bluuebunny/crossref_metadata_2025 huggingface dataset:
Hyposomatomedinemia in Men with Post‐Poliomyelitis Syndrome
Authors: Shetty Kaup R. , Mattson Dale E. , Rudman Inge W. , Rudman Daniel
Published: April 2015

The age of onset of the post‐poliomyelitis syndrome (PPS) coincides with the tendency for declining activity of the growth hormone/somatomedin C (GH/SmC) axis. The normal plasma SmC range in men before the age of 40 is 0.50 to 1.50 units/mL. After age 40 about 30% of men have a plasma SmC level below 0.35 units/mL, signifying no detectable spontaneous GH secretory pulses. Because the GH/SmC axis stimulates DNA, RNA, and protein synthesis in muscle cells and increases their size and number, a deficiency of the GH/SmC axis could theoretically contribute as a secondary factor to the occurrence or severity of the PPS. Accordingly, the authors measured the plasma SmC level in 10 men with PPS, ages 35 to 63, and in 94 healthy men of similar age. In the PPS men, 100% of the values were ≤0.40 units/mL, and 90% were ≤0.35 units/mL The corresponding proportions in the healthy men were 40% and 27%. Analysis of variance including age as a factor showed SmC to be significantly lower in the PPS men than in the healthy men. In an additional comparison, totally immobile nursing home men did not have lowered SmC values. In fact their SmC values were slightly higher than those of healthy men of similar age. The data revealed a new biochemical feature of PPS, hyposomatomedinemia, which might play a contributory role in the pathogenesis of the syndrome.
The Metabolic Effects of Calcium Supplementation in the Elderly
Authors: Kochersberger Gary , Westlund Ronald , Lyles Kenneth W.
Published: April 2015

Because the value of calcium supplementation in age‐related bone loss is controversial, we conducted a study to examine the effects of six months of calcium supplementation on parathyroid hormone (PTH) and other indices of bone metabolism. Calcium carbonate (1.2 grams elemental calcium/day) or placebo was administered for 6 months to a group of 42 healthy, ambulatory men and women with a mean age of 71. Fasting blood samples and 2‐hour urine collections were performed at baseline and at 1 and 6 months. The decline in serum PTH levels from baseline in the calcium‐supplemented group was significant in comparison with the placebo group changes (for the calcium group: 40.9 pg/mL at baseline to 34.0 pg/mL at 1 month and 33.2 at 6 months). This drop in PTH was associated with a decline in 1,25 OH‐Vitamin D levels from a mean of 38.3 pg/mL to 30.4 pg/ml at 1 month and 31.9 at 6 months. During calcium supplementation, no changes were observed in serum bone Gla protein values. A decline in urinary hydroxyproline excretion was observed at 6 months, but this did not reach significant levels.

The present study demonstrates suppression of PTH levels with calcium supplementation, an effect which lasts at least 6 months. This change was accompanied by a decrease in serum 1,25 OH‐Vitamin D. The lack of significant changes in either serum bone gla protein or urine hydroxyproline excretion fails to support any significant change in bone turnover occurring with this decrease in PTH.
Falls in the Elderly: Reliability of a Classification System
Authors: Lach Helen W. , Reed A. Thomas , Arfken Cynthia L. , Miller J. Philip , Paige Gary D. , Birge Stanley J. , Peck William A.
Published: April 2015

To determine risk factors for falls, previous studies have classified falls according to the contribution of factors both intrinsic and extrinsic to the host. Due partly to the lack of operational definitions and the absence of information on reliability, no consensus on classification has been reached. Consequently, in a 3‐year prospective study of falls occurring in a probability sample of community‐dwelling elderly (n = 1,358), a fall classification system was developed and tested for interrater reliability. The 366 falls in the first year of the study were independently classified by two reviewers on the basis of a narrative description and structured interview. The falls in the four major categories of the classification system included: falls related to extrinsic factors (55%), falls related to intrinsic factors (39%), falls from a non‐bipedal stance (8%) and unclassified falls (7%). The interrater reliability for the four major categories was 89.9% with a kappa of 0.828. The system provides operational definitions for types of falls and a reliable and flexible method for classifying falls in the elderly.
The Prevalence and Nature of Podiatric Problems in Elderly Diabetic Patients
Authors: Evans Scott L. , Nixon Brent P. , Lee Irvin , Yee David , Mooradian Arshag D.
Published: April 2015

To determine if diabetes in the elderly is associated with increased prevalence of podiatric problems, a random sample of diabetic patients (n = 74) was compared to a group of elderly non‐diabetic patients (n = 79). The two groups were comparable in age (range 70–90 years), smoking habits, and consumption of alcohol. The mean duration of diabetes was 14.5 ± 11.7 years (± SD), and mean serum fructosamine level was 3.3 ± 0.66 mmol/L. The number of medical diagnoses and medications used was significantly higher in the diabetic group. Diabetic patients had modestly higher prevalence of neuropathy, vascular disease, kidney disease, and eye complications. The most common podiatric problem in both groups was elongated toenails. The prevalence of podiatric problems such as cellulitis, amputation, tinea pedia, onychomycosis, calluses, bunions, and hammer toe deformity were not increased in diabetic patients. Active foot ulcers were more common in diabetic patients (13/74 vs 5/79, P < 0.05). It is concluded that diabetes in the elderly, unlike in young patients, increases the risk of foot problems only marginally.
Is the Serum Cholesterol‐Coronary Heart Disease Relationship Modified by Activity Level in Older Persons?
Authors: Harris Tamara B. , Makuc Diane M. , Kleinman Joel C. , Gillum Richard F. , Curb J. David , Schatzkin Arthur , Feldman Jacob J.
Published: April 2015

Although coronary heart disease remains a leading cause of death and disability in old age, the relationship of serum cholesterol level to risk of coronary heart disease in old age is controversial. Data for 2,388 white persons aged 65–74 who participated in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow‐up Study (NHEFS) were examined to determine the relationship of serum cholesterol level to coronary heart disease incidence and whether activity level would modify this relationship.

While there was no overall relationship between serum cholesterol level and coronary heart disease risk in either men or women, the relationship between serum cholesterol level and coronary heart disease differed within activity groups. For persons who were more active, serum cholesterol level was associated with a graded increase in risk of coronary heart disease, from 1.3 (95% CI 0.7,2.3) in those with serum cholesterol level of 4.7–5.1 to 1.7 in those with serum cholesterol level of 6.2 mmol/L or more (95% CI 1.0,2.7), when compared with those with serum cholesterol level below 4.7. For the least active persons, all levels of cholesterol were associated with a significant inverse relative risk, including cholesterol of 6.2 mmol/L or more (Relative risk = 0.4 (95% CI 0.2,0.7)).

These data suggest that factors such as activity level may modify the serum cholesterol‐coronary heart disease association in old age. The serum cholesterol‐coronary heart disease association in more active older persons resembles that seen in younger populations, whereas the association in less active persons is that of serum cholesterol level and risk of cancer or death. The modification of the serum cholesterol‐coronary heart disease association by activity level may have implications for appropriate clinical management as well as appropriate design of research studies of this association.
Resident Behavior and Staff Distress in the Nursing Home
Authors: Everitt Daniel E. , Fields David R. , Soumerai Stephen S. , Avorn Jerry
Published: April 2015

Newly enacted Federal regulations have focused increasing attention on the use of psychoactive drugs and on the treatment of disruptive behavior in the nursing home. To study the interaction between resident behavior and staff distress in nursing homes, we measured the frequency of seven types of behavior problems among 346 residents of intermediate care facilities who were receiving some form of psychoactive medication. Nurses were interviewed on two shifts to determine their perception of the frequency and severity of each behavior in each patient as well as the level of distress it caused among caregivers. The most common behavior problems noted were agitation (42%), withdrawal (33%), and noisiness (27%). Only half of the reported instances of behavior disorders were considered distressful by nursing home staff. While physical abuse caused distress 92% of the time and verbal abuse 90% of the time, wandering was seen as distressful to staff only 50% of the time. Nearly a third of “wandering” patients were restrained; they produced less distress than non‐restrained wanderers.

There was substantial disagreement, ranging from 6% to 22% for individual residents, over the presence of distress‐causing behavior, although day and evening nursing shifts rated the frequencies of behavior and the degrees of distress equally on average. Residents with higher cognitive function were less likely to cause distress for all behaviors, except for verbal abuse where the reverse was true. Age and dependency in activities of daily living were not associated with problematic behavior or staff distress. These findings indicate that the existence of “problematic” behaviors in a given resident is often perceived differently by different staff, and its impact on staff also differs widely.
The Effect of Nursing Home Quality on Patient Outcome
Authors: Braun Barbara I.
Published: April 2015

This historical cohort study investigated the relationship between nursing home quality and the group outcomes of mortality, rehospitalization, and discharge. Multiple logistic regression was used to determine if nursing home quality indices increased the prediction of these outcomes when patient severity of illness and case‐mix differences were in the model. Three hundred ninety veterans discharged to 11 nursing homes were followed for 6 months. Nursing home quality was assessed using indices from the Multiphasic Environmental Assessment Procedure and the Rush‐Medicus Methodology for Monitoring Quality of Nursing Care. An increased likelihood of death was associated with the diagnoses of cancer and heart disease and with being rehospitalized. Four nursing home quality indices significantly improved the prediction of mortality (RN hours, nursing process, security, and mean quality). Rehospitalization was associated with the patient factors of heart disease, hypertension, race, and level of care and with size of the nursing home. Discharge from the facility was inversely associated with the diagnosis of cancer and directly related to the index of nursing process. The results support the notion that group outcomes may be related to nursing home quality and suggest the need for further studies to investigate the specific elements of nursing home quality which relate to improved outcome.
A New Behavioral Assessment Scale for Geriatric Out‐ and In‐Patients: the NOSGER (Nurses' Observation Scale for Geriatric Patients)
Authors: Spiegel René , Brunner Christ , Ermini‐Fünfschilling Doris , Monsch Andreas , Notter Marianne , Puxty John , Tremmel Lothar
Published: April 2015

Although a great number of psychometric tests and rating scales for the assessment of psychogeriatric patients is available, there is still an urgent need, in research and practice, for a clinical rating instrument that meets the following main requirements: (1) applicable to institutionalized and community patients and covering a wide range of behavioral pathology; (2) acceptable and easy to use for professionals and lay persons alike; (3) covering a wide range of behavior relevant to daily functioning but independent of sex or social status of the individual assessed. The NOSGER contains 30 items of behavior, each rated on a 5‐point scale according to frequency of occurrence. Item scores are summarized into 6 Dimension scores (memory, instrumental activities of daily life, self‐care, mood, social behavior, and disturbing behavior) which are clinically relevant in dementia, depression, and other psychiatric disorders of old age. Validation studies with a preliminary version of the NOSGER indicated good acceptance of the scale, high inter‐rater and test‐retest reliability, and high correlations of all NOSGER Dimension scores with results of a variety of established assessment instruments. The NOSGER is currently being used in a number of European and North American centers and should turn out to be a useful instrument for longitudinal studies in psychogeriatrics.
Improving Primary Care in Nursing Homes
Authors: Kane Robert L. , Garrard Judith , Buchanan Joan L. , Rosenfeld Alan , Skay Carol , McDermott Susan
Published: April 2015

We conducted a quasi‐experiment to evaluate the impact of a Medicare waiver which allowed the use of nurse practitioners (NPs) and physicians assistants (PAs) to deliver primary care to Massachusetts nursing home patients and removed the limits on the reimbursable numbers of visits per month. A carefully matched set of 1,327 Medicaid patients from 95 non‐participating homes in the same areas of Massachusetts was compared to 1,324 Medicaid demonstration patients from 75 homes. Information came from specially designed record reviews and the Medicaid and Medicare information systems. Separate analyses were done for newly admitted cases and rollovers. Comparisons of quality of care suggested that the medical groups using NPs and PAs provided as good or better care than did the physicians in the control group. There were no differences in functional status changes or in the use of medications. The demonstration patients received more attention, as reflected in more orders written and an average of one additional visit a month. Demonstration patients showed higher scores on three of seven specially designed quality tracers, congestive heart failure and hypertension for both new admissions and rollovers, and new urinary incontinence for new admissions. Rollovers had significantly fewer emergency and total hospital days. A cost analysis suggests that the use of NPs and PAs saves at least as much as it costs and may save additional money with more sustained use.
A Community Study of Vitamin B12 and Folate Levels in the Elderly
Authors: Hanger H. C. , Sainsbury R. , Gilchrist N. L. , Beard M. E. J. , Duncan J. M.
Published: April 2015

Objective: To measure the prevalence of low serum vitamin B12, folate, and red cell folate levels and their relationship with other nutritional indices.

Design: Prospective survey of elderly subjects using radioisotope dilution assays.

Setting: Primary care medical center, Christchurch, New Zealand.

Patients: 257 elderly subjects (age 65 years and over), residing in their own homes or in residential homes, were randomly selected. Of these, 204 (79%) participated. The study population was comparable to the elderly population of New Zealand.

Main Outcome Measures: Vitamin B12, serum, and red cell folate levels.

Results: The prevalence rates for low levels of serum vitamin B12, folate, and red cell folate were 7.3%, 1%, and 3.3%, respectively. The elderly cohort had lower vitamin B12 (P < 0.001) but higher serum and red cell folate levels (P < 0.001) than our normal reference range (age 18–65 years). Red blood cell folate levels showed positive correlations with nutritional indices and mental test scores. No correlations were found between vitamin B12 levels and diet or other nutritional indices.

Conclusions: Low folate levels in older people living at home are infrequent findings. In contrast low vitamin B12 levels are more common. Poor diet and undernutrition may contribute to low folate levels, but these factors are less important for the low B12 levels found.
Effects of Short‐Term Administration of Glucocorticoids on Bone Metabolism in Healthy Elderly Men
Authors: Mitchell David R. , Jackson Thomas W. , Lyles Kenneth W.
Published: April 2015

Objective: To determine the effects of short‐term glucocorticoid administration in healthy elderly men on bone GLA protein (BGP) levels, as well as levels of calcium, phosphorus, immunoreactive parathyroid hormone (PTH), and alkaline phosphatase.

Design: Subjects served as own control before and after prednisone treatment.

Setting: Male subjects were recruited by telephone from the Duke University Aging Center Volunteer Registry and the Department of Veterans Affairs Medical Center Gerofit Program (a supervised exercise program).

Participants: Healthy males age greater than 60 years with no history of diabetes mellitus, glucose intolerance, or prior glucocorticoid use. Subjects could not be taking diuretic agents and could not have osteoporosis. The seven subjects mean age + std dev was 68.6 + 5.3 years.

Interventions: Prednisone 40 mg orally for 5 days. Fasting serum was obtained at baseline, on days 7 through 11, 13, 15, and 17. Assays of BGP, calcium, phosphorus, PTH, and alkaline phosphatase were performed.

Main Outcome Measures: Changes in serum BGP levels was the primary outcome measure. Changes in serum calcium, phosphorus, PTH, and alkaline phosphatase levels were secondary outcome measures.

Results: Treatment caused reduction in BGP levels within 24 hours of first dose of prednisone, with levels dropping an average of 78% during the 5 days of treatment (P = 0.004). Within 24 hours of stopping treatment, BGP was no different from baseline. Other variables did not change with treatment.

Conclusion: Glucocorticoid treatment suppresses BGP production in healthy elderly men in the same fashion as it does in younger healthy men.
Effectiveness of Geriatric Psychiatry Consultation in an Acute Care Hospital: A Randomized Clinical Trial
Authors: Cole Martin G. , Fenton Fred R. , Engelsmann Frank , Mansouri Iradj
Published: April 2015

Objective: To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients.

Design: Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later.

Setting: Primary acute care hospital.

Patients: Eighty hospitalized patients aged 65 or older who were referred to a multi‐disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty‐three patients completed the trial.

Interventions: Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow‐up at least once per week for 8 weeks. Control patients received usual medical care.

Main Outcome Measures: Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale.

Results: The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P < 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home.

Conclusions: Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.
Physiological Factors Associated with Falls in an Elderly Population
Authors: Lord Stephen R. , Clark Russell D. , Webster Ian W.
Published: April 2015

Objective: To determine whether a battery of 13 sensorimotor, vestibular, and visual tests discriminates between elderly fallers and elderly non‐fallers.

Design: One‐year prospective study.

Setting: Conducted at a 124‐bed Hostel for Aged Persons, in Sydney, Australia.

Participants: Ninety‐five persons aged between 59 and 97 years (mean age 82.7 years) took part in the study. Of the 29 non‐participants, four were ill, five were absent (on holidays, etc), and 20 declined. Residents were generally independent in activities of daily living although personal care assistance was available.

Results: Eighty‐four participants were available for follow‐up. In the follow‐up year, 40 subjects experienced no falls, 11 subjects fell one time only, 33 residents fell on two or more occasions. There was a total of 145 falls. Discriminant function analysis identified proprioception in the lower limbs, visual contrast sensitivity, ankle dorsiflexion strength, reaction time, and sway with the eyes closed as the variables that significantly discriminated between subjects who experienced multiple falls and subjects who experienced no falls or one fall only. This procedure correctly classified 79% of subjects into multiple faller or non‐multiple faller groups. Quadriceps strength was poorer in the multiple fallers compared with the non‐fallers and once‐only fallers, although the difference was not statistically significant. There was little difference in the mean scores for the tests of vestibular function in the non‐fallers, once‐only fallers, and multiple fallers.

Conclusion: It appears that this approach highlights some key physiological factors that predispose elderly individuals to falls.
Benign Prostatic Hyperplasia: Pathogenesis and Medical Therapy
Authors: Geller Jack
Published: April 2015

Epidemiologic studies in castrates strongly support the key role of the testis in the pathogenesis of benign prostatic hyperplasia (BPH). Since the testis secretes androgen and estrogen, both of these hormones have been implicated in BPH. Much information supports the important role of dihydrotestosterone (DHT) in BPH, including intraprostatic activities of enzymes that regulate DHT. Although controversy still exists, DHT levels in BPH may be higher than in normal prostate tissue. Based upon these findings and the ability to quantitate prostate size and function with reliable new techniques, suppression of androgen‐mediated action has been tested to assess the validity of the DHT theory. A variety of drugs has been demonstrated to decrease prostate size by approximately 30% by either blocking secretion of circulating testosterone and adrenal androgen, inhibiting 5α‐reductase to prevent DHT formation, or blocking DHT binding to androgen receptors. Accompanying these changes in size was significant improvement in clinical symptoms of prostatism in about 50% of patients, when double‐blind, large multicenter studies were conducted with one of these drugs.

Although these results suggest a very important role for androgen, particularly DHT, in the pathogenesis of BPH, other abnormalities may coexist since significant numbers of patients do not show a total reversal of disease. There is strong indirect evidence for a possible role for estrogen in the pathogenesis of BPH, and studies are under way to test the effects of estrogen withdrawal on prostate size and symptoms. Similarly, dynamic aspects of prostatic obstruction, which are under alpha‐adrenergic regulation, may also be a component of this disease and amenable to therapy with alpha‐adrenergic blockers. Therefore it would seem that BPH may be multifactorial and require combined therapy. Androgen would certainly appear to be necessary but perhaps not sufficient for the pathogenesis of this disorder.
Artificial Feeding: The Least Restrictive Alternative?
Authors: Scofield Giles R.
Published: April 2015

Of all the reasons that justify a decision to withhold or withdraw a feeding tube, the most basic is that it is not needed in order to nourish the patient adequately and safely. The controversy that surrounds feeding tubes decisions in the so‐called right‐to‐die context has distracted attention from this aspect of their use. This creates the risk that they will be initiated inappropriately, without adequate evaluation or consent. By re‐incorporating the concepts of medical indication and the least restrictive alternative doctrine into the consent process, as new federal regulations require, physicians can restore balance to clinical judgment and deter improper practices. In order for these concepts to make a real difference to patients and physicians, society must improve the quality of care it provides the elderly.
Two‐Year Trends in Physical Performance following Supervised Exercise among Community‐Dwelling Older Veterans
Authors: Morey Miriam C. , Cowper Patricia A. , Feussner John R. , DiPasquale Robert C. , Crowley Gail M. , Sullivan Robert J.
Published: April 2015

The extent to which exercise can delay the normal decline in physical performance associated with aging is unknown. We examined the impact of 2 years of supervised exercise on cardiovascular fitness, flexibility, and strength in a group of elderly (age 65–74) veterans. Seventy‐five patients exercised 3 days/week for 90‐minute sessions emphasizing aerobic, flexibility, and strength development. Thirty‐six (47%) completed 2 years of a voluntary supervised exercise program (n = 25 with complete data). Over a 2‐year follow‐up period, cardiovascular outcome variables improved significantly: metabolic equivalents increased 20% (7.4 ± 2.2 to 9.0 ± 2.4, P < 0.001) and submaximal heart rate decreased 7% (68.5 ± 8.0 to 63.6 ± 8.4 beats/minute, P = 0.02). Resting heart rate decreased 8% (131.4 ± 14.8 to 121.0 ± 18.5 beats/minute, P = 0.06), but this difference did not reach statistical significance. Flexibility, measured by hamstring length, improved 11% (57.5 ± 15.1 to 64.0 ± 11.1 degrees, P = 0.02). Strength variables did not improve. The study indicates that improvements in cardiovascular function and flexibility achieved by the elderly in the early stages of an exercise program can be maintained for at least 2 years.
Increased Serum Conjugated Dienes in Elderly Diabetic Patients
Authors: Mooradian Arshag D.
Published: April 2015

To determine if lipid peroxidation by‐products are increased in the serum of elderly diabetic patients, serum concentrations of conjugated dienes were measured in 45 Type 2 diabetic men over the age of 60 years, and the results were compared to those of 24 age‐matched healthy men. Patients with diabetic complications such as retinopathy, nephropathy, neuropathy, peripheral vascular disease, coronary or cerebrovascular disease, (n = 22) had significantly increased serum levels of conjugated dienes (0.4951 ± 0.065 O.D./mL) compared to healthy controls (0.2368 ± 0.028 O.D./mL) (P < 0.01). The level of conjugated dienes in diabetic patients without complications (0.3854 ± 0.0316 O.D./mL) was intermediate between the level found in control subjects and the level in patients with diabetic complications. The serum levels of conjugated dienes correlated best with serum triglyceride concentration (r = 0.51) and to a lesser extent with serum glucose concentration (r = 0.36). It is concluded that elderly patients with diabetes, especially those with complications, have increased serum levels of lipid peroxidation by‐products. This can not be totally attributed to alterations in serum cholesterol, phospholipid, or triglyceride levels.
Evaluating the Oregon Priority Plan
Authors: Callahan Daniel
Published: April 2015

The Oregon priority plan represents an innovative method of reforming its Medicaid program. It would replace the present system of limiting the number of people in the program with one that would, after setting priorities, limit treatment benefits. The strength of the plan is that it would provide all the poor with health care coverage; its potential drawback is that it might put expectant mothers and children at a disadvantage and possibility make some forms of needed care inaccessible to other groups as well. Despite the drawbacks and uncertainties of the priority plant, it deserves to be given a chance to prove itself.
The Incidence of Attempted CPR in Nursing Homes
Authors: Finucane Thomas E. , Boyer John T. , Bulmash Jack , Fanale James E. , Garrell Marvin , Johnson Larry E. , Katz Paul R. , Pattee James J. , Rappaport Stephen A. , Ryan Joseph J. , Simpson William M. , Tangalos Eric G.
Published: April 2015

We studied the frequency with which cardiopulmonary resuscitation (CPR) is attempted on residents of American nursing homes. Each author (all members of the Clinical Practice Committee of the American Geriatrics Society) completed a questionnaire in 1989 about policy and practice regarding CPR during 1988 in each of three to seven nursing homes, by questioning the medical or nursing director or the administrator. Because of the vagaries of nursing home record‐keeping, data from some homes were allowed when they were “accurate to within 10%.”

Data from 58 nursing homes, totalling 10,836 bed‐years were available. In 33 of these homes, accounting for 5,425 bed‐years, CPR was never attempted. CPR was more likely to be foregone in nursing homes with religious affiliation than in nursing homes without (13 of 17 vs 18 of 38; χ2 = 4.0; P < 0.05). Religious affiliation was unknown for three nursing homes. Academic affiliation (10 of 16 vs 20 of 37 in non‐affiliated nursing homes) and non‐profit status (14 of 19 vs 16 of 23 in for‐profit nursing homes) did not significantly affect the likelihood that CPR would never be used. In 31 of 54 nursing homes with explicit do not resuscitate (DNR) policies, CPR was never performed, compared to 2 of 4 homes without such policies. For nursing homes with complete data, there were 1,196 deaths in 32 facilities where CPR was never attempted compared to 1,294 deaths for 24 nursing homes with CPR. For 22 nursing homes without CPR, there were 2,172 emergency room transfers compared to 1,363 emergency room transfers in 18 nursing homes where CPR was attempted.

In this non‐random sample, most nursing home residents who died in 1988 were in nursing homes that never attempted CPR. In homes where CPR was attempted, its utilization was variable, but generally very infrequent.
Behavioral Complications of Drug Treatment of Parkinson's Disease
Authors: Cummings Jeffrey L.
Published: April 2015

A variety of neuropharmacologic agents, including anticholinergic drugs, amantadine hydrochloride, levodopa, selegiline, bromocriptine, and pergolide, are now available for the treatment of Parkinson's disease. Of patients treated with dopaminergic agents, 30% develop visual hallucinations, 10% exhibit delusions, 10% have euphoria, 1% have mania, 10% to 15% experience increased anxiety, 15% have confusional periods, and a few exhibit altered sexual behavior. Anticholinergic drugs have a greater tendency to produce confusional states than dopaminergic compounds. Elderly patients and those with underlying dementia are most likely to have untoward side effects with anti‐parkinsonism treatment. Dosage reduction is the optimum management strategy, although anti‐psychotic agents may be necessary in patients with delusions, and lithium may help control drug‐induced mania. Dopaminergic agents share the property of stimulation of D2 dopamine receptors, and this action may play an essential role in mediating their neuropsychiatric effects.
Dipyridamole Echocardiography as a Useful and Safe Test in the Assessment of Coronary Artery Disease in the Elderly
Authors: Ferrara Nicola , Leosco Dario , Abete Pasquale , Landino Pietro , Caccese Pompilio , Sederino Salvatore , MD Domenico Acanfora , Rengo Franco
Published: April 2015

We prospectively studied the sensitivity, specificity, feasibility, and safety of high‐dose dipyridamole echocardiography, compared to exercise electrocardiography in 130 subjects (67 younger and 63 elderly patients) referred for angiographic evaluation of suspected or proven coronary artery disease. Sensitivity, specificity, and feasibility of dipyridamole echocardiography were respectively 75.5%, 100%, and 88.0% in younger patients and 82.9%, 100%, and 79.4% in elderly patients (P = NS). The sensitivity of exercise electrocardiography was 72.7% in young and 66.6% in elderly patients (P = NS); specificity 66.0% vs 60.0% (P = NS); feasibility 83.6 vs 63.5 (P = 0.05). Forty‐nine younger and 38 elderly patients performed both tests. Sensitivity of dipyridamole echocardiography compared to exercise electrocardiography was 76.2% vs 73.8% in young patients and 83.3% vs 70% in the older group (P = NS). The feasibility of the two tests was significantly different in the elderly group only (dipyridamole echocardiography 79.4% vs exercise electrocardiography 63.5%; P < 0.01).

The incidence of side effects during dipyridamole echocardiography was similar in the two groups, except for dyspnea which was observed in 20% of older and 5% of younger patients (P < 0.05). Our data demonstrate that the dipyridamole test combined with echocardiographic monitoring of regional myocardial contractility may be considered a valid non‐invasive method for evaluating coronary artery disease in the elderly and that this test is a satisfactory alternative to the exercise stress test.
Pharmacological Treatment of Agitation in a Nursing Home
Authors: Billig Nathan , Cohen‐Mansfield Jiska , Lipson Steven
Published: April 2015

Agitation is a significant problem in the management of residents in long‐term care settings. This study assessed the pharmacological treatment of agitation in a 550‐bed nursing home and correlated nurses' ratings of agitation with pharmacological treatment. It further examined the differential use of various psychotropic agents in the management of several sub‐types of agitated behavior.

Significant results included: (1) subjects designated as demented and agitated were most likely to receive neuroleptics, while non‐demented agitated residents were most likely to be treated with a benzodiazepine; (2) agitated individuals received significantly less antidepressant treatment than non‐agitated patients.

The sub‐typing of agitation may allow for the possibility of more selective treatment of various agitation syndromes.
Major Depressive Disorder in Hospitalized Medically Ill Patients: An Examination of Young and Elderly Male Veterans
Authors: Koenig Harold G. , Meador Keith G. , Shelp Frank , Goli Veeraindar , Cohen Harvey J. , Blazer Dan G.
Published: April 2015

Objective: To study the epidemiology of depressive disorder in younger and older medical inpatients.

Design, Patients, & Setting: Depressive disorders were examined using the Diagnostic Interview Schedule in 116 young and 332 elderly medically ill men hospitalized in a VA medical center.

Results: Major depressive disorder was diagnosed in 22.4% of men under 40 and 13.3% of those age 70 or over; minor depression was found in 18.1% of young and 29.2% of older men. Besides age, other risk factors for major depression were impaired social support, severe medical illness or functional disability in older men, and history of psychiatric problems primarily in younger men; specific medical diagnosis was not a risk factor. Major depression was associated with more severe symptomatology in younger patients; in both age groups, however, symptoms were of prolonged duration and frequently included suicidal thoughts.

Conclusions: Depressive disorder in hospitalized male veterans is common, varies with age, severity of medical illness, degree of social support, and history of psychiatric problems and is associated with considerable psychological morbidity.
Monitoring Progression in Alzheimer's Disease
Authors: Galasko Douglas , Corey‐Bloom Jody , Thal Leon J.
Published: April 2015

Objective: To compare several clinical methods of following change in Alzheimer's disease (AD) over time.

Data sources: MEDLINE search (restricted to English language); bibliographies of pertinent articles or books.

Study selection: Studies included only if aim was to follow a cohort of AD patients; diagnosis of AD used DSM‐III‐R or NINCDS‐ADRDA guidelines; techniques or scales used for serial assessment were well‐established in terms of validity and reliability.

Data extraction: All 3 authors reviewed all studies cited and reached consensus about interpretation.

Results: Global instruments detect long term deterioration in AD and describe distinct though possibly artificial stages. Cognitive screening tests decline at a consistent rate for groups of AD patients but show considerable variability. Scales measuring activities of daily living (ADLs) need further study to determine annual rate of change. Instrumental ADLs decline early in AD and reach a floor before cognitive screening tests. Electrophysiologic or radiographic techniques do not necessarily change over time and are not superior to clinical methods for following AD. Variability in rate of cognitive change and prognosis in AD has not been adequately explained.

Conclusions: Cognitive screening tests provide useful measures of rate of change in AD for clinical and therapeutic studies. Further studies should take advantage of longer follow‐up and more sophisticated statistical techniques to optimize use of these measures.
Patients in a Persistent Vegetative State Attitudes and Reactions of Family Members
Authors: Tresch Donald D. , Sims Farrol H. , Duthie Edmund H. , Goldstein Michael D.
Published: April 2015

Patients in a persistent vegetative state (PVS) constituted approximately 3% of the population in four Milwaukee nursing homes. In order to understand family members' attitudes and reactions toward such patients, 33 (92%) of 36 family members of patients in PVS contacted were studied. The age of the patients ranged from 19 to 95 with a mean age of 73.4 ± 17.2 years, and family members' ages ranged from 41 to 89 with a mean age of 61.8 ± 3.3 years. The etiology of the PVS varied from dementia to cerebral trauma. The mean duration of the PVS was 54 ± 8.4 months (range 12 to 204). Family members reported that they visited patients 260 times during the first year following the onset of the PVS and were still visiting at a rate of 209 visits yearly at the time of the interview. There was no significant correlation between the frequency of the family members visits and the duration of the PVS, the patient's or family member's age, or the family member's relationship to the patient. Ninety percent of patients were considered by family members to have some awareness of pain, light or darkness, environment, taste, verbal conversation, or the family member's presence. Most family members thought they understood the patient's medical condition, and the majority did not expect the patient to improve. Nevertheless, the majority of family members wanted the patient to undergo therapeutic interventions, including transfer to the acute hospital and surgery. Concerning tube feeding, 29 of 33 family members retrospectively agreed with the initial decision to insert the tube, and only six disagreed prospectively with continuing the tube feeding as long as oral feeding was not possible.
Breast Cancer Screening in Older Women: Practices and Barriers Reported by Primary Care Physicians
Authors: Weinberger Morris , Saunders Amy F. , Samsa Gregory P. , Bearon Lucille B. , Gold Deborah T. , Brown J. Trig , Booher Patricia , Loehrer Patrick J.
Published: April 2015

Annual mammography, in combination with clinical breast examinations, can reduce mortality from breast cancer. However, surveys of both patients and physicians suggest that mammography is underutilized. This study examined whether physicians' reported breast cancer screening practices and barriers to mammography varied with patients' age. Data from 576 primary care physicians (internal medicine, family/general practice, and obstetrics/gynecology) who participated in a mailed statewide survey were analyzed. Physicians reported screening elderly women significantly less often than younger women, regardless of family history of breast cancer. With the exception of medical specialty, physicians' demographic and practice characteristics were not associated with reported screening practices. However, physicians' knowledge and beliefs about breast cancer in older women were associated with reported screening practices. When analyzing barriers to ordering mammography, cost to the patient was viewed as a barrier for women of all ages, and pain was viewed as a greater barrier for younger women; otherwise, physicians consistently believed that their elderly patients faced considerably more barriers compared with younger women. Further investigation is required to examine why primary care physicians report age‐related differences in both breast screening and barriers to mammography.
Delayed Plasma Clearance of Phenylalanine and Tyrosine in Elderly Men
Authors: Rudman Daniel , Abbasi Adil A. , Chaudry Farooq , Mattson Dale E.
Published: April 2015

The plasma levels of 17 amino acids were measured in three groups of men: healthy young men, healthy elderly men, and demented tube‐fed elderly men living in a nursing home, prior to, and again 2, 4, and 6 hours after the consumption of a standard protein‐containing meal. The standard meal provided per kilogram of body weight 8.3 calories, 0.33 grams of protein, 0.90 grams of carbohydrate, and 0.37 grams of fat.

The concentrations of all amino acids, except tryptophan, rose significantly at 2 hours and returned to baseline by 6 hours. Plasma phenylalanine and tyrosine were significantly (P < 0.05) higher at 2 hours in the two groups of elderly men than in the young healthy men. In other respects the pre‐ and post‐prandial amino acid profiles were not influenced by age. The ratio, tyrosine/other large neutral amino acids (tyr/LNAA), was significantly higher in both elderly groups than in the young men at nearly all time points before and after the test meal. It was generally higher in the demented older men than in the healthy older men.

The data demonstrated a delayed plasma clearance of phenylalanine and tyrosine in old age. The elevated plasma tyr/LNAA ratio in the elderly men may have tended to augment an entry of tyrosine, the precursor of norepinephrine and dopamine, into their brains.
Ostium Secundum Atrial Septal Defect in the Elderly
Authors: Landi Francesco , Cipriani Luca , Cocchi Alberto , Zuccala Giuseppe , Carbonin Pierugo
Published: April 2015

Atrial septal defect (ASD) is one of the most common congenital cardiac anomalies in adults. Life expectancy is shortened, and almost 90% of patients die by the age of 60 years. The progression of this congenital disease to congestive heart failure has been related to several factors such as the onset of pulmonary hypertension, arrhythmias, bronchopulmonary infections, or the development of other cardiovascular diseases. We describe three cases of very old patients with significant ASDs and late development of symptoms. Given the higher risks and poorer long‐term results of surgical closure of the defect in advanced age, the indications for such an intervention in elderly patients should be carefully evaluated.
Inadequate Treatment of Depressed Nursing Home Elderly
Authors: Heston Leonard L. , Garrard Judith , Makris Lukas , Kane Robert L. , Cooper Susan , Dunham Trudy , Zelterman Daniel
Published: April 2015

Objective

To determine the prevalence of antidepressant drug treatment among nursing home elderly with major depression.

Design

Survey early and late in nursing home stay.

Setting

Sixty Medicaid/Medicare‐certified skilled nursing homes.

Participants

Admission cohort of 5,752 residents age 65 or older in 1976 through 1983.

Measures

Chart review by nurse‐abstractors of physicians' diagnoses, drug used, and alertness rating. Diagnosis of depression equivalent to DSM‐III‐R major depression.

Results

Of 868 persons with a diagnosis of depression in the medical record, only 10% were treated with antidepressant drugs. More received neuroleptics and benzodiazepines than received antidepressants, but most (52%) received no psychoactive drug at all. A subset of 258 depressed persons had positive notations in their records supporting a mental status rating of “alert and oriented.” Of that subset, only 15% received antidepressants. When followed from admission to discharge or end of study the prevalence rate of antidepressant drug treatment increased by 4%.

Conclusions

In the late 1970's and early 1980's, even when the primary care physician made and recorded a diagnosis of depression, most such nursing home residents remained untreated, incorrectly treated, or inadequately treated.
Recurrent Unexplained Syncope in the Elderly: The Use of Head‐Upright Tilt Table Testing in Evaluation and Management
Authors: Grubb Blair P. , Wolfe Douglas , Samoil Daniela , Madu Ernest , Temesy‐Armos Peter , Hahn Harry , Elliott Laura
Published: April 2015

Objective

To investigate the usefulness of head‐upright tilt table testing for vasovagal episodes in the evaluation and management of elderly patients with recurrent idiopathic syncope.

Design

Prospective survey.

Setting

Electrophysiology laboratory of a university hospital.

Patients

Twenty‐five patients (11 male, 14 female; mean age 73 ± 6 years) with recurrent unexplained syncope and seven control subjects with other causes of syncope (4 male, 3 female; mean age 70 ± 4 years).

Methods

Each patient underwent head‐upright tilt table testing for 30 minutes with or without an infusion of isoproterenol (1–3 μg/min given intravenously) in an attempt to provoke bradycardia, hypotension, or both.

Main Results

Syncope occurred in nine patients (36%) during the baseline tilt and in seven patients (28%) during isoproterenol infusion (total positives 64%). None of the controls had syncope during the test. All of the patients who had positive test results eventually became tilt table negative with therapy, and over a mean follow‐up period of 24 months, no further syncopal episodes have occurred.

Conclusions

Head‐upright tilt table testing combined with isoproterenol infusion may be a useful tool in the diagnosis of vasovagal syncope in the elderly and in the evaluation of preventive therapy.
The Mini‐Mental State Examination: Identifying the Most Efficient Variables for Detecting Cognitive Impairment in the Elderly
Authors: Braekhus Anne , Laake Knut , Engedal Knut
Published: April 2015

Objectives

To study how well the scoring on each item of the MMSE relates to the sum‐score when the purpose is to identify persons with cognitive impairment, and to identify an equally effective subset of MMSE items for predicting cognitive impairment.

Design

Retrospective survey of MMSE data for 850 elderly. Setting: A variety of clinical settings.

Participants

Mean age 82 years (range 54 to 99), 74% women. The subjects were of three different categories: geriatric in‐patients, patients living under supervision, and elderly people living independently at home.

Results

Five of the binomial (“State,” “Town,” “Name a pencil,” “Name a watch,” “Read and obey”) and one of the polychotomous MMSE variables (“Learn three words and repeat immediately”) had low sensitivity and gave high percentages of misclassifications versus the sumscore dichotomized at the cut‐point 23/24. Univariate logistic regression indicated that the three remaining polychotomous variables (“Spell backwards,” “Recall three words,” and “Three‐stage command”) can be scored binomially. Two factors were identified on factor analysis. Logistic regression analysis showed that 12 of the original 20 items predicted the sumscore dichotomized at 23/24 with only 3% misclassifications. Validation against the psychogeriatrician's diagnosis showed that this 12‐item MMSE derivative performs as well as the full MMSE.

Conclusions

Six of the 20 MMSE variables perform poorly regarding sensitivity and misclassifications versus the sum‐score at cut‐point 23/24. Two additional items did not contribute to the prediction of a low/high sumscore. The remaining 12 MMSE items can all be scored binomially and produce a sumscore which is equally as effective as the sumscore of the full MMSE when the purpose is to identify elderly patients with cognitive impairment.