bluuebunny/crossref_metadata_2025 huggingface dataset:
Persistent Dizziness in Geriatric Patients
Authors: Sloane Philip D. , Baloh Robert W.
Published: April 2015

Among the 116 consecutive patients aged 70 and older who were evaluated for dizziness in the UCLA neurotology clinic, the mean duration of symptoms was 36.2 months. One or more specific diagnoses were identified in 100 patients (86.2%), with the most common diagnoses being benign positional vertigo (25.9% of patients) and cerebrovascular disorders (21.6%). Benign positional vertigo was characterized by brief episodes of positional vertigo, a positive Hallpike maneuver, and lack of focal signs on neurologic examination and electronystagmography. Cerebrovascular disease presented as two entities, infarction and transient ischemic attacks, each of which had a distinct clinical picture. Patients who could not be definitively diagnosed frequently described presyncopal lightheadedness provoked by upright posture, and usually had normal physical examinations and electronystagmography. The clinical history, particularly the description and temporal nature of the patient's symptoms, provided the key diagnostic data in 69.0% of cases.
Short‐Term Outcomes of Elderly Patients Discharged from an Emergency Department
Authors: Denman Susan J. , Ettinger Walter H. , Zarkin Beth Ann , Coon Patricia Jay , Casani Julie A.
Published: April 2015

To determine the short‐term functional and medical outcomes and predictors of outcome following discharge from an acute hospital emergency department, 100 elderly (≥65 yr) and 100 nonelderly (<65 yr) patients were studied prospectively. Patients were interviewed at three days and again at three weeks following emergency department discharge. The number of new prescriptions given to both groups in the emergency department was similar (elderly 41%; nonelderly, 31%). The elderly were as likely as the nonelderly to know the correct name (elderly, 88%; nonelderly, 87%), dosage schedule (elderly, 90%; nonelderly, 90%) and purpose (elderly, 85%; nonelderly, 94%) of their new medications. There was no difference in patients' understanding of the diagnosis (elderly, 72%; nonelderly, 72%) or in medication compliance (elderly, 81%; nonelderly, 74%). Elderly patients were more likely to keep scheduled follow‐up appointments (87% vs 65%; P < .05). Despite these similarities the elderly had worse medical outcomes at three weeks; 67% of the elderly were better and 20% were worse, including seven patients who required interim hospitalization, four of whom died. In contrast, 82% of the nonelderly were better and only 4% were worse (P < .01). None of the nonelderly required hospitalization or had died. Functional impairments were more common in the elderly both at baseline (elderly, 26%; nonelderly, 6%; P < .01) and at three weeks (elderly, 27%; nonelderly, 5%; P < .001). Independent predictors of poor medical outcome included age ≥65 (P < .009) and functional impairment at baseline (P < .022). Older patients with impaired functional status who are discharged from an emergency department should be targeted for close medical surveillance and ready access to health services.
Hierarchical Measures of Physical Function in Ambulatory Geriatrics
Authors: Siu Albert L. , Reuben David B. , Hays Ron D.
Published: April 2015

Brief and uncomplicated methods for obtaining information on functional status would facilitate the assessment of older patients. We evaluated the potential usefulness, reliability, and validity of four hierarchical measures of physical function in 123 elderly subjects seen in four ambulatory geriatrics settings. Although the vast majority (83.2%) of subjects were fully independent on the Katz Activities of Daily Living Scale, a broader scope of functional difficulty was reported on the Spector‐Katz, five‐item OARS, and Rosow‐Breslau scales. The three scales all had either borderline or more acceptable coefficients of scalability (0.57–0.77); the hierarchical order of items was not observed in 5.3% to 13.6% of subjects. Combining items from these established measures resulted in two new scales with acceptable scalability and construct validity; however, some errors in item order persisted. Although their ease of administration is clearly advantageous, clinicians using short hierarchical scales to assess functional status of older patients should be aware of their limitations.
Metals and the Liver in Alzheimer's Disease An Investigation of Hepatic Zinc, Copper, Cadmium, and Metallothionein
Authors: Lui Edmund , Fisman Michael , Wong Cindy , Diaz Fernando
Published: April 2015

Significant alterations of tissue metal levels have been reported in Alzheimer's disease (AD). Because the liver is intimately involved in metabolism and storage of metals, it may provide a useful site for study of these metals in AD. This study compares livers in AD and controls in their concentrations of zinc, copper, cadmium, and metallothionein, a metal‐binding protein important in regulation of metal metabolism. Liver tissue was obtained from 17 patients with AD and 17 age‐ and sex‐matched controls within 12 hours of death and stored at − 70°C. Neuropathologic confirmation of diagnosis was available in all cases. Liver homogenates (20%) were used for metal analysis by atomic absorption spectroscopy after wet digestion. Cytosolic metallothionein levels were quantitated by the cadmium or silver saturation method. A significant decline in body and liver weight was found in patients with AD, with no significant change in liver protein or DNA concentration. Total hepatic cadmium (P < .001) and zinc (P < .030) concentrations were significantly elevated in AD. The Sephadex G75 chromatographic profile was altered in AD with reduction in zinc bound to metallothionein fractions and increased binding to high molecular weight fractions. These data suggest that the metabolism of cadmium and zinc is altered in AD.
Completed Suicide at Age 50 and Over
Authors: Conwell Yeates , Rotenberg Melanie , Caine Eric D.
Published: April 2015

The authors present data abstracted from medical examiners' investigative reports of 246 completed suicides of persons over the age of 50 years classified into four age groups. The sample population conformed to epidemiologic studies with regard to sex distribution. With increasing age, more suicide victims were widowed, and significantly fewer were single, separated, or divorced. Violent methods of suicide were more prevalent and alcohol use and psychiatric histories less common with aging. Physical illness and loss became the most common definable precipitants to suicide, whereas job, financial, and family relationship problems became less frequent with increasing age. The indications for future research and intervention in primary care settings are discussed.
An Outbreak of an Influenza‐Like Illness in a Nursing Home
Authors: Osterweil Dan , Norman Dean
Published: April 2015

As part of an ongoing infection surveillance program, data were collected on an outbreak of respiratory illness affecting 29% of residents in a 231‐bed long‐term care facility. Viral titers could be collected on 60% of the ill residents and respiratory syncytial virus (RSV) was established in 14 of the symptomatic patients and was thought to be the probable cause of the outbreak. Compared with previously reported long‐term institutional outbreaks of RSV, there were significantly fewer cases of pneumonia (5% vs. 14% to 55%) and deaths (2% vs. 6% to 20%). However, morbidity was substantial in this outbreak, with 46% of patients suffering prolonged malaise and anorexia; the mean duration of symptoms was four weeks. Respiratory syncytial virus may be an important cause of respiratory illness in nursing homes and may be unappreciated if specific diagnostic methods are not employed. The recent availability of rapid diagnostic tests and specific antiviral therapy for RSV warrant further clinical studies to develop management strategies for this infection.
Screaming in Nursing Home Residents
Authors: Cohen‐Mansfield Jiska , Werner Perla , Marx Marcia S.
Published: April 2015

This article reports the results of two studies of screaming in the nursing home. The first was a survey study of 408 nursing home residents, which revealed that 25% of the residents screamed at least four times a week. Screaming was associated with cognitive impairment, depressed affect, social networks of poor quality, and severe impairment in the performance of activities of daily living. The second study was an in‐depth observational study of five residents who screamed frequently. Residents screamed more often when they were alone in their rooms during the evening hours, suggesting that screaming may arise as a response to social isolation.
Needlestick Injuries and Needle Disposal in Minnesota Nursing Homes
Authors: Crossley Kent , Willenbring Karen , Thurn Joseph
Published: April 2015

We examined needle use and disposal, needlestick injuries and their management, and employee education regarding the acquired immunodeficiency syndrome and needle use by means of a questionnaire sent to all long‐term care facilities certified for skilled care in Minnesota. Responses were received from 297 of 349 (85.1%) homes. Nearly all homes (271 of 293; 92.5%) provided education for new nursing employees about use and disposal of needles. Disposal of needles and sharps was generally consistent with current recommendations for short‐term care hospitals. Needlestick injuries were usually related to recapping and were most common in registered and licensed practical nurses but were infrequent (i.e., <1 injury per home per employee‐year) probably because parenteral therapy is infrequently used in long‐term care settings. Only slightly over half (166 of 286; 58%) of the homes had protocols for management of needlestick injuries.

Although Minnesota nursing homes properly dispose of needles and sharps, many of these institutions need to develop policies for management of needlestick injuries that are consistent with current recommendations.
Book Review
Authors: Barzel Uriel S. , Wiener Alfred
Published: April 2015

Geriatric Psychiatry and Psychopharmacology: A Clinical Approach. By Jenike MA. Chicago, IL, Year Book Medical Publishers, 1989. 396 pages, PNS.
Book Review
Authors: Kleiman Michael B.
Published: April 2015

Experiences from Longitudinal Studies of Aging: Conceptualization, Organization, and Output. By Deeg DJH. Nijmegen, The Netherlands, Netherlands Institute of Gerontology, 1989. 250 pages. Softcover, $23.00.
The Accuracy of Medication Histories in the Hospital Medical Records of Elderly Persons
Authors: Beers Mark H. , Munekata Mark , Storrie Michele
Published: April 2015

Medication histories written in medical records are important sources of information for clinicians and researchers. Medication histories in outpatient records are frequently inaccurate; the accuracy of the histories in hospital records has not previously been studied. We evaluated the accuracy of medication histories recorded in hospital medical records of 122 persons over the age of 65 at three sites, comparing the written record to a structured history obtained from the patient by the research staff. We defined an error as either the failure to record the use of a medication the patient claimed to use or the recording of a medication that the patient denied using.

We found that 83% of all patients had at least one such error, and 46% had three or more. We reanalyzed the data excluding over‐the‐counter, topical, and cold medications, and found that 60% of all patients still had at least one error, and 18% had three or more. Failure to record use in the record was more common than recording medications the patient denied using. There were no qualitative differences between hospitals or between the histories obtained by interns and attending physicians.

This analysis suggests that medication histories in the hospital medical record are not accurate sources of information in elderly persons. Errors in the history may adversely affect clinical care; researchers relying on hospital medical records to determine medication use at the time of admission should first validate their data.
Long‐Term Enteral Feeding of Aged Demented Nursing Home Patients
Authors: Peck Arthur , Cohen Camille E. , Mulvihill Michael N.
Published: April 2015

The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late‐stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied.

Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P < .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P < .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance.

All of the intubated patients were severely demented, with MMSE scores of zero. Seventy‐one percent of the nonintubated group were demented, with MMSE scores of < 23.

Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life‐span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy.
Differences in Health Status Between Older and Younger Homeless Adults
Authors: Gelberg Lillian , Linn Lawrence S. , Mayer‐Oakes S. Allison
Published: April 2015

The Institute of Medicine has placed a priority on determining the special health‐care needs of elderly homeless persons. As part of a community‐based study of 521 homeless adults in two beach communities of Los Angeles, we compared the demographic characteristics and health of older (age range, 50–78, n = 61) and younger (age range, 18–49, n = 460) homeless individuals. Compared with younger adults, older adults were more likely to be white (85% versus 61%), veterans (59% versus 27%), retired (36% versus 3%), and living in a vehicle (21% versus 8%). Older adults were more likely to report having a chronic disease (69% versus 49%), functional disabilities, no informal social contacts during the previous month (49% versus 27%), observed high blood pressure (42% versus 22%), elevated creatinine (11% versus 2%), and elevated cholesterol (57% versus 36%). Older adults were less likely to have a toothache (3% versus 30%), report psychotic symptoms (25% versus 42%), and to be illegal drug users (15% versus 55%). Although they are chronologically younger, the constellation of health and functional problems of older homeless adults resemble those of geriatric persons in the general population. We suggest that geriatricians could play a significant role in training other primary‐care providers to evaluate and treat socially isolated older homeless adults in a more comprehensive way than is currently standard in practice (e.g., interdisciplinary team care and emphasis on functional status, rehabilitative medicine, and assessment for sensory impairment).
BOOK REVIEWS
Authors: Rhymes Jill
Published: April 2015

Geriatric Rehabilitation. Edited by Kemp B, Brummel‐Smith K, Ramsdell JW. Boston, College Hill Press, 1990. 459 pages. PNS.
Aging and Postural Control
Authors: Maki B. E. , Holliday P. J. , Fernie G. R.
Published: April 2015

Two different balance testing methods were compared: (1) measurement of spontaneous postural sway during quiet standing, and (2) measurement of induced postural sway in response to an applied postural perturbation. Eyes‐open tests were performed in 64 healthy young and elderly adults and in five elderly subjects with a history of falling. In both balance tests, the sway was defined in terms of the displacement of the center of pressure on the feet. Spontaneous sway was quantified using a number of different amplitude‐ and frequency‐based parameters. Induced sway was measured in response to anterior‐posterior acceleration of a platform on which the subject stood. The induced‐sway test was specially designed to be safe and nonthreatening for elderly subjects; thus, the platform perturbation was confined to small accelerations and a gentle pseudorandom motion was used. To derive a measure of postural stability, the data from this test were fitted with a model that was then used to predict the response to sudden (transient) perturbations, thereby simulating the response in actual falls. Although both induced‐ and spontaneous‐sway measures demonstrated significant aging‐related decreases in stability, the differences were more pronounced for the induced‐sway data. Conversely, some of the spontaneous‐sway measures were much more successful in distinguishing the fallers from the nonfallers. There was a significant correlation between induced‐sway and certain spontaneous‐sway measures in the normal young adults; however, in the elderly normals and fallers, the data from the two types of balance tests either showed no correlation or, for certain spontaneous‐sway measures, tended to show an inverse relationship.
The Use of Simvastatin, an HMG CoA Reductase Inhibitor, in Older Patients with Hypercholesterolemia and Atherosclerosis
Authors: Bach Leon A. , Cooper Mark E. , O'Brien Richard C. , Jerums George
Published: April 2015

Epidemiological evidence suggests that elevated serum cholesterol, especially the low density lipoprotein (LDL) fraction, the total/high density lipoprotein (HDL)–cholesterol ratio, and the LDL/HDL–cholesterol ratio, remains a risk factor for atheromatous disease up to the age of 79 years. We studied the efficacy and tolerability of simvastatin, an HMG CoA reductase inhibitor, in 20 patients aged 65 to 75 years with clinical evidence of atheromatous disease. After four weeks of treatment, there was a 29% fall in LDL‐cholesterol levels (P < .01 vs placebo) with low dose simvastatin and a 38% fall with high dose simvastatin (P < .001 vs placebo). Similar falls were seen in total cholesterol levels and the LDL/HDL–cholesterol and total/HDL–cholesterol ratios. Apoprotein B levels decreased by approximately 20% with both doses (P < .05 vs placebo). In an open extension of the study, the decreases in lipid parameters were sustained for a further 48 weeks of treatment with doses of simvastatin ranging from 10 to 40 mg. Two patients required the addition of cholestyramine. Although a small study like this cannot establish safety and tolerance, side effects were minor and did not require stopping therapy in any patient. Simvastatin is an effective cholesterol lowering agent in older patients.
Effects of Long‐Term Treatment with Probucol on Serum Lipoproteins in Cases of Familial Hypercholesterolemia in the Elderly
Authors: Morisaki Nobuhiro , Mori Seijiro , Kobayashi Junji , Ishikawa Yo , Shinomiya Masaki , Shirai Kohji , Saito Yasushi , Yoshida Sho
Published: April 2015

The effect of probucol in lowering serum lipoprotein in young and middle‐aged (YM) and elderly (E) patients with familial hypercholesterolemia were compared. Probucol at 1000 mg/day was administered orally to 37 YM patients and 14 E patients for an average of 10 months. Probucol treatment for this period caused significant reductions in the serum levels of total cholesterol, low density lipoprotein cholesterol (LDL‐C), high density lipoprotein cholesterol, and apoprotein AI, AII, B, and CIII in both groups. The decreases in the levels of total cholesterol, LDL‐C, and apoprotein B were greater in the E group than in the YM group (total cholesterol: YM, −19.3%, E, −31.3% [P < .001]; LDL‐C: YM −17.0%, E, −35.4% [P < .001]; apoprotein B: YM, −12.3%, E, −28.1% [P < .01]). The decreases in other parameters in the two groups were not significantly different. The serum probucol concentrations in the YM and E groups were not significantly different. No significant side effects were observed in any patient. Thus probucol reduced the serum level of LDL more in the E group than in the YM group, and did so without any increase in the serum concentration of the drug or in side effects, suggesting that probucol is safe and beneficial for use in elderly patients.
Somatostatin‐Like Immunoreactivity in the Cerebrospinal Fluid of Aged Patients with Parkinson's Disease
Authors: Masson H. , Popescu I. , Strubel D. , Cramer H. , Kuntzmann F.
Published: April 2015

Cerebrospinal fluid (CSF) somatostatin concentrations were measured in 35 aged patients with Parkinson's disease (mean age, 79.5 years) and 11 control subjects (mean age, 82.3 years). In patients with Parkinson's disease the levels of somatostatin‐like immunoreactivity were lower than in controls (P < .02); these values were lowest in the untreated group. Somatostatin‐like immunoreactivity levels in the CSF tended to increase with treatment but not significantly (P = .11). Somatostatin values were not correlated to age, sex, or duration of the disease. Somatostatin concentrations tended to be lower in more severely affected patients with higher scores on the Hoehn and Yahr (P = .13) and Webster staging scales (P = .13) and lower scores on Mini‐Mental State (P = .10), but without statistical significance for these correlations.
Growth of the Teaching Nursing Home
Authors: Rubenstein Laurence Z. , Wieland Darryl , Pearlman Robert A. , Grover Prakash , Mabry Judith
Published: April 2015

Nursing homes are becoming increasingly involved with medical education, and the Veterans Administration (VA) has been particularly active in this movement. We conducted a system‐wide survey of VA nursing home facilities to determine the degree to which they participate in medical and other professional training and the features associated with such training. Of the 116 VA nursing homes in 1987, 113 (97.4%) returned completed questionnaires. Compared to “standard” VA facilities (n = 85), “teaching” nursing homes (n = 28)—those in which physicians received at least 20 hours of training per capita annually—were significantly larger, admitted and discharged significantly more patients per occupied bed, and placed a significantly larger proportion of discharged patients in noninstitutional community settings. Care costs in the teaching nursing homes were slightly but not significantly higher, despite significant increases in levels of professional staffing and amounts of training activities in all disciplines. During the survey year, teaching nursing homes provided training experiences for 440 students, residents, and fellows in internal and rehabilitation medicine, as well as for 2,700 other health professionals. The growth of teaching nursing homes in the VA system appears to be associated with positive changes in the pattern of health‐care delivery, and it is increasing the number of health‐care professionals trained in long‐term care.
Deciding to Restrain Medical Patients
Authors: Macpherson David S. , Lofgren Richard P. , Granieri Rosanne , Myllenbeck Sharon
Published: April 2015

To determine when and why patients are placed in mechanical restraints, we surveyed the nurse and physician caring for each of 102 restrained patients from the general medical floors of an acute‐care hospital. Ninety‐three percent of the questionnaires were completed. Nursing questionnaires indicated that over half of patients were restrained during the evening shift. Nurses initiated the use of restraints in 75% of cases. Fifteen percent of the patients' physicians were unaware that the patient had been restrained. In the majority of cases, the nurse and physician believed that restraint was the best alternative for managing the patient although more physicians (11%) than nurses (2%) thought an alternative intervention would be better (P < .02). As a group, physicians and nurses restrained patients for similar reasons, most often to prevent falls from bed (69%) or to protect medical devices (36%). However, there was poor agreement between the nurse and physician as to the reason for restraint in an individual patient (kappa statistic range from .02 to .43). These findings suggest that nurse and physician communication regarding restraint is poor. We recommend that acute‐care hospitals adopt policies to promote communication between nurses and physicians concerning restraints to ensure that use of this potentially hazardous intervention is used only when necessary.
Nutritional Intake, Socioeconomic Conditions, and Health Status in a Large Elderly Population
Authors: Bianchetti Angelo , Rozzini Renzo , Carabellese Corrado , Zanetti Orazio , Trabucchi Marco
Published: April 2015

The nutritional intake of a large population of noninstitutionalized older people living in an urban area was studied in relation to socioeconomic conditions (living environment, income, and education) and health status (affective, functional, and physical health) to identify the subgroups at risk for malnutrition. Twenty‐four‐hour dietary recall was used to determine the percentage of older subjects with dietary intake of specific nutrients below two thirds of the 1980 Recommended Dietary Allowances. Ninety percent of the older people examined showed inadequate intake of thiamine and vitamin B6, and 30% to 40% demonstrated deficiencies of vitamin A, vitamin C, niacin, vitamin B12, calcium, and iron; only 10% of subjects had inadequate intake of protein. Poor nutritional intake was correlated more strongly with socioeconomic conditions, functional level, and affective status than with physical health status.
Cruzan v Harmon, andIn the Matter of O'Connor
Authors: Gasner M. Rose
Published: April 2015

Two recent court cases,Cruzan v HarmonandIn the Matter of O'Connor, denied family requests to withhold or withdraw life‐sustaining treatment. The facts of the cases are discussed, as well as the impact on medical practice for physicians in Missouri and New York. Approaches of other state courts are pointed out. While critical of the judicial reasoning in both cases, the article provides guidance to doctors about how to work within the court decisions and still honor patient wishes.
Early Readmission of Elderly Patients With Congestive Heart Failure
Authors: Vinson Janice M. , Rich Michael W. , Sperry Jane C. , Shah Atul S. , McNamara Timothy
Published: April 2015

Repetitive hospitalizations are a major health problem in elderly patients with chronic disease, accounting for up to one fourth of all inpatient Medicare expenditures. Congestive heart failure, one of the most common indications for hospitalization in the elderly, is also associated with a high incidence of early rehospitalization, but variables identifying patients at increased risk and an analysis of potentially remediable factors contributing to read‐mission have not previously been reported.

We prospectively evaluated 161 patients 70 years or older that had been hospitalized with documented congestive heart failure. Hospital mortality was 13% (n = 21). Among patients discharged alive, 66 (47%) were readmitted within 90 days. Recurrent heart failure was the most common cause for readmission, occurring in 38 patients (57%). Other cardiac disorders accounted for five readmissions (8%), and noncardiac illness led to read‐mission in 21 cases (32%). Factors predictive of an increased probability of readmission included a prior history of heart failure, four or more admissions within the preceding 8 years, and heart failure precipitated by an acute myocardial infarction or uncontrolled hypertension (all P < .05). Using subjective criteria, 25 first readmissions (38%) were judged possibly preventable, and 10 (15%) were judged probably preventable. Factors contributing to preventable readmissions included noncompliance with medications (15%) or diet (18%), inadequate discharge planning (15%) or follow‐up (20%), failed social support system (21%), and failure to seek medical attention promptly when symptoms recurred (20%).

Thus, early rehospitalization in elderly patients with congestive heart failure may be preventable in up to 50% of cases, identification of high risk patients is possible shortly after admission, and further study of nonpharmacologic interventions designed to reduce readmission frequency is justified.
Beliefs and Policies of Maryland Nursing Home Medical Directors Regarding Tetanus Immunization
Authors: Richardson James P. , Knight Aubrey L. , Stafford Douglas T.
Published: April 2015

Tetanus is more common in the elderly, who have a higher case‐fatality rate than younger age groups. Immunization against tetanus is recommended for all elderly, including nursing home residents, but the tetanus immunization policies of nursing homes are unknown. Nursing home medical directors in Maryland were surveyed about their beliefs concerning tetanus and the tetanus immunization policies of their nursing homes. One hundred twenty‐five directors of 212 responded (59%). In most of the nursing homes, no policies existed for routine tetanus immunization. Medical directors graduating from medical school after 1960 and medical directors with more than 50 nursing home patients were more likely to believe that tetanus immunization is cost‐effective in nursing home patients. Only 3% of the respondents always immunize their nursing home patients with chronic skin ulcers. We believe tetanus immunization is an uncommon practice in Maryland nursing homes. Nursing home medical directors should establish policies to promote tetanus immunization.
Causes of Death in the Elderly and Their Changing Pattern in Hisayama, a Japanese Community
Authors: Ueda Kazuo , Hasuo Yutaka , Ohmura Takao , Kiyohara Yutaka , Kawano Hideo , Kato Isao , Shinkawa Atsushi , Iwamoto Hiromitsu , Nakayama Keizo , Omae Teruo , Fujishima Masatoshi
Published: April 2015

The causes of death for the elderly were prospectively studied in Hisayama, Japan, a rural community. We compared 1,621 subjects, aged 40 years or over, recruited in 1961, and 2,053 subjects recruited in 1974. Each cohort was studied in a follow‐up that lasted 10 years; they had autopsy rates of 82.1% and 86.1% during each 10‐year period, respectively. The most common causes of death for those aged 70 years or over were cerebrovascular disease, malignant neoplasms, and pneumonia. Deaths due to cerebrovascular disease tended to decrease in the recent cohort, but the proportion of decline was more prominent in cases aged 40 to 69 years. There was a sex difference in the changing pattern of mortality from heart diseases including ischemic heart disease. Deaths by both heart diseases and ischemic heart disease increased in the more recent cohort of aged women, whereas they decreased in the aged men. Pneumonia was an important cause of death for the elderly in both cohorts. Deaths due to “senility” were rare, being only 1% of the deceased aged 70 or over. With prolonged lifespan, especially for women, the impact of atherosclerosis and its related disorders on the recent Japanese aged population appears to have increased.
The Trajectory of Dying
Authors: Bortz Walter M.
Published: April 2015

The case records of the 97 patients in the largely geriatric clinical practice at the Palo Alto Medical Clinic who died in 1987 were reviewed. Functional states 12 months, six months, and one week before death were determined retrospectively in an attempt to establish the degree of functionality in the period before death, and particularly to assess the impact of age on this functionality. The data of the series suggest that age per se is not closely correlated with dysfunction. Further, use of the hospital for terminal care was largely confined to more functional patients.
Effects of Exercise Training in the Elderly on the Occurrence and Time to Onset of Cardiovascular Diagnoses
Authors: Posner Joel D. , Gorman Kevin M. , Gitlin Laura N. , Sands Laura Prouty , Kleban Mortan , Windsor Lisa , Shaw Carl
Published: April 2015

To examine the long‐term effects of aerobic exercise on the occurrence and time to onset of cardiovascular diagnoses, 184 initially healthy older subjects were randomized into either a long‐term exercise group (Group A, n = 80), a short‐term exercise group (Group B, n = 42), or a contact control group (Group C, n = 62). After completion of two years in the study, data on new cardiovascular diagnoses and time to onset of these diagnoses in each of the three groups were compared. The occurrence rates for new onset diagnoses were as follows: Group A, 2.5%; Group B, 2%; and Group C, 13%; the average time to onset was greatest for the long‐term exercisers and shortest for the contact control group (P ≤ .02). The results suggest that a regular program of exercise may have cardiovascular benefits for those over 60 years of age.
A Randomized Trial of Family Caregiver Support in the Home Management of Dementia
Authors: Mohide E. Ann , Pringle Dorothy M. , Streiner David L. , Gilbert J. Raymond , Muir Gisele , Tew Michelle
Published: April 2015

A randomized trial of family caregiver support for the home management of older people suffering from moderate to severe progressive irreversible dementia was conducted in an urban center in southern Ontario. Thirty caregivers were allocated to receive the experimental intervention consisting of: caregiver‐focused health care, education about dementia and caregiving, assistance with problem solving, regularly scheduled in‐home respite, and a self‐help family caregiver support group. Thirty control subjects received conventional community nursing care. Before completion of the intervention, 18 (30%) were withdrawn, almost equally from each group. The most frequent reason was long‐term institutionalization of the demented relative (n = 10). At baseline, caregivers in both groups were suffering from above‐average levels of depression and anxiety. After the six‐month intervention period, we found neither experimental nor control group improved in these areas. However, the experimental group showed a clinically important improvement in quality of life, experienced a slightly longer mean time to long‐term institutionalization, found the caregiver role less problematic, and had greater satisfaction with nursing care than the control group.
Caregiver Burden Should Be Evaluated During Geriatric Assessment
Authors: Brown Lisa J. , Potter Jane F. , Foster Betty G.
Published: April 2015

This study examines the relationship between caregiver burden and use of long‐term care services following geriatric assessment. One hundred nine older subjects underwent comprehensive assessment, which included a questionnaire completed by the primary caregiver to assess the sense of burden in providing care. Logistic regression was used to identify independent predictors of service use at 12 months. Among measures of the older person's cognitive and physical abilities, only activities of daily living predicted increased use of services. When the measure of caregiver burden was added, it also entered as an independent predictor, which significantly improved the prediction of service use (χ2 = 5.9, P < .02). In a separate analysis, caregiver burden predicted both the use of home services and nursing‐home placement. During longitudinal follow‐up, the measure of burden decreased over 12 months for the sample, with the greatest reduction in burden occurring for caregivers whose relative was placed in a nursing home. The fact that caregiver burden was the most important factor in determining who would use formal services suggests that burden should be evaluated as part of geriatric assessment.
Does Inpatient Interdisciplinary Geriatric Assessment Help the Family Caregivers of Acutely Ill Older Patients?
Authors: Silliman Rebecca A. , McGarvey Stephen T. , Raymond Patricia M. , Fretwell Marsha D.
Published: April 2015

Comprehensive geriatric assessment has emerged as an effective strategy for improving outcomes for frail older patients in the hospital setting. Attention, however, has not been given to determining whether this process has any effect on their family caregivers. As part of a randomized controlled clinical trial designed to test the efficacy of early interdisciplinary geriatric assessment for acutely ill hospitalized patients 75 years of age or older, their family caregivers were studied to determine if the process had a positive effect on caregivers' self‐reported health and emotional well‐being. One hundred forty‐two caregivers were approximately evenly distributed between experimentals (n = 69) and controls (n = 73). By three months after the patients' hospitalization, experimental caregivers were more likely to report good general health (81% vs 63%, P = .049) than were controls. The positive effect persisted after statistical adjustment for confounding variables. Experimental caregivers were not significantly more likely to have good emotional health at follow‐up than were controls (65% vs 58%, P = .43), even after statistical adjustment. Although the findings are modest, they suggest that the acute hospital setting may be an ideal place to develop interventions designed to enhance family caregivers' well‐being during the early months following hospitalization. This may be particularly true when the interventions with caregivers are coupled with a geriatric assessment and care plan process.
Taking to Bed
Authors: Clark Linda P. , Dion Denise M. , Barker William H.
Published: April 2015

The objective of this study was to determine the incidence and selected clinical outcomes of taking to bed among a population of independently ambulating older individuals. It was designed as a retrospective case series and was conducted in the intermediate‐care facility of a not‐for‐profit, teaching nursing home. Our study group was composed of individuals over 65 years of age who became bed bound. Thirty‐six taking‐to‐bed episodes occurred in 36 individuals during one calendar year, giving an incidence of 13 per 1,000 resident‐months (95% CI, 4 to 23 per 1,000). Twelve of the 36 died within 3 months, and 17 within 6 months, but almost all who survived regained ambulation. Survival was significantly shorter for the five without localizing symptoms (P < .05). Orthopedic, neurologic, psychiatric, and iatrogenic conditions were most commonly identified as concurrent medical events. Almost half who took to bed had multiple concurrent medical events, and these residents were more likely to present without localizing symptoms (P < .05). Twenty‐one (58%) of the episodes occurred after a fall.

The incidence of taking to bed in this population indicates that clinicians caring for older persons should be alert to its occurrence. The dramatic decline in mobility deserves careful assessment because it initiated a period of relatively rapid change in the health careers of the individuals we studied: almost half died within 6 months, but nearly all who survived regained ambulation. Those without localizing symptoms may have more complex interacting medical problems and a worse prognosis.
A Hierarchical Exercise Scale to Measure Function at the Advanced Activities of Daily Living (AADL) Level
Authors: Reuben David B. , Laliberte Linda , Hiris Jeffrey , Mor Vincent
Published: April 2015

Standard functional assessment instruments often fail to capture subtle impairment in community‐dwelling older persons. To create a scale to measure function at the Advanced Activities of Daily Living (AADL) level, we chose three questions to separate a community sample into four levels: frequent vigorous exercisers (8.0%), frequent long walkers (10.8%), frequent short walkers (23.7%), and nonexercisers (57.5%). These levels of exercise formed a hierarchical scale that correlated positively in a graduated manner with progressively advanced social activities of daily living, current health status, and mental health. At 1‐year follow‐up, 20% of persons declined in exercise level, 63% showed no change in exercise level, and 17% improved their exercise level. Changes in exercise level in both directions were associated with changes in mental health status. The Advanced Activities of Daily Living scale may be a sensitive measure of earlier functional decline, but longer follow‐up will be necessary to determine its clinical usefulness.
Comorbid Psychiatric Disorders in Elderly Medical Patients: A 1‐Year Prospective Study
Authors: Rapp Stephen R. , Parisi Sharon A. , Wallace Clinton E.
Published: April 2015

Cross‐sectional studies have revealed a high prevalence of comorbid psychological problems among geriatric medical patients, a low rate of detection by primary care professionals, and greater psychosocial dysfunction and poorer physical health associated with comorbidity. Less is known about the course and impact of psychiatric comorbidity. Psychiatric status, physical health status, psychosocial functioning, and health care utilization for a sample of geriatric patients (n = 102) were assessed on admission to a medical hospital and again one year later. Results revealed a very stable and high prevalence of comorbid psychological problems, especially depression, a low rate of treatment by mental health professionals, greater physical impairment consistently associated with psychiatric comorbidity, but few health care utilization differences. A closer look at depression revealed that it typically began in late life and did not readily resolve.
Mini‐Mental State Exam Scores Vary with Education in Blacks and Whites
Authors: Murden Robert A. , McRae Thomas D. , Kaner Steven , Bucknam Mary E.
Published: April 2015

Previous studies have suggested that education and race may affect performance on standardized mental status tests. In order to more clearly define these relationships, a prospective longitudinal study was devised to answer two questions: (1) whether race or level of education affects scores on the Mini‐Mental State (MMS) exam in non‐demented people and (2) what numerical cutpoints maximize the sensitivity and specificity of utilizing the MMS to help diagnose dementia in blacks of varying educational attainment.

A total of 100 white and 258 black individuals, recruited from two city hospital primary care geriatric clinics, were evaluated and subsequently followed longitudinally over a 2 1/2 year period in order to assess accurately the presence or absence of dementia. In the non‐demented, total MMS scores and performance on each item of the MMS were analyzed, revealing that people with an 8th grade or less education consistently had significantly (P < .01) worse results than the better educated (9th grade or better) on borough, attention items, recall of table and dog, copying, sentence writing, phrase repeating, and total score. Furthermore, a total of 25% of the lower education group had an MMS score in the 18–23 range, traditionally thought to suggest dementia. There were no consistently significant differences between blacks and whites of equal education. In the better educated groups, using a score of 23 or less to define dementia maximizes the sensitivity and specificity of using the MMS in this diagnosis at 93% and 100%, respectively. In the lower education group, using 17 or less to define dementia maximizes sensitivity and specificity at 81% and 100%, respectively. It is concluded that MMS results are affected by education but not by race, that only certain MMS items are educationally related and perhaps could be modified, and that on the unmodified MMS a score of 17 or less should be used as the outpoint for suggesting the presence of dementia in the poorly educated.
Geropsychiatry in Long‐Term Care: A Nurse‐Centered Approach
Authors: Santmyer Karen S. , Roca Robert P.
Published: April 2015

High prevalence rates of psychiatric disorders and disruptive behaviors in nursing home residents create the need for structured programs of psychiatric consultation and teaching in the long‐term care setting. Over 40 months, 473 residents were evaluated by a psychiatric consultation‐liaison clinical nurse specialist; 100 of these cases were reviewed in detail. Apparent depression was the most common reason for referral, and depressive and adjustment disorders were the most common diagnostic conclusions of the consultation team. Behavioral complications of dementia were also frequently diagnosed. Treatment recommendations usually included the development of a behavioral management plan, but the institution of psychotropic medications, usually antidepressants, was indicated in about one‐fifth of the 100 cases. Treatment interventions were effective in the majority of cases. About one‐half of the problems prompting referral were within the expertise of the nurse specialist and did not require the direct involvement of the geropsychiatrist. This nurse‐centered consultation model proved effective, well accepted, and easy to implement.
The Effect of Caffeine on Postprandial Hypotension in the Elderly
Authors: Heseltine D. , Dakkak M. , Woodhouse K. , Macdonald I. A. , Potter J. F.
Published: April 2015

In a double‐blind, randomized trial the effects of caffeinated and decaffeinated drinks on postprandial hemodynamic and neurohumoral changes were studied in seven fit, elderly subjects after a standard 2.4MJ meal. There was a significant difference in supine postprandial systolic blood pressure between the placebo and caffeine phases (P < 0.01); at 60 minutes, supine systolic blood pressure had fallen 14 mmHg [95% confidence interval (CI) −7 to −11 mmHg, p < 0.01) after placebo, but was unchanged after caffeine (+9 mmHg, CI 0 to 18 mmHg, NS]. Similar differences between placebo and caffeine were seen in erect systolic and diastolic blood pressure (P < 0.01), although orthostatic tolerance was maintained throughout each study period. Postprandial plasma noradrenaline levels were higher (P < 0.02) and the increase greater (P < 0.02) after caffeine than after placebo. Caffeine administered at the end of a standard test meal prevents the postprandial fall in blood pressure in fit, elderly subjects. The clinical relevance of this finding has yet to be determined, but it may offer a simple remedy for patients with symptomatic postprandial hypotension.
The Influence of Food Temperature on Postprandial Blood Pressure Reduction and Its Relation to Substance‐P in Healthy Elderly Subjects
Authors: Kuipers Harrie M. M. , Jansen René W. M. M. , Peeters Theo L. , Hoefnagels Willibrord H. L.
Published: April 2015

Blood pressure (BP) in the elderly may decrease after a meal or oral glucose loading. The mechanism of this phenomenon is still unclear. In addition, the effect of the temperature of a meal on postprandial BP is unknown. However, it has been suggested that vasoactive gastrointestinal peptides are involved in the etiology of postprandial BP reduction. Therefore, we studied the effects of a cold and a warm glucose solution on BP, heart rate, plasma glucose, insulin, and substance‐P levels in 15 healthy elderly subjects with a mean age of 74 ± 3 (SD) years. With an interval of at least 2 days, a warm (50° C) and a cold (5° C) solution (75 g glucose/300 mL water) were given in random order. After the cold glucose loading mean arterial pressure increased by a maximum of 3.9 ± 1.3 mmHg (P < 0.01). In contrast, BP decreased after the warm solution by a maximum of 8.0 ± 1.1 mmHg (P < 0.001). Neither test had an influence on plasma substance‐P levels. Our data suggest that postprandial blood pressure reduction in the elderly is dependent on food temperature. Substance‐P does not seem to play a role in this phenomenon.