiatry, Cornell University Medical College. The treatment phase of the study was conducted in participants' homes.

Participants: Sixteen men and women between the ages of 62 and 81 years were studied. All subjects were free of hypnotic medication, and all had experienced sleep disturbance for at least 1 year prior to entering the study.

Results: Exposure to bright light resulted in substantial changes in sleep quality. Waking time within sleep was reduced by an hour, and sleep efficiency improved from 77.5% to 90%, without altering time spent in bed. Increased sleep time was in the form of Stage 2 sleep, REM sleep, and slow wave sleep. The effects were remarkably consistent across subjects.

Conclusions: The findings demonstrate the effectiveness of timed exposure to bright light in the treatment of age‐related sleep maintenance insomnia. With further refinement of treatment regimens, this non‐drug intervention may prove useful in a large proportion of sleep disturbed elderly.
Aggressive Behaviors among the Institutionalized Elderly
Authors: Malone Michael L. , Thompson Lori , Goodwin James S.
Published: April 2015

Objective: To describe the incidence and characteristics of aggressive behaviors in a group of institutionalized elderly.

Design: Retrospective survey.

Setting: 350‐bed, urban skilled nursing facility.

Patients: All nursing home residents who had an incident report completed after an aggressive behavior.

Measurements: Examination of all incident reports of aggressive behavior for 1 year.

Results: There were 94 reports of aggressive behaviors. Twenty‐nine residents exhibited one aggressive behavior, 12 residents two, and six residents exhibited three or more aggressive behaviors. These six residents accounted for 44% of all events. The incidence of aggressive behavior was 0.27 per resident per year for the entire facility; on the Alzheimer's unit the incidence was 0.75 per resident per year. Sixty‐two percent of the victims of aggressive behavior were other nursing home residents, 37% were employees, and 1% were visitors. The charts of the six residents with three or more aggressive behaviors were reviewed. These residents received trials of multiple scheduled psychotropic medications, often exhibited several additional agitated behaviors around the time of the attack, were at risk for psychiatric hospitalizations during the study period, and often were noted to have underlying acute medical illnesses near the time of the attack.

Conclusion: Approximately two aggressive behaviors per week occurred in a large nursing home. Residents and staff of Alzheimer's units have a higher risk of being victims of aggressive behavior. A small number of patients account for nearly half of the behaviors, even on the Alzheimer's unit. Aggressive behaviors may be clinical indicators of underlying acute medical illnesses.
A Comparison of the Cardiac Safety and Therapeutic Efficacy of Trimipramine versus Doxepin in Geriatric Depressed Patients
Authors: Nair N. P. Vasavan , Amin Mohammed , Schwartz George , Dastoor Dolly , Thavundayil Joseph X. , Mirmiran Jamal , MacDonald Carolyn , Phillips Robert
Published: April 2015

Objective: To compare the cardiac safety and therapeutic efficacy of trirnipramine and doxepin.

Design: A 1‐week single‐blind placebo period followed by a 5‐week randomized double‐blind parallel group clinical trial.

Setting: Psychiatric out‐patient clinic of a general hospital.

Patients: 37 young‐elderly patients with a diagnosis of Major Depressive Episode (DSM‐III criteria).

Interventions: Placebo for 1 week, 2 weeks of titration with either drug in the dosage range of 75 mg/day up to a maximum of 200 mg/day.

Measurements: We measured the psychiatric effects with the Hamilton Rating Scale for Depression, the Hamilton Anxiety Rating Scale, and the Clinical Global Impression Scale. Cardiovascular effects were assessed on 12‐lead standard electrocardiograms plus 1‐minute rhythm and high speed recordings; orthostatic (lying/standing) blood pressures were also taken. Physical exams, lab tests, cognitive functions (Buschke Selective Reminding Test, Hierarchic Dementia Scale, Word Fluency) and adverse reactions were also noted.

Results: Both drugs were equally effective in relieving symptoms of depression and anxiety. The cardiovascular effects of both drugs were minimal. Trimipramine did lower blood pressure but this was without clinical significance. Three trimipramine patients and five doxepin patients developed occasional premature ventricular or atrial contractions. Of these, two trimipramine patients and one doxepin patient were among those with abnormal ECG's at entry. The doxepin patient was withdrawn from the study after 21 days of treatment when the PVC's became increasingly frequent.

Conclusions: Trimipramine and doxepin are equally safe and effective antidepressants in the young‐elderly.
Age‐Related Trends in Cardiovascular Morbidity and Physical Functioning in the Elderly: The Cardiovascular Health Study
Authors: Bild Diane E. , Fitzpatrick Annette , Fried Linda P. , Wong Nathan D. , Haan Mary N. , Lyles Mary , Bovill Edwin , Polak Joseph F. , Schulz Richard
Published: April 2015

Objective: To describe relationships between age and subclinical cardiovascular disease, manifest chronic disease, and physical functioning and limitations among persons aged 65 years and older, with emphasis on the “oldest old,” those 85 years and older.

Design: Observational population‐based study.

Setting: Four U.S. communities: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania.

Participants: 5,201 men and women aged 65 years and older.

Measurements: Demographic data; histories of cardiovascular disease (CVD), chronic lung disease, arthritis, diabetes, and hypertension; measures of subclinical disease including arm and ankle blood pressures, internal carotid wall thickness and stenosis, ejection fraction, left ventricular mass, fractional shortening, and diastolic function, electrocardiographic left ventricular hypertrophy and cardiac injury score, forced expiratory flow and volume; functional status including self‐reported physical functioning, hearing and sight limitations and health status, and performance‐based measures of function. These variables were examined among men and women in three age groups: 65–74 years, 75–84 years, and 85+ years. Subgroups of participants with and without manifest CVD were also examined.

Main Results: In women, the prevalence of CVD and other chronic conditions increased with age, and the highest rates occurred among those 85 years and older. In men, prevalence rates increased between the two younger groups, but the oldest group had lower than expected rates for coronary heart disease, cerebrovascular disease, hypertension, and chronic lung disease. In contrast, there were strong age‐related linear trends in most of the subclinical measures of blood pressure, atherosclerosis and pulmonary function and in virtually all measures of functional status in both gender groups across the age range. There was a particularly marked decline in functional status between the two older age groups. While subclinical disease was greater and functional status was poorer among those with manifest CVD, with few exceptions, age‐related trends were not significantly different between the two groups.

Conclusions: Lower than expected prevalence rates of CVD among those aged 85 years and older, particularly among men, in this study of community‐dwelling elderly may represent selection bias or a real plateauing in disease prevalence with age. However, subclinical disease appears to increase and functional status to decline across the age range in both men and women regardless of the presence of CVD. The apparent increase in subclinical disease with age indicates potential for CVD prevention after age 65.
Cognitive Impairment and the Use of Health Services in an Elderly Rural Population: The MoVIES Project
Authors: Ganguli Mary , MPH Eric Seaberg , PhD Steven Belle , MPH Lynn Fischer , DrPH Lewis H. Kuller MD
Published: April 2015

Objective: To describe the patterns of use of health and human services by elderly rural individuals and to determine whether cognitively impaired persons had a distinctive pattern of service utilization.

Design: An epidemiological survey and cognitive screening of an age‐stratified random community sample.

Setting: The mid‐Monongahela Valley, a rural community in Southwestern Pennsylvania.

Participants: 1366 non‐institutionalized persons aged 65 years and older, fluent in English, and with at least a sixth grade education.

Measurements: We administered a battery of cognitive screening tests (the Mini‐Mental State Examination; Immediate and Delayed Recall of a Story; Immediate and Delayed Recall of a Word List; CERAD modification of the Boston Naming Test; Verbal Fluency for initial letters P and S and for names of Fruits and Animals; Temporal Orientation; Praxis; Clock Drawing; and Trailmaking Tests A and B.) We also obtained basic demographic information and enquired about the use of health and human services in the previous year.

Results: Approximately 10% of the sample was classified (by operational criteria) as cognitively impaired. In univariate analyses, cognitive impairment was found to be significantly associated with the use of certain health services: hospitalization in the previous 6 months (odds ratio, OR = 2.1; 95% CI = 1.3, 3.3), previous nursing home use (OR = 9.3; 95% CI = 3.8, 22.9), home health care (OR = 4.6; 95% CI = 2.7, 8.0), social services (OR = 6.5; 95% CI = 3.4, 12.4), mental health services (OR = 2.8; 95% CI = 1.2, 6.2), and the regular use of prescription medications (OR = 2.0; 95% CI = 1.3, 3.2). Visits to physicians were not significantly different between the impaired and unimpaired groups. In a multiple regression model, which included age and educational level, the use of home health care (OR = 3.4; 95% CI = 1.8, 6.4) and social services (OR = 2.3; 95% CI = 1.1, 4.9) remained significantly associated with cognitive impairment.

Conclusions: The association of cognitive impairment with the use of these health and human services underscores the general frailty of the impaired group. These findings also point to potential target groups in the community for further evaluation and services for dementia. The findings support the need for education regarding cognitive impairment and dementia to be made available to providers of these services, particularly informal social services such as those provided by church groups.
Age‐Related Variability in the Use of Cardiovascular Imaging Procedures
Authors: Bearden Donna M. , Allman Richard M. , Sundarum Srini Vasan , Burst Nickie M. , Bartolucci Alfred A.
Published: April 2015

Objective: To determine if older patients undergo fewer cardiovascular imaging procedures (CIPs) than younger patients when admitted to a tertiary care academic medical center for an acute myocardial infarction (MI), after adjusting for disease severity and comorbidities.

Design: Non‐current prospective cohort study.

Setting: Urban tertiary care academic medical center.

Patients: Medical records of 294 patients admitted and diagnosed with an acute MI between January 1990 and April 1991 were reviewed.

Measurements: The total number of different CIPs performed during hospitalization was determined. Cardiac catheterizations, echocardiograms, radionuclide ventriculograms, and thallium scans counted as CIPs. Disease severity was assessed by the Acute Physiology Score (APS) of APACHE II, admission Killip's Classification, and peak creatine phos‐phokinase (CPK) levels. Comorbidities were assessed using a modified Comorbidity Damage Index of Charlson.

Results: The mean (± SD) number of different CIPs performed during hospitalization was significantly less for those ≥75 years old (1.3 ± 1.0) than for those <75 years old (1.7 ± 1.0) (P = 0.01), and CIP number negatively correlated with age (Spearman r = −0.178; P = 0.01). Mean CIP number decreased from 2.0 ± 1.1 for those <45 years old to 0.9 ± 0.6 for those >85 years old (P = 0.02). Other factors positively associated (P ≤ 0.10) with CIP number were: CPK values in the highest quartile of the study population (>355 U/L); admission to a cardiology, medical, or family practice service; no CIP performed at an outside hospital prior to transfer; admission Killip's Classification of less than IV, and a Q‐wave MI. After adjusting for these variables in a multiple regression model, age ≥75 remained an independent predictor of decreased CIP use (P = 0.003). The modified comorbidity index score and the APS score, a general measure of severity of illness, were not significantly associated with CIP use. When procedures were examined individually, no significant age‐related differences were noted in the use of thallium scans, radionuclide ventriculograms, or echocardiograms. Older patients did, however, remain less likely to undergo cardiac catheterizations (P < 0.001).

Conclusion: Older patients, regardless of underlying disease severity or comorbidities, undergo fewer invasive cardiovascular evaluations than younger patients when admitted to a tertiary care academic medical center for an acute MI.
Constipation in the Elderly
Authors: Harari Danielle , Gurwitz Jerry H. , Minaker Kenneth L.
Published: April 2015

Objective: To explore the distinction between true clinical constipation and the subjective complaint of constipation in elderly people and to review the pathophysiology, symptoms, diagnosis, causes, and treatment.

Data Sources: A computer‐assisted and manual search of the English language literature using MEDLINE 1966–1991, Index Medicus 1988–1992, reference lists of selected articles, and relevant textbooks.

Study Selection: Studies that provide information on lower bowel function and laxative and enema use in the elderly subjects were reviewed. Article selection was not limited by study design.

Data Extraction: Relevant data were abstracted from the results of physiological, cohort and case‐control studies, and clinical trials. The text discusses the methodological strengths and flaws of these studies and excludes management approaches formulated from uncontrolled clinical observation.

Results of Data Synthesis: Constipation of the elderly is not well defined in the current literature. Self‐reported constipation and laxative use increase with age, while a similar escalation in true clinical constipation is not shown. Physiological changes in the lower bowel predisposing toward constipation do not occur with normal aging. Patient selection criteria for studies examining the pathophysiology of constipation differ in their definition of constipation and their inclusion of coexisting chronic illness. Nevertheless, there is consistent evidence for prolonged transit through the sigmoid colon and rectum, especially in frail elderly patients, and reduced rectal tone with impaired sensation, particularly in patients with rectal impaction. Few studies rigorously examine “risk factors” and non‐pharmacological interventions in constipation. The results of most laxative trials require cautious interpretation because of inclusion of patients without diagnostically proven constipation, use of combined laxative preparations, and unreliable outcome measures. Certain laxative agents however appear more appropriate for use in elderly people.

Conclusion: Although the subjective complaint of constipation and habitual laxative use increase with age, the epidemiological data suggest that true clinical constipation does not. Physiological changes predisposing toward constipation are not an inevitable consequence of aging, but appear to be specific to the condition. The available data do not confirm many suspected “risk factors” nor the benefits of commonly used non‐pharmacological and pharmacological treatments, but they do provide enough information to formulate a practical approach to constipation in elderly persons. J Am Geriatr Soc 41:1130–1140, 1993
Over 80 Years and No Evidence of Coronary Heart Disease: Characteristics of a Survivor Group
Authors: MD A. John Campbell , Busby Wendy J. , Robertson M. Clare
Published: April 2015

Objective: To determine factors that characterize those 80 years and over free of clinical coronary heart disease (CHD).

Design: Cross‐sectional intergroup comparison.

Setting: Rural New Zealand town.

Subjects: All those 70 years and over registered with the sole health center. Seven hundred eighty‐two subjects were seen, a 91.4% response rate. Subjects were divided by World Health Organization cardiovascular questionnaire criteria, history, examination, and coded 12‐lead electrocardiogram into four groups: 1) those 70–79 years of age with evidence of CHD; 2) those 80 years and older with evidence of CHD; 3) those 70–79 years of age free of CHD; and 4) those 80 years and older free of clinical CHD.

Measurements: Mean values and distributions of cholesterol, high‐density lipoprotein (HDL) cholesterol, apolipoproteins (apos), triglycerides, insulin, glucose, anthropometric measurements, and psychosocial variables.

Results: In the initial analysis of variance there was a significant difference in the mean values among the four groups for body mass index (BMI), HDL cholesterol, apo A1, and triglycerides. Using the Duncan procedure, the mean value of HDL cholesterol in the group 80 years and older with no evidence of clinical CHD was significantly higher than in each of the other groups. The group 80 years and older without clinical CHD had a significantly higher mean value for apo A1 and significantly lower mean values for triglycerides and BMI than the group 70–79 years old with CHD (P < 0.05).

Three‐factor analysis of variance showed those free of clinical CHD had significantly higher values of HDL cholesterol (P = 0.024) and apo A1 (P = 0.022), and lower values of BMI (P = 0.017) and triglycerides (P = 0.018) compared with those who had CHD after controlling for age and sex. Those 80 years and older had lower values of BMI (P = 0.001) and triglycerides (P = 0.018) than those 70–79 years old after controlling for CHD and sex.

The group who were 80 years and older and free of clinical CHD had a significantly narrower distribution of values for insulin (P < 0.001), glucose (P = 0.001), diastolic blood pressure (P = 0.001), BMI (P = 0.001), and waist‐hip ratio (P = 0.002) when compared with those 80 years and older with CHD; a significantly narrower distribution of values for insulin (P = 0.024), glucose (P = 0.003), and BMI (P = 0.002) when compared with those 79–79 years old with CHD and a significantly narrower distribution of glucose (P = 0.002) and BMI (P = 0.014) when compared with those 70–79 years old and free of clinical CHD.

Conclusion: Those 80 years and older who were free of clinical CHD were characterized by differences in lipid and anthropometric values, particularly higher HDL cholesterol and apo A1 levels. Results were also consistent with this survivor group maintaining tighter homeostatic control over a number of variables.