bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes in Small‐Intestine Permeability with Aging
Authors: Saltzman John R. , Kowdley Kris V. , Perrone Gayle , Russell Robert M.
Published: April 2015

OBJECTIVE: To evaluate small‐intestine mucosal integrity and permeability with advancing age as measured by the lactulose/mannitol absorption test in healthy subjects.

DESIGN: Prospective cohort study.

SETTING: Clinical research unit of the USDA Human Nutrition Research Center on Aging.

STUDY PARTICIPANTS: Fifty‐six subjects were recruited in three age groups: 20 to 39 years (n = 20), 40 to 59 years (n = 19), and ≥60 years (n = 17). Subjects were healthy, community‐dwelling volunteers.

INTERVENTION: After an 8‐hour fast, all subjects ingested 10 g of lactulose and 5 g of mannitol. Urine was collected for 6 hours and analyzed for lactulose and mannitol by high performance liquid chromatography. Twenty‐four‐hour urinary creatinine clearances were determined.

MAIN OUTCOME MEASURES: Percentages of lactulose and mannitol excreted, the lactulose/mannitol ratio (x100), and the 24‐hour creatinine clearance.

RESULTS: With increasing age, both the percentage of lactulose excreted (P = 0.09) and the percentage of mannitol excreted (P = 0.05) tended to decrease progressively. The lactulose/mannitol ratio (x100) did not change with increasing age (P = 0.65) because both the percentages of lactulose and mannitol excreted declined. The creatinine clearance decreased markedly with advancing age (P < .001) and accounted for the decline in percentages of lactulose and mannitol excreted (P < .02).

CONCLUSIONS: There is a progressive decline in the ability to excrete lactulose and mannitol with increasing age. This is probably attributable to a decline in renal function with advancing age. However, because of parallel decreases in lactulose and mannitol excretion, the lactulose/mannitol ratio does not change. Thus small‐intestine “leakiness” does not increase with aging as measured by the lactulose/mannitol absorption test.
Diagnostic and Prognostic Value of Stress Testing in Older Persons
Authors: Fleg Jerome L.
Published: April 2015

OBJECTIVE: To review the diagnostic and prognostic utility of exercise and pharmacologic stress testing in older individuals.

DATA SOURCE: A computer‐assisted search of the literature, followed by a manual reference review of pertinent articles.

STUDY SELECTION: Studies addressing the use of exercise and pharmacologic stress testing for coronary artery disease (CAD) detection and prognosis were reviewed. Emphasis was placed on those studies applying these procedures to older populations.

DATA EXTRACTION: Pertinent data were extracted regarding the diagnostic and prognostic accuracy and safety of exercise and nonexercise stress testing techniques in older patients.

DATA SYNTHESIS: Available data from relevant articles were summarized and the merits and limitations of the available techniques discussed.

CONCLUSIONS: Numerous studies over the past 2 decades support the usefulness of the exercise ECG and exercise thallium‐201 perfusion scan for detecting CAD in older populations. Although exercise echocardiography generally appears to have diagnostic and prognostic accuracy similar to thallium‐201 imaging, greater technical difficulty with this technique is frequently encountered in older patients. Non‐exercise forms of stress testing, particularly those employing pharmacologic agents such as dipyridamole, adenosine, or dobutamine, combined with either thallium‐201 scintigraphy or echocardiography, allow accurate CAD diagnostic and prognostic assessment in even very frail older patients. Additional studies are needed to compare the accuracy and cost‐benefit ratio of the many stress testing modalities now available for older patients.
Higher Respiratory Infection Rates on an Alzheimer's Special Care Unit and Successful Intervention
Authors: MD Thomas T. Perls , Herget Mary
Published: April 2015

OBJECTIVE: To determine the rates of various types of infections on an Alzheimer's special care unit (ASCU) compared with the rates found on traditional nursing home units. Because patients on the ASCUs are allowed to wander throughout the unit and typically come into contact with each other more frequently, we hypothesized that the rate of communicable infections such as upper respiratory infections are significantly higher than on other units where patients are more easily isolated when sick.

METHODS: A 4‐year retrospective case control study, 1990–1993.

SETTING: A metropolitan long‐term care skilled nursing facility. Three floors are traditional nursing care units (123 beds), and one floor is the ASCU (41 beds).

PRIMARY OUTCOME: Annual nosocomial infection rates per 10,000 patient days were measured for six types of infection during the 1990–1993 study period. Data were segregated by location of infection, either the traditional nursing units or the ASCU. In 1992, patients on the Alzheimer's unit were placed in smaller activity groups, and an education program for the control of infectious agents was provided to the unit's staff.

RESULTS: The relative order of prevalence for the different infection types remained constant during the 4 years. The most common type of infection for all 4 years of the study period was urinary tract infection (UTI), followed by upper respiratory infection (URI), Lower respiratory tract infection (LRI), cutaneous infection, gastrointestinal (GI) infection, and eye infection. Of these various infections, only URI rates remained consistently higher on the ASCU versus the traditional nursing unit over the 4‐year study period (in years 1990, 1991, and 1993; these differences were statistically significant, P < .05). In 1992, the year in which nursing interventions to curb the relatively high rates of URI on the ASCU took place, the rates of URI on the two unit types were not statistically different.

CONCLUSIONS: This study suggests that an inherent risk of ASCUs is an increased exposure to highly contagious infections such as upper respiratory infections. An intervention program effective in decreasing this risk to the level of traditional nursing units is proposed. A prospective study is needed to confirm these findings.
Physician‐Reported Determinants of Screening Mammography in Older Women: The Impact of Physician and Practice Characteristics
Authors: Roetzheim Richard G. , Fox Sarah A. , Leake Barbara
Published: April 2015

OBJECTIVE: Despite having markedly higher breast cancer risk, compliance of older women with screening mammography has been poor. This study was undertaken to determine which physician and patient practice characteristics were associated with high self‐reported mammography referral rates for older women.

METHODS: Primary care physicians (n = 129) from three socioeconomically diverse communities in Los Angeles were surveyed. Agreement with annual screening and self‐reported referral rates were assessed for two groups of women, those 65 to 74 years of age and those 75 years and older. Screening outcomes were compared with physician and patient practice characteristics using bivariate and multivariate techniques.

RESULTS: Although 73% of physicians agreed with annual screening of women aged 65 to 74 years, only 24% of physicians reported actually screening most women seen in this age group. Similarly, 57% of physicians agreed that women age 75 years and older should be screened annually, but only 21% reported recommending mammograms for most women seen in this age group. In multivariate analysis, white physicians (adjusted OR = 9.1), younger physicians (adjusted OR = 3.85), and those who used the American Cancer Society's low cost mammography projects (adjusted OR = 5.01) were more likely to report screening the majority of women seen.

DISCUSSION: This study suggests that although physicians' intentions to screen older women may be relatively high, a gap exists between intentions and what is reported to be accomplished in practice. Race/ethnicity and physician specialty were the two strongest predictors of high self‐reported referral rates, suggesting that targeted interventions may be useful.
Bone Density, Vitamin D Nutrition, and Parathyroid Hormone Levels in Women with Dementia
Authors: Kipen Eva , Helme Robert D. , Wark John D. , Flicker Leon
Published: April 2015

OBJECTIVE: To determine whether patients with dementia have reduced bone mass, altered vitamin D, or parathyroid hormone status.

DESIGN: Survey.

SETTING: University hospital outpatient department.

PARTICIPANTS: Twenty women with DSM‐III‐R mild dementia living in the community were compared with 40 cognitively normal community‐dwelling women, matched for age, who had been recruited as part of studies in elderly twins.

MEASUREMENTS: Bone density at the lumbar spine and neck of femur by dual‐energy X‐ray absorptiometry, intact serum PTH, and 25‐hydroxyvitamin D levels.

MAIN RESULTS: There was no significant difference in bone density between the subjects with mild dementia and the age‐ and sex‐matched controls. The intact PTH (mean ± SD) in the demented subjects was 4.9 ± 2.1 pmol/L compared with 2.9 ± 1.7 pmol/L in the twin controls (P < .01). The mean 25‐hydroxyvitamin D in the demented subjects was 61 ± 33 nmol/L, whereas it was 90 ± 38 nmol/L in the twin controls (P < .01).

CONCLUSIONS: We conclude that there were no significant differences in the bone density of community‐dwelling women with mild dementia compared with normals. However, there were significant differences in parathyroid hormone and vitamin D levels between the two groups, suggesting that there is a high prevalence of subclinical hypovitaminosis D in demented women in the community.
Predictors of 2‐Year Mortality Among Older Male Veterans on a Geriatric Rehabilitation Unit
Authors: McMurtry Cynthia T. , Rosenthal Amy
Published: April 2015

OBJECTIVE: To determine if nutritional parameters and discharge setting are associated with mortality in older male veterans on a Geriatric rehabilitation unit (GRU).

DESIGN: Two‐year follow‐up of sequential admissions to the GRU who had laboratory studies completed on admission to the acute hospital and on transfer to and discharge from the GRU.

SETTING: University‐affiliated VA medical center.

PATIENTS: Eighty‐three consecutive older male veterans admitted to the GRU.

MEASUREMENT: Mortality during a period of 2 years post‐discharge.

MAIN RESULTS: In a univariate analysis, predictors of mortality were serum albumin level ≤ 3.5g/dL on admission to the GRU (P = .01), moderate or severe Nutritional Status Score (P = .03), discharge to a place other than home (P = .01), and use of antibiotics while on the GRU (P = .05). Discharge albumin remained the single significant predictor of mortality in a multivariate analysis (P = .005).

CONCLUSIONS: Serum albumin is the strongest predictor of 2‐year post‐hospitalization mortality of older patients cared for on a GRU. Other predictors were presence of infection, Nutritional Status Score of moderate or severe compromise, and discharge to a place other than home.
Evaluation of Outpatient Geriatric Assessment: A Randomized Multi‐site Trial
Authors: Silverman Myrna , Musa Donald , Martin David C. , Lave Judith R. , Adams Janet , Ricci Edmund M.
Published: April 2015

OBJECTIVE: To evaluate the process and outcome of outpatient consultative geriatric assessment compared with traditional community care.

DESIGN: Randomized, controlled clinical trial, with 12‐month follow‐up.

SETTING: Four hospital‐based ambulatory geriatric assessment clinics and community physicians' offices.

PARTICIPANTS: 442 recruited older adults with a health problem or recent change in health status.

INTERVENTION: Outpatient consultative geriatric assessment or usual physician assessment.

MAIN OUTCOME MEASURES: Identification of health problems, mortality, nursing home admissions, health status, health services utilization, satisfaction with care, and caregiver well‐being.

RESULTS: Geriatric assessment, in comparison with usual community care, resulted in the identification of a significantly greater number of patients with cognitive impairment (P < .0001), depression (P = .0004) and incontinence (P < .0001). The group receiving a geriatric assessment had greater improvement in anxiety levels at 1 year (P = .036). Caregivers of participants in the geriatric assessment group had less caregiver stress at 1 year (P = .002). No outcome differences in mortality, nursing home admissions, cognitive health, functional health, or health services utilization were observed. Some evidence of greater patient satisfaction with respect to qualities of the physician was found for the geriatric assessment group.

CONCLUSIONS: Consultative outpatient geriatric assessment led to significantly improved diagnosis of the common health problems of cognitive impairment, depression, and incontinence, to psychological and emotional benefits for patients, and to reduced levels of caregiver stress. Even with limited follow‐up care and control of treatment, outpatient geriatric assessment has potential for significant positive effects
Predictors of Hospital Mortality in Older Patients with Subdural Hematoma
Authors: Rozzelle Curtis J. , Wofford James L. , Branch Charles L.
Published: April 2015

Predictors of Hospital Mortality in Older Patients with Subdural Hematoma

OBJECTIVE: To identify presenting characteristics of older patients with subdural hematoma who are unlikely to survive hospitalization.

DESIGN: A retrospective cohort.

PATIENTS: All patients ≥ 65 years of age hospitalized at a tertiary care center from 1985–1990 with the primary diagnosis of subdural hematoma.

MEASUREMENTS: Chart review was performed to characterize presenting clinical characteristics, hospital course, and outcome at the time of hospital discharge.

MAIN RESULTS: Of the 157 eligible patients, 42% (66/157) were ≥80 years of age. Although 30% of patients had no recorded trauma, 54% experienced a fall before hospitalization. Twenty‐six percent (47/157) of patients had been on antithrombotic therapy (14 on coumadin, two on heparin, 31 on antiplatelet agents, one on both coumadin and an antiplatelet agent). Sixty percent of patients had no focal neurologic findings, and the mean Glasgow Coma Score was 12.3 (±3.6). The hematoma was considered chronic in 49% (77/157) of cases, based on time from antecedent trauma or on neuroimaging criteria. Midline shift by neuroimaging was present in 69%.

Overall hospital mortality was 31% (48/157). Using logistic regression to control for other factors, level of consciousness (Glasgow Coma Score ≤7) (OR = 10.4), age ≥ 80 (OR = 3.7), duration of hematoma considered acute (OR = 2.7), and craniotomy (OR = 2.6) were significantly associated with hospital mortality. Presence of focal symptoms, previous antithrombotic medication use, nature of trauma, comorbidity score, and presence of midline shift were not associated with hospital mortality.

CONCLUSIONS: Among older patients with subdural hematoma, level of consciousness, extreme old age, duration of the hematoma, and nature of the intervention were significantly associated with hospital mortality. These factors should help physicians in clinical decision making and formulation of advance directives for geriatric patients with subdural hematoma. J Am Geriatr Soc 43: 240–244, 1995.
Effect of Psyllium on Absorption of Co‐ingested Calcium
Authors: Heaney Robert P. , Weaver Connie M.
Published: April 2015

Effect of Psyllium on Absorption of Co‐ingested Calcium

OBJECTIVE: To determine whether psyllium fiber (in the form of Metamucil®) interferes with absorption of calcium ingested at the same meal.

DESIGN: Three‐way, randomized, cross‐over study in 15 healthy postmenopausal women, with calcium‐fortified orange juice as the calcium source in all three meals. The test load of calcium was 219 mg (∼5.5 mmol). One test meal contained Metamucil, providing 3.4 g psyllium fiber; one had an equivalent amount of neutral cellulose; the third had no added fiber.

METHODS: The calcium‐fortified orange juice was extrinsically labeled with 45Ca; calcium absorption fraction was calculated from the specific radioactivity of serum calcium at 5 hours after tracer ingestion.

RESULTS: Fractional absorption of calcium from orange juice without added fiber averaged 0.341 ± 0.059; in the presence of psyllium fiber, 0.317 ± 0.067; and in the presence of neutral fiber, 0.354 ± 0.083. While the absorption with cellulose was slightly higher than in the absence of fiber, and the absorption with psyllium was slightly lower, neither difference was statistically significant. However, the difference between added psyllium and cellulose was statistically significant (P < .05).

CONCLUSION: Psyllium in the form of Metamucil makes little practical difference to availability of co‐ingested calcium when ingested at typical therapeutic doses. J Am Geriatr Soc 43: 261–263, 1995.
A Randomized Comparison of Intravenous Amrinone Versus Dobutamine in Older Patients with Decompensated Congestive Heart Failure
Authors: Rich Michael W. , Woods William L. , Davila‐Roman Victor G. , Morello Patric J. , Kurz Howard , Barbarash Rick , Spinner Lisa , Sperry Jane , Beckham Valerie , Coulter Lynn , Brown Peggy
Published: April 2015

A Randomized Comparison of Intravenous Amrinone Versus Dobutamine in Older Patients with Decompensated Congestive Heart Failure

OBJECTIVE: To compare the hemodynamic effects of amrinone and dobutamine in patients 75 years of age or older who have severe congestive heart failure requiring invasive hemodynamic monitoring and inotropic support.

DESIGN: Prospective, randomized, double‐blind clinical trial.

SETTING: Coronary care unit of a university teaching hospital.

PARTICIPANTS: Fourteen patients ≥75 years of age (mean 80.3 ± 5.7 years) with refractory New York Heart Association class IV congestive heart failure. All patients had a cardiac index <2.5 L/min/M2 (mean 1.8 ± 0.3 L/min/M2), pulmonary capillary wedge pressure ≥18 mm Hg (mean 26 ± 10 mm Hg), and left ventricular ejection fraction <40% (mean 26 ± 10%).

INTERVENTION: Patients were randomly assigned to treatment with 2‐hour infusions of amrinone (n = 7) or dobutamine (n = 7) at fixed dosages of 5 and 10 μg/kg/min.

MEASUREMENTS: Complete hemodynamic data were obtained at baseline and after each 2‐hour medication infusion. Transthoracic two‐dimensional echocardiography was performed at baseline and after the 10 μg/kg/min medication dose. The primary analysis compared the effects of the two drugs on cardiac index and stroke volume index at each of the two dosages.

RESULTS: Both amrinone and dobutamine had salutary hemodynamic effects, as indicated by improvements in cardiac index, stroke volume index, pulmonary capillary wedge pressure, and systemic vascular resistance (all P < .05 except effect of amrinone on stroke index and wedge pressure). Although the overall hemodynamic effects of amrinone and dobutamine were similar, stroke volume index was higher with dobutamine at the 10 μg/kg/min dose (35 ± 7 ml/M2 vs 26 ± 6 mL/M2; P = .045). Two dobutamine patients were withdrawn from the study after the 5 μg/kg/min dose due to adverse effects (tachycardia, increased ventricular ectopy). One additional patient in each group was noted to have ventricular arrhythmias not requiring termination of the protocol.

CONCLUSIONS: Both amrinone and dobutamine are efficacious in improving hemodynamics in older patients with severe congestive heart failure caused by left ventricular contractile dysfunction. Despite the effect of aging on β‐ad‐renergic responsiveness, dobutamine is at least as effective as amrinone but may be associated with a higher incidence of arrhythmic side effects. J Am Geriatr Soc 43: 271–274, 1995.
Urine Specimen Collection from Incontinent Female Nursing Home Residents
Authors: Ouslander Joseph G. , Schapira Moises , Schnelle John F.
Published: April 2015

Urine Specimen Collection from Incontinent Female Nursing Home Residents

OBJECTIVE: To determine if a clean catch technique can accurately diagnose bacteriuria among incontinent female nursing home residents.

DESIGN: Cultures and dipstick screening test results from paired urine specimens, one collected by a clean catch technique and the other collected by sterile in‐and‐out catheterization, were compared.

PARTICIPANTS: A total of 101 incontinent female nursing home residents who were being assessed for participation in a larger clinical intervention trial for incontinence.

MEASUREMENTS: Each urine was tested by a dipstick method for leukocyte esterase and nitrite and sent to a bioclinical laboratory for quantitative culture.

RESULTS: Positive and negative culture results matched in 92 of the 101 paired specimens. Using the catheter specimen as a gold standard, the clean catch had a sensitivity of 90%, specificity of 92%, positive predictive value of 81%, and a negative predictive value of 95%. In a population with symptoms suggestive of infection, among whom the prevalence of bacteriuria would likely be higher than in the asymptomatic residents we studied (e.g., 60% vs 30%), the positive predictive value would increase to 95%, but the negative predictive value would decrease to 86%. The concordance of the results of the urine screening tests was not as good, except for the detection of a positive leukocyte esterase test and a negative nitrite test.

CONCLUSION: Incontinent female nursing home residents do not necessarily have to be catheterized in order to obtain an accurate quantitative urine culture. Our results using a careful clean catch technique are comparable to those previously reported using urine obtained from a urine‐soiled diaper as well as those using a condom catheter technique in men. J Am Geriatr Soc 43: 279–281, 1995.
Breast Lump in an 85‐Year‐Old Woman with Dementia: A Decision Analysis
Authors: Robinson Bruce E. , Balducci Lodovico
Published: April 2015

Breast Lump in an 85‐Year‐Old Woman with Dementia: A Decision Analysis
Urinary Incontinence and Dementia: The Perils of Guilt by Association
Authors: DuBeau Catherine E. , Resnick Neil M.
Published: April 2015

Urinary Incontinence and Dementia: The Perils of Guilt by Association
Two‐Year Trends in Cardiorespiratory Function Among Older Tai Chi Chuan Practitioners and Sedentary Subjects
Authors: Lai Jin‐Shin , Lan Ching , Wong May‐Kuen , Teng Shi‐Hai
Published: April 2015

OBJECTIVE: To evaluate the training effects of Chinese shadow boxing, Tai Chi Chuan (TCC), on the maintenance of cardiorespiratory function in older individuals.

DESIGN: Prospective study of a cohort of TCC practitioners and a group of sedentary controls examined 2 years after initial examination.

SETTING: Research project at a hospital‐based exercise physiology laboratory.

PARTICIPANTS: Eighty‐four community‐dwelling older adults (mean age: 64 ± 9 years) with no significant cardiovascular, pulmonary, and musculoskeletal disease completed this study. The TCC group, 23 male and 22 female subjects, had been practicing TCC regularly for 6.7 ± 3.3 years. The control group included 21 male and 18 female sedentary subjects with age and body size matched to the TCC group.

INTERVENTION: During the period of the study, the TCC practitioners practiced TCC 5.0 ± 1.1 times per week. Each session included 20 minutes of warm up, 24 minutes of TCC training, and 10 minutes of cool down. The baseline cardiorespiratory function was recorded in the initial exercise test. The same measurements were repeated 2 years later to determine the rate of decline of cardiorespiratory function. Furthermore, heart rates (HR) were monitored in 18 men and 16 women during the performance of TCC to determine the exercise intensity of TCC.

MAIN OUTCOME MEASURE: The study measured 2‐year trends of cardiorespiratory function in both groups.

RESULTS: In the TCC group, the males showed a 2.8% decrease in maximal oxygen uptake (O2max) from 31.6 ± 7.6 mL × kg.−1 × min−1 to 30.7±7.1 mL × kg.−1 × min−1; the females showed a 2.9% decrease in O2max from 20.7±2.3 mL × kg.−1 × min−1 to 20.1±2.5 mL × kg.−1 × min.−1 In contrast, the male control group showed a 6.6% decrease in O2max from 24.4±4.4 mL × kg1 × min1 to 22.8 ± 4.4 mL × kg1 × min1; the females showed a 7.4% decrease in O2max from 16.2±2.3 mL × kg.−1 × min−1 to 15.0 ±2.7 mL × kg.−1 × min.−1 At the ventilatory threshold (Vet), the sedentary group also showed a significant decrease in O2. During the steady‐state performance of TCC, subjects' mean HR was approximately the HR at the Vet (53–57% of HRmax reserve).

CONCLUSION: The data substantiate that practicing Tai Chi Chuan regularly may delay the decline of cardiorespiratory function in older individuals. In addition, TCC may be prescribed as a suitable aerobic exercise for older adults.
Association of Silent Myocardial Ischemia with New Atherothrombotic Brain Infarction in Older Patients With Extracranial Internal or Common Carotid Arterial Disease with and without Previous Atherothrombotic Brain Infarction
Authors: Aronow Wilbert S. , Ahn Chul , Mercando Anthony D. , Epstein Stanley , Gutstein Hal , Schoenfeld Myron R.
Published: April 2015

OBJECTIVE: To correlate silent myocardial ischemia with the incidence of new atherothrombotic brain infarction (ABI) in older patients with 40 to 100% extracranial carotid arterial disease (ECAD) with and without prior ABI.

DESIGN: In a prospective study of 208 older patients with 40 to 100% ECAD diagnosed by carotid duplex ultrasonogra‐phy, 24‐hour ambulatory electrocardiograms were obtained to detect silent myocardial ischemia. At 42‐month mean follow‐up, silent myocardial ischemia was correlated with the incidence of new ABI in patients with and without prior ABI.

SETTING: A large long‐term health care facility where 208 older patients with 40 to 100% ECAD and technically adequate 24‐hour ambulatory electrocardiograms for detecting silent myocardial ischemia were studied.

PATIENTS: The 208 patients included 68 men and 140 women, mean age 81 ± 8 years (range 60 to 100). One‐hundred three (50%) of the patients had prior ABI.

MEASUREMENTS AND MAIN RESULTS: Sixy‐nine (33%) of the 208 patients had silent myocardial ischemia. Mean follow‐up was 42 ± 25 months (range 3 to 101 months). At follow‐up, the incidence of new ABI was 64% in patients with prior ABI and 32% in patients with no prior ABI (P < .0001). At follow‐up, the incidence of new ABI was 65% in patients with silent ischemia and 40% in patients with no silent ischemia (P = .0005). The multivariate Cox regression model showed that patients with prior ABI have a 2.5 times higher chance of developing new ABI than those without prior ABI after controlling other prognostic variables. Patients with silent ischemia have a 2.1 times higher probability of developing new ABI than those without silent ischemia after controlling other prognostic variables.

CONCLUSIONS: Prior ABI and silent ischemia are independent risk factors for the development of new ABI in patients with 40 to 100% ECAD. This probably reflects that silent ischemia is a marker for more advanced or more significant atherosclerotic disease rather than a causal factor for ABI.
Weight Loss Precedes Dementia in Community‐Dwelling Older Adults
Authors: Barrett‐Connor Elizabeth , Edelstein Sharon L. , Corey‐Bloom Jody , Wiederholt Wigbert C.
Published: April 2015

OBJECTIVE: To determine whether the weight loss associated with Alzheimer's disease precedes or follows the dementia.

DESIGN: Older community‐dwelling men (n = 134) and women (n = 165) were followed for 20 years before they were diagnosed as cognitively intact or demented. A repeated measures analysis was used to compare weight change in those who developed Alzheimer's Disease (AD) with those who remained cognitively intact.

MEASUREMENTS: Weight was measured at three clinic visits between 1972‐74, 1984‐87, and 1990‐93. Participants were classified as having probable or possible AD or being cognitively intact at the 1990‐93 evaluation. Diagnoses were made by two neurologists and a neuropsychometrist, based on neuropsychological tests and physical examination, using NINCDS‐ADRDA criteria.

RESULTS: There were 36 men and 24 women diagnosed with probable or possible AD; they were considered to have mild to moderate dementia based on their test scores and community‐dwelling status. Those who developed dementia were older than those diagnosed as cognitively intact. In age‐adjusted analyses, both men and women who were later diagnosed with AD had a significant decrease in weight after the baseline visit (P < .001 and P < .003, respectively), but there was no significant weight loss in the men and women who remained cognitively intact. These differences were not explained by lifestyle, depression, or other illness.

CONCLUSION: Weight loss precedes mild to moderate dementia; early weight loss is, therefore, unlikely to be a consequence of AD patients being unable or unwilling to eat.
Inner‐City Older Blacks Have High Levels of Functional Disability
Authors: Miller Douglas K. , Carter Myrtle E. , Miller J. Philip , Fornoff Jane E. , Bentley Judy A. , Boyd Sheila D. , Rogers Jason H. , Cox Matthew N. , Morley John E. , Lui Li‐Yung Lily , Coe Rodney M.
Published: April 2015

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner‐city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program.

DESIGN: Cross‐sectional descriptive study.

SETTING: Community‐based samples.

PARTICIPANTS: A population‐based sample of 416 older adults living in a 3.5‐square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois.

MEASUREMENTS: Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups.

RESULTS: The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age‐gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one‐half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one‐leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large.

CONCLUSIONS: The special attributes of inner‐city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans.
Impact of Physical Illness on Quality of Life and Antidepressant Response in Geriatric Major Depression
Authors: Small Gary W. , Birkett Martin , Meyers Barnett S. , Koran Lorrin M. , Bystritsky Alexander , Nemeroff Charles B. ,   Fluoxetine Collaborative Study Group
Published: April 2015

OBJECTIVE: Because physical illness may influence quality of life, we assessed its impact on functional status and treatment outcome in older depressed patients who participated in a clinical trial, which showed a significantly higher remission rate for fluoxetine over placebo (31.6% vs 18.6%, P < .001).

DESIGN: Six‐week, randomized, double‐blind, placebo‐controlled trial of fluoxetine, 20 mg daily.

SETTING: Multiple clinical sites, both university and private.

PARTICIPANTS: Outpatients (N = 671) were ≥ 60 years (mean ± SD = 67.7 ± 5.7), met DSM‐III‐R criteria for unipolar major depression and had baseline scores ≥ 16 on the Hamilton Depression Rating Scale.

MEASUREMENTS: The 36‐item short‐form health survey (SF‐36) was used to measure baseline and posttreatment functional health and well‐being. Physical illness was rated by number of current chronic or historical illnesses. Change from baseline to endpoint in the Hamilton Depression Rating Scale total score was used to measure depression outcome.

MAIN RESULTS: Most patients reported physical illness: 83% had one or more chronic illness, and 89% had one or more historical illness. Greater numbers of baseline chronic illness indicated worse physical functioning, general health perceptions, and vitality and greater bodily pain and role limitation from physical problems. Historical physical illness was associated with worse physical functioning, vitality, general health perceptions, social functioning, and mental health. Although the number of chronic illnesses did not influence treatment response, historical physical illness was associated with greater fluoxetine response and lower placebo response.

CONCLUSIONS: These findings suggest that both current and previous physical illness are associated with lower quality of life in geriatric depression and that depressed older patients with chronic physical illness respond to antidepressants as well as those without such illness. Recovery from previous physical illness should be explored as a potential predictor of antidepressant treatment outcome.
Recent Advances in the Genetics of Alzheimer's Disease and Vascular Dementia with an Emphasis on Gene‐Environment Interactions
Authors: Plassman Brenda L. , Breitner John C.S.
Published: April 2015

OBJECTIVE: To review recent findings in the genetics of Alzheimer's disease (AD) and vascular dementia (VaD) with particular emphasis on gene‐environment interactions.

DESIGN: A survey and critique of recent literature on the genetic etiology of AD and VaD.

CONCLUSIONS: Recent research has identified several genes associated with AD, including loci on chromosome 1, 14, 19, and 21. Two of these loci, encoding the β‐amyloid precursor protein and apolipoprotein E, have gene products that are well characterized and of evident significance in the pathogenesis of AD. The four genes together probably account for little more than 50% of all cases of AD, but other undiscovered loci are likely. Interaction of genetic effects with environmental influences may affect both onset and expression of AD. By contrast, only a small minority of VaD cases can be attributed to a pure genetic etiology. The majority of VaD is caused by both genetic and environmental factors. Many of the environmental antecedents also have genetic determinants (e.g., smoking). Knowledge of the gene‐environment interactions for both AD and VaD will facilitate identification of early preclinical symptoms of disease, a stage of the disease process during which treatment may be most beneficial.
Physical Restraints in Geriatric Care in Sweden: Prevalence and Patient Characteristics
Authors: Karlsson Stig , Bucht Gösta , Eriksson Sture , Sandman P.O.
Published: April 2015

OBJECTIVE: Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints.

DESIGN: A point prevalence study of patients cared for in various types of geriatric settings.

SETTING: Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden.

PARTICIPANTS: A total of 1325 patients, mean age 82 years, 64% of whom were women.

MEASUREMENTS: The Multi‐Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument.

RESULTS: Twenty‐four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety‐four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances.

CONCLUSIONS: This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints. J Am Geriatr Soc 44:1348–1354, 1996.
Association Between Alzheimer's Disease and Bound Autochthonous IgM on T Cells
Authors: Kell Sherron H. , Allman Richard M. , Harrell Lindy E. , Liu Tiepu , Solvason Nanette
Published: April 2015

OBJECTIVE: To determine whether there is an association between the number of peripheral T cells binding IgM per total T cell population (%IgM + T cells) and dementia.

DESIGN: Cross‐sectional study.

SETTING: Two inpatient and two outpatient sites at a university medical center.

PARTICIPANTS: Fifty‐three adults.

MEASUREMENTS: Peripheral blood was collected from each individual, and the %IgM + T cells was determined by flow cytometry. The data obtained by medical record chart review were analyzed to determine whether the %IgM + T cells correlated with cognitive diagnoses, demographic variables, medical diagnoses, or prescribed medications.

RESULTS: The %IgM + T cells was negatively correlated with MMSE scores (r = ‐.33, P = .016). There was a significant difference in the mean %IgM + T cells between Alzheimer's disease (AD) and non‐AD patients (35.6% ± 30.2% vs 14.6% ± 23.9%, P < .001) but no statistically significant association between the mean %IgM + T cells and age, sex, race, prescribed medications (except gastrointestinal (GI) medications), or medical diagnoses (except stroke). After statistically controlling for GI medications and stroke, AD remained independently associated with the %IgM + T cells (P = .008).

CONCLUSIONS: Patients with AD had significantly more of their T cells coated with IgM than did non‐AD patients. J Am Geriatr Soc 44:1362–1365, 1996.
Sedative‐Hypnotic Use and Increased Hospital Stay and Costs in Older People
Authors: Zisselman Marc H. , Rovner Barry W. , Yuen Elaine J. , Louis Daniel Z.
Published: April 2015

OBJECTIVE: To assess the relationship between sedative‐hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital.

DESIGN: Retrospective review of computerized hospital and pharmacy data bases.

SUBJECTS: A total of 856 older consecutive medical and surgical admissions from November 1993 to March 1994.

MEASUREMENTS: Sedative/hypnotic utilization in accord with the Health Care Financing Administration (HCFA) guidelines for S/H use in nursing homes. Jefferson Disease Staging to estimate severity of illness. Hospital records to obtain demographic characteristics, length of stay, and hospital costs.

RESULTS: Patients whose S/H use exceeded HCFA guidelines, compared with those within the guidelines and those receiving no drugs, had longer lengths of stay (21.5 days vs 12.3 days vs 6.7 days, P < .001), increased hospital costs ($29,245 vs $15,219 vs $7,516, P < .001), and greater severity of illness (245.8 vs 189.5 vs 148.5, P < .001). S/H use exceeding and within HCFA guidelines were associated with increased length of stay (both P < .0001) and hospital costs (both P < . 0001).

CONCLUSIONS: Older hospitalized patients receiving S/H have greater severity of illness, longer lengths of stay, and higher hospital costs compared with other patients. S/H use, and, in particular, S/H use exceeding the HCFA guidelines, are associated with increased hospital stay and cost. J Am Geriatr Soc 44:1371–1374, 1996.
Laparoscopic Cholecystectomy in the Geriatric Population
Authors: Golden William E. , Cleves Mario A. , Johnston Judith C.
Published: April 2015

OBJECTIVE: To assess effectiveness and conversion rates of inpatient laparoscopic cholecystectomy in older people living in the community.

SETTING AND SUBJECTS: All acute care hospitals providing cholecystectomy in a single state. Medicare patients who underwent inpatient cholecystectomy in fiscal year 1994 in Arkansas.

METHODS: A random sample comprising 449 of 2182 geriatric patients who underwent inpatient cholecystectomy in fiscal year 1994, stratified by hospital bed size, had charts reviewed for type of cholecystectomy performed, occurrence of conversion from a laparoscopic to an open cholecystectomy, surgical complications, and need for transfusion.

RESULTS: Eighty‐two percent of nonincidental cholecystectomies were initially laparoscopic. Total conversion rate for all inpatient laparoscopic cases was 20%. Forty‐two percent of this group suffered acute cholecystitis, with male patients exhibiting a higher rate of acute cholecystitis than female patients. Conversion rates for elective cholecystectomy for both sexes was between 13 and 14%. Conversion rate to an open procedures was 28% for patients with acute disease, with male patients again having a higher rate than female patients (40% vs 19%, P < .001). Surgical complications and intraoperative transfusions were rare. Conversion rates did not vary between large and small hospitals or among different age groups within the older population.

CONCLUSIONS: Inpatient laparoscopic cholecystectomy is common in older people both for acute and chronic gallbladder conditions. Conversion rates ranged from 13% for elective cholecystectomy to 28% for acute disease. These rates are higher than published literature, which focuses on younger populations undergoing elective procedures. Audit committees need to be aware of this higher conversion rate in older people when assessing surgical proficiency. J Am Geriatr Soc 44:1380–1383, 1996.
Percutaneous Transhepatic Cholangioscopy for Diagnosis and Therapy of Biliary Diseases in Older Patients
Authors: Van Steenbergen W. , Van Aken L. , Van Beckevoort D. , Stockx L. , Fevery J.
Published: April 2015

OBJECTIVE: To describe the use of percutaneous cholangioscopy in older patients with complex diagnostic and therapeutic bile duct disorders.

DESIGN: Case series.

SETTING: Tertiary care center.

PATIENTS: Fourteen patients with a mean age of 74 (SD ± 9) years (range, 60–91 years) underwent percutaneous cholangioscopy. Eleven of these patients presented with endoscopically irretrievable bile duct stones. These 11 patients represent 4.1% of a group of 342 patients (age ≥ 60 years) with a mean age of 76 (SD ± 9) years who were treated endoscopically because of common bile duct stones between January 1993 and January 1996. Three patients presented with obstructive jaundice resulting from a bile duct stricture. In these three patients, brushing cytology of the strictures had proved to be negative.

INTERVENTION: After creation and dilatation of a percutaneous transhepatic tract, cholangioscopy was carried out with a flexible cholangioscope. All procedures were performed under mild sedation and analgesia. Stone disintegration was obtained by electrohydraulic lithotripsy, applied through the working channel of the cholangioscope.

RESULTS: Complete stone disintegration and removal was obtained after one to three cholangioscopic sessions in all 11 patients with stones. A histological diagnosis of malignancy was obtained in the three patients with biliary strictures.

CONCLUSIONS: Percutaneous cholangioscopy is a well tolerated and promising technique in our diagnostic and therapeutic strategy in older patients with complex biliary disorders not responsive to peroral endoscopic diagnosis or treatment. J Am Geriatr Soc 44:1384–1387, 1996.
Prevalence of Atrial Fibrillation and Association of Atrial Fibrillation with Prior and New Thromboembolic Stroke in Older Patients
Authors: Aronow Wilbert S. , Ahn Chul , Gutstein Hal
Published: April 2015

OBJECTIVE: To correlate atrial fibrillation with the incidence of new thromboembolic (TE) stroke in older patients with and without prior TE stroke.

DESIGN: In a prospective study of 2101 older patients, electrocardiograms showed that atrial fibrillation was present in 283 patients (13%). At 42‐month mean follow‐up, atrial fibrillation was associated with the incidence of new TE stroke in patients with and without prior TE stroke.

SETTING: A large long‐term health care facility where 2101 older patients were studied.

PATIENTS: The 2101 patients included 1451 women and 650 men, mean age 81 ± 8 years (range 60 to 103).

MEASUREMENTS AND MAIN RESULTS: Atrial fibrillation was present in 283 of 2101 patients (13%). The mean age was 84 ± 7 years in patients with atrial fibrillation and 81 ± 8 years in patients with sinus rhythm (P = .0001). The prevalence of atrial fibrillation was 5% in patients aged 60 to 70 years, 14% in patients aged 71 to 80 years, 13% in patients aged 81 to 90 years, and 22% in patients aged 91 to 103 years (P < .0001). Mean follow‐up was 31 ± 18 months in patients with atrial fibrillation and 44 ± 27 months in patients with sinus rhythm (P = .0001). Previous TE stroke occurred in 123 of 283 patients (43%) with atrial fibrillation and in 431 of 1818 patients (24%) with sinus rhythm (P < .0001). New TE stroke occurred in 131 of 283 patients (46%) with atrial fibrillation and in 303 of 1818 patients (17%) with sinus rhythm (P < .0001). The log‐rank test showed that patients with atrial fibrillation had a significantly higher probability of developing new TE stroke than those with sinus rhythm (P < .0001). The multivariate Cox regression model showed that independent risk factors for new TE stroke were male sex (relative risk = 1.3), prior TE stroke (relative risk = 3.1), and atrial fibrillation (relative risk = 3.3).

CONCLUSIONS: Atrial fibrillation, prior TE stroke, and male sex are independent risk factors for the development of new TE stroke in older patients.
Community‐Acquired Pneumonia in Older Patients
Authors: Janssens Jean‐Paul , Gauthey Laurent , Herrmann François , Tkatch Lubos , Michel Jean Pierre
Published: April 2015

OBJECTIVE: To document the prevalence of Legionella sp., Mycoplasma Pneumoniae and Influenza A and B in older patients hospitalized for community‐acquired pneumonia (CAP) or nursing‐home acquired pneumonia (NHAP) and to determine risk factors associated with fatal outcome or prolonged hospital stay.

DESIGN: Prospective clinical and serological study.

PATIENTS: All patients with CAP or NHAP — confirmed by chest roentgenogram — admitted to a 320‐bed acute care geriatric university hospital from May 1, 1988, to August 31, 1989, were included. Serological testing was performed upon admission and after 2 and 4 weeks. Relevant data concerning medical history, clinical examination, and laboratory data were recorded upon admission. Ninety‐nine patients (age: 85 ± 6.3 years, 36 male, 63 female) met inclusion criteria; 20 came from nursing homes, 79 from their homes in the community.

MAIN RESULTS: Fourteen patients died during the month after admission. An etiological diagnosis could be established in 22 patients. No cases of Legionella pneumonia and one case of M. pneumoniae were detected. Seven patients had evidence of Influenza pneumonia. Nonsurvivors were more likely to have been admitted from a nursing home and to have a temperature less than 37.5°C and elevated urea nitrogen (BUN). Cyanosis, involvement of upper lobes, elevated white blood cell counts, and higher percentage of band forms were associated statistically with longer treatment.

CONCLUSIONS: This study confirms the low prevalence of Legionella sp. and M. Pneumoniae infection in CAP and NHAP in this age group. Risk factors as to outcome and length of treatment may be used as pointers to identify high risk patients, with special attention to patients coming from nursing homes, and patients with high BUN.