bluuebunny/crossref_metadata_2025 huggingface dataset:
A Sensitive Thyroid Stimulating Hormone Assay for Screening of Thyroid Functional Disorder in Elderly Japanese
Authors: Okamura Ken , Ueda Kazuo , Sone Hisao , Ikenoue Hiroshi , Hasuo Yutaka , Sato Kaori , Yoshinari Mototaka , Fujishima Masatoshi
Published: April 2015

The use of a screening test for thyroid functional disorder by sensitive thyroid stimulating hormone assay in the elderly was investigated. The basal thyroid stimulating hormone levels predicted the response of thyroid stimulating hormone to thyrotropin releasing hormone; it was suppressed in 99 (99.0%) of 100 hyperthyroid patients. Therefore, not only primary hypothyroidism but also hyperthyroidism can be excluded when the serum thyroid stimulating hormone levels are normal.

An epidemiological study was then performed on 2,421 (76.7%) of the Japanese general population aged 40 or over recruited from the residents in Hisayama town and also in 122 residents between 20 and 40 years of age. Additional free T4 measurement was necessary in about 10% of the residents with abnormal TSH levels to confirm the diagnosis of hyperthyroidism or distinguish latent from overt hypothyroidism. There was a significant correlation between age and serum thyroid stimulating hormone levels after logarithmic conversion (r = 0.1533, P < .001). The prevalence of thyroid dysfunction found in 1,026 males and in 1,395 females aged 40 or over was, respectively: hyperthyroidism, < 0.1% and 0.2%, latent (subclinical) hypothyroidism, 3.2% and 5.5%, and overt hypothyroidism, 0.4% and 0.7%.

We conclude that the screening with this sensitive thyroid stimulating hormone assay and additional free T4 measurement is useful for detection of patients with thyroid functional disorder.
Deaths from Residential Fires among Older People, United States, 1984
Authors: Gulaid Jama A. , Sacks Jeffrey J. , Sattin Richard W.
Published: April 2015

Deaths from fires are the fifth leading cause of injury death among people aged 65 years or older. To describe the epidemiology of deaths from residential fires among older people, we analyzed mortality data for 1984 collected by the National Center for Health Statistics. Although older people represented only 12% of the U.S. population in 1984, they accounted for 29% (1,278) of that year's 4,466 residential fire deaths. Conflagrations accounted for 78% of older people's deaths from residential fires; clothing ignitions and other fires accounted for 11% each. Residential fire death rates increased with advancing age. Older black people had death rates 4.6 times the death rates of older white people. Older males had higher death rates than older females. Host, environmental, and behavioral risk factors for residential fire deaths among older people and potential strategies for intervention are discussed. Unless intervention strategies are focused on older people, the residential fire death toll in the U.S. may actually grow as the population of older people increases from 12% of the population in 1984 to about 21% of the population in 2030.
Patient Age as a Factor in Radiotherapy
Authors: Steinfeld Alan D. , Diamond James J. , Hanks Gerald E. , Coia Lawrence R. , Kramer Simon
Published: April 2015

We studied the effect of patient age on treatment decisions related to radiation therapy using data obtained through the Patterns of Care Study. Definitive treatment given for breast cancer (191 patients) and palliative therapy given for a variety of symptoms (784 patients) were investigated using data collected from 49 facilities selected on a random basis to reflect fairly the national practice of radiotherapy. Elderly (aged 70 or older) patients accounted for 23.6% of the palliatively treated patients and 19.5% of the definitively treated breast patients. No correlation was found between patient age and the dose or number of days used in palliative therapy. Older patients were more likely to have the “boost” dose of radiation to the tumor bed delivered through external rather than implant techniques. While statistically significant, this difference is not felt to be clinically important. We conclude that once a patient is selected for a course of radiation therapy, age per se, is not a basis for prejudicial treatment.
Evaluation of a Supervised Exercise Program in a Geriatric Population
Authors: Morey Miriam C. , Cowper Patricia A. , Feussner John R. , DiPasquale Robert C. , Crowley Gail M. , Kitzman Dalane W. , Sullivan Robert J.
Published: April 2015

Most studies that assess the effects of exercise in the elderly involve subjects who are in good health. The objective of this prospective longitudinal study was to examine the impact of exercise on cardiovascular fitness, flexibility, and strength in an elderly population that included chronically ill individuals. Patients were recruited initially from a population of veterans over 64 years of age who use a VA outpatient clinic as their regular source of care. The exercise intervention consisted of 90 minutes of exercise 3 days per week at 70% of the patient's maximal capacity. Activities included stationary cycling, stretching, weight training, and walking. Of 69 patients who began the program, 49 (71%) reached 4‐month follow‐up. Most patients completing follow‐up (76%) had at least one chronic disease, such as arthritis, hypertension, or heart disease. Patients who dropped out were more likely to have multiple chronic illnesses than those who remained in the program. Average weekly attendance was 65% and was stable over time. Improvements in cardiovascular fitness at 4‐month follow‐up were significant: Metabolic equivalents increased from 7.1 ± 2.3 to 8.3 ± 1.6 (P < .001), treadmill time increased from 8.5 ± 3.8 to 11.2 ± 4.1 minutes (P < .001), submaximal heart rate decreased from 123.7 ± 18.8 to 118.8 ± 19.4 beats per minute (P < .001) and resting heart rate decreased from 68.1 ± 10.6 to 63.3 ± 11.6 beats per minute (P = .005). Hip flexibility also increased significantly from 58.5 ± 13.8 to 67.7 ± 9.9 degrees (P < .001), and abdominal strength increased significantly from 88.8 ± 32.4 to 104 ± 28.4 foot‐pounds (P < .001). No major complications resulted from exercise. This study demonstrates that elderly individuals, including those with chronic diseases, will participate in an exercise program and experience improvements in cardiovascular fitness, strength, and flexibility. Whether these improvements will enable elderly individuals to live independently for a longer period of time and avoid or postpone the need for long‐term care requires additional study and follow‐up.
Acute Mesenteric Infarction in Elderly Pati
Authors: Finucane Paul M. , Arunachalam Tilakaprakash , O'Dowd John , Pathy M. S. John
Published: April 2015

The clinical features, the treatment given, the factors governing treatment selection, and the result of such treatment were analyzed in all patients aged 65 years and over in whom a tissue diagnosis of acute mesenteric infarction was made at a major teaching hospital. Thirty‐two such patients, of mean age 78.5 years, were identified during the 8‐year study period. Expected clinical features of bowel infarction were commonly absent; for example, there was no abdominal pain and no abdominal tenderness in 29% and 26% of patients, respectively. A sizeable minority of patients (29%) were acutely confused at presentation. All patients not undergoing surgery died shortly after admission to hospital. For those 20 patients (63%) who underwent abdominal surgery, half were discharged alive from hospital. Whether or not the patient survived was associated with the ward to which they were originally admitted. Those admitted to a surgical ward tended to be younger and had a more typical clinical presentation than their counterparts admitted to a medical ward. In particular they were more likely to have abdominal pain and distention and less likely to be confused. Surgical intervention was undertaken more often and earlier in those admitted to surgical wards and this may have accounted for the better outcome. It should be emphasized that acute mesenteric ischemia is a potentially correctable surgical condition even in very elderly people. A realization that the presentation is often atypical should increase the likelihood of early recognition and lead to improved patient survival.
The Malpractice Crisis: Relevance for Geriatrics
Authors: Kapp Marshall B.
Published: April 2015

The adverse effects of the current American medical malpractice problem on the practice of geriatric medicine have thus far been relatively minor, but real. This article discusses some of the prominent public policy issues involved in the ongoing debate about malpractice, with special application to older patients and their physicians. Suggestions are made for appropriate actions by geriatricians individually and collectively, in response to the malpractice situation.
Impaired Vision and Hip Fracture
Authors: Felson David T. , Anderson Jennifer J. , Hannan Marian T. , Milton Roy C. , Wilson Peter W. F. , Kiel Douglas P.
Published: April 2015

Falls affect a large proportion of the elderly and can result in a variety of injuries, including hip fractures. Several studies have suggested that visual impairment contributes to falls, but studies have not used standardized definitions of visual impairment and have not examined injurious falls or fractures. We looked at the risk of hip fracture associated with visual impairment in those members of the Framingham Study Cohort who took part in the Framingham Eye Study in 1973–75. Of 2,633 subjects followed for 10 years after the eye exam, 110 sustained hip fractures. The fracture rates in those with moderately impaired (20/30 to 20/80) vision (8.5%) and poor (20/100 or worse) vision (11.3%) were higher than in those with good (20/25 or better) vision (3.0%). After adjustment for age, sex, weight, alcohol consumption, and (in women) estrogen use, the relative risk of fracture in those with moderate impairment was 1.54 (95% CI = 0.95–2.49), while for those with poor vision, the relative risk was 2.17 (95% CI = 1.24–3.80). Of note, those with moderately impaired vision in one eye and good vision in the other had a higher risk of fracture (relative risk = 1.94) than those with a similar degree of binocular impairment (relative risk = 2.11). Poor vision in one or both eyes was linked to an elevated fracture risk. This suggests that good stereoscopic vision may be necessary to prevent falls. The risk of fracture with poor and moderately impaired vision combined was increased in women (relative risk = 1.96, 95% CI = 1.23–3.11) but not in men (relative risk = 0.79, 95% CI = 0.23–2.72). 17.5% (17/97) of women with poor vision in at least one eye sustained a hip fracture during the 10 years of the study. Cataracts were the most common cause of fracture‐related visual impairment, but neither cataracts nor other common eye diseases had an independent effect on fracture risk after adjustment for visual acuity. In sum, visual impairment is an important risk factor for hip fracture, especially among elderly women.
Distinguishing Alzheimer's Disease from Other Dementias
Authors: Kukull Walter A. , Larson Eric B.
Published: April 2015

Epidemiologic study of Alzheimer's disease by family history requires that Alzheimer's be distinguished from other dementias. Identification of demented family members is usually based on recall by relatives. This study examines the validity of the classification of Alzheimer's disease and other dementias based on relatives' reports. Close relatives of autopsy‐confirmed dementia cases were asked to complete a questionnaire describing the patient's symptoms. These informants were familiar with the patient's disease and involved in his/her care prior to death. The questionnaire included the DSM‐III criteria for Primary Degenerative Dementia and the Hachinski Ischemic Scale. A diagnosis derived from the close relatives' responses was compared to the neuropathologic diagnosis for thirty‐six cases: 20 Alzheimer's disease, 9 mixed Alzheimer's disease, and 7 non‐Alzheimer's disease dementias. The diagnosis of Primary Degenerative Dementia derived from questionnaire responses had a sensitivity of 0.93 and specificity of 0.43 for pathologic Alzheimer's disease. Few vascular dementias were included in the series, thereby precluding the study of so‐called multi‐infarct dementia. Hachinski scores based on relatives' responses classified 40% of pathologically pure Alzheimer's disease cases as multi‐infarct dementia (HIS > 7). Thus, using these elevated Hachinski scores to rule out Alzheimer's disease would cause substantial misclassification. Diagnosis based on questionnaire Primary Degenerative Dementia criteria was quite sensitive but relatively nonspecific. When attempting to obtain a complete family history or pedigree that describes the occurrence of Alzheimer's disease and other dementias in all family members, the questionnaire approach should be supplemented with additional information from medical records, physicians, and other relatives.
TRH Tests in a Healthy Elderly Population
Authors: Targum Steven D. , Marshall Lois E. , Magac‐Harris Kelly , Martin David
Published: April 2015

Thyrotropin releasing hormone (TRH) tests were conducted in 99 healthy elderly men and women between the ages of 65 and 89. The TRH test identified elderly patients with subclinical thyroid dysfunction not recognized by basal TSH values alone. Men revealed significantly diminished TSH responses to TRH injection relative to women. Mean ΔmaxTSH was 9.0 ± 8.3 μIU/mL in men vs 15.7 ± 14.8 μIU/mL in women (P < .01) reflecting the need to consider gender effect in the interpretation of TRH test responses.
Utility of Fever, White Blood Cells, and Differential Count in Predicting Bacterial Infections in the Elderly
Authors: Wasserman Michael , Levinstein Mark , Keller Eugene , Lee Stephen , Yoshikawa Thomas T.
Published: April 2015

A total of 221 elderly patients between the ages of 70 to 99 years who presented to a community‐based teaching hospital emergency room were prospectively evaluated by assessing for fever (≥ 37.5°C), leukocytosis (≥ 14,000/ mm3) and bandemia (> 6%) as a screening method for predicting the presence of bacterial infection. Thirty‐three patients had documented bacterial infections. Although with increasing body temperature the percent of patients who were infected increased, 48% of the infected elderly patients had no fever. In patients with fever, 39% had a bacterial infection compared to only 9% in the afebrile group. In patients with fever, leukocytosis, and bandemia, all patients were infected. Conversely, in the absence of fever, leukocytosis, and bandemia, only 6% had bacterial infection.

All elderly patients who present with an acute or subacute change in health status or functional capabilities associated with fever, leukocytosis, or bandemia should be carefully assessed for the high probability of a bacterial infection.
Dizziness in a Community Elderly Population
Authors: Sloane Philip , Blazer Dan , George Linda K.
Published: April 2015

Dizziness was studied in 1,622 community‐dwelling adults aged 60 and older who were interviewed as part of the Duke Epidemiologic Catchment Area study. The lifetime prevalence of dizziness (defined as severe enough to see a physician, to take a medication, or to interfere with daily activities) was 29.3%; the 1‐year prevalence was 18.2%. When the subgroup with dizziness was compared with those who never suffered dizziness, using logistic regression, four variables displayed the strongest associations: a constructed variable of risk for multiple neurosensory deficits, a cardiovascular risk score, a depression symptom inventory, and perception of self as a nervous person. In this population, dizziness was not associated with increased risk of death or institutionalization at the 1‐year follow up.
Behavioral Disturbance, Cognitive Dysfunction, and Functional Skill
Authors: Ten Linda , Borson Soo , Kiyak H. Asuman , Yamagishi Midori
Published: April 2015

The nature and severity of behavioral problems, and their relationship to cognitive and functional abilities, was investigated in 56 community‐residing patients with Alzheimer's disease. Measures evaluated three domains of function: behavior, cognition and activities of daily living. Problems of cognitive functioning, such as memory loss, confusion, and disorientation were most prevalent, reported to occur in 84%, 82%, and 64% of the sample, respectively. Problems with activity and emotional distress were next, affecting 20 to 43% of the sample. The mean number of problems reported was 10 per patient. Twenty‐two percent of caregivers reported a minimum of 15 problems occurring at least twice a week and no caregiver reported an absence of problems. Male patients were reported to have more behavioral difficulties. Level of behavioral disturbance was largely unrelated to cognitive or functional ability. Age was unrelated to cognitive or behavioral disturbance but significantly related to activities of daily living. Results indicated that behavioral problems are prevalent and pervasive in even moderately impaired community‐residing Alzheimer disease patients, and that age may be more important than level of cognitive dysfunction in predicting difficulties with activities of daily living.
Increasing Influenza Vaccination Adherence Through Voice Mail
Authors: Leirer Von O. , Morrow Daniel G. , Pariante Grace , Doksum Teresa
Published: April 2015

The number of influenza and influenza‐related deaths is alarmingly high, yet mean vaccination adherence rates among the high‐risk elderly population remain at only 20%. The present study investigates the use of an inexpensive voice‐mail system, TeleMinderTM, as a method of increasing influenza vaccination adherence among a subpopulation of elders identified as low adherers. The first group of older people received no intervention. Group 2 received a voice‐mail message informing them of the cost, time, date, and location of an influenza vaccination clinic. Group 3 was exposed to posted and verbal announcements alone. Group 4 both received voice mail and was exposed to posted and verbal announcements. Vaccination adherence levels for groups 1 through 4 were 1.5%, 11.8%, 7.4%, and 37.5%, respectively. Voice mail significantly increased vaccination adherence either alone or in combination with posted and verbal announcements. These findings suggest that voice mail provides an inexpensive means of increasing influenza vaccination rates.
Treatment of an Influenza A Outbreak in a Teaching Nursing Home
Authors: Peters Nancy L. , Oboler Steven , Hair Carole , Laxson Linda , Kost Jan , Meiklejohn Gordon
Published: April 2015

The safety and efficacy of current ACIP guidelines for the prevention and control of influenza in nursing home populations are uncertain. An outbreak of influenza A/Sichuan (H3N2) in a teaching nursing home during 1988 gave us the opportunity to evaluate the effectiveness of an influenza vaccination and amantadine prophylaxis protocol. Over 13 days, 12 of 60 residents developed influenza. Prior influenza vaccination had been given to 94% of the residents. Protection from infection occurred in those tested who had antibody levels ≥ 1:16 to the A/Leningrad (H3N2) antigen contained in the standard 1987–88 trivalent vaccine. However, five of 17 vaccinated residents who were tested had antibody levels ≤ 1:16 at the start of the outbreak. Amantadine (≤ 100 mg/day) was given to all but one resident starting on the third day of the outbreak, and to employees starting on the sixth day of the outbreaks. Seven residents developed illness after the start of amantadine, although amantadine appeared to ameliorate their symptoms. Although amantadine was generally well tolerated by residents, employees receiving amantadine identified a high incidence of side effects and only 44% of employees took at least 70% of the prescribed amantadine. In our opinion, early detection and protocol‐directed intervention probably abated a more severe influenza outbreak. Therefore we support existing recommendations that formal nursing home policies be established to ensure that residents and employees receive annual influenza vaccine and that chemoprophylaxis be used when outbreaks of influenza A are suspected.
Impact of Mild to Moderate Hearing Loss on Mental Status Testing
Authors: Uhlmann Richard F. , Teri Linda , Rees Thomas S. , Mozlowski Ken J. , Larson Eric B.
Published: April 2015

Mild to moderate hearing loss has been hypothesized to decrease performance on verbally‐administered cognitive tests as an artifact of testing. To evaluate this hypothesis, we conducted a randomized trial of a written version of the Mini‐Mental State Examination (MMSE), a cognitive screening instrument which, in its standard form, is primarily verbally administered. After baseline standard MMSE testing, 71 outpatients with Alzheimer's type dementia, 39 of whom (55%) had mild to moderate hearing deficits, and 32 of whom (45%) had normal hearing, were randomly assigned to receive either a written or standard MMSE. Hearing‐impaired patients exhibited lower standard MMSE scores than hearing‐unimpaired patients at baseline (P = .005). Contrary to expectation, however, on experimental administration, written MMSE scores were somewhat lower than standard MMSE scores in hearing‐impaired patients (P not significant). Furthermore, written MMSE scores were slightly higher than standard MMSE scores in hearing‐unimpaired patients (P not significant). These results suggest that the diminished cognitive performance associated with mild to moderate hearing loss is not necessarily an artifact of cognitive testing. In addition, these results provide preliminary evidence that a written MMSE is comparable to the standard MMSE and, thus, deserves further consideration for cognitive screening of profoundly hearing‐impaired individuals.
Nicergoline in Mild to Moderate Dementia
Authors: Battaglia Angelo , Bruni Giancarlo , Ardia Alfredo , Sacchetti Gabriele ,   Behalf of the Italian Nicergoline Study Group
Published: April 2015

In view of some controversies still existing about the real efficacy of ergot derivatives in the management of dementia, a double‐blind, randomized, parallel group trial extending up to 6 months was carried out to compare the effects of nicergoline, 60 mg daily, and placebo in 315 patients suffering from mild to moderate dementia. Clinical evaluation was performed by the SCAG scale. The trial, which included a 1‐month placebo run‐in period, showed that both placebo and nicergoline were associated with some degree of improvement. The effect of nicergoline, however, was significantly greater and more sustained, steadily increasing with time. In particular, the difference between nicergoline and placebo in mean total SCAG score was 5.5 at 3 months (95% confidence interval: 3.6–7.4) and increased to 9.8 at 6 months (95% confidence interval: 7.8–11.8). A comparison of nicergoline versus placebo in the frequencies of changes in each item of the SCAG showed also a significant difference at 6 months, the percent of patients displaying an improvement by at least 2 points ranging from 13.5 (bothersome) to 30.2 (disorientation) in nicergoline group, against 4.1 (self‐care) to 14.3 (fatigue) in placebo group. The safety of nicergoline, as judged by hemodynamic changes and drug‐related adverse reactions, was quite satisfactory.
The Effectiveness of Diabetes Education Programs for Older Patients and Their Spouses
Authors: Gilden Janice L. , Hendryx Michael , Casia Carla , Singh Sant P.
Published: April 2015

Improvements in diabetes knowledge, psychosocial functioning, and metabolic control were assessed following a six‐week diabetes education program for older male patients (aged 65 to 82 years) and their spouses. Before and after the program, scored questionnaires were administered to patients and their wives regarding knowledge, quality of life, stress, family involvement in diabetes care, and patient involvement in social activities. The patients were again assessed six months later. Results were compared to those of younger adult male patients (aged 28 to 64 years). The older patients significantly increased their knowledge of diabetes (P < .05), and to an extent equal to that of younger individuals. Reduction in stress correlated with their increase in knowledge (r = 0.9; P < .05) and their improved diet‐related quality of life (r = 0.7; P < .02). A decrease in stress was still evident six months after the program (P < .01). Perceived quality of life for areas requiring greater life‐style modification (diet and exercise) increased (P < .01), and was maintained at six months. In contrast, younger patients reported decreases in perceived quality of life (P < .05). Older patients with participating spouses, compared to those without, showed greater improvement in knowledge (P < .02), increase in family involvement (P < .05), less stress (P < .02), and improvement in metabolic control of diabetes (P < .001). The program increased spouses' knowledge and perceived involvement in the care of their diabetic partners (P < .01). This study suggests that diabetes education is an effective intervention for elderly patients and their spouses. A theoretical model of compliance and control specific to diabetes in the elderly is proposed.
Effect of Aging on Serum Albumin
Authors: Cooper James K. , Gardner Carole
Published: April 2015

Some studies have shown a negative association between age and serum albumin. Several of these studies included older people with known disease. Disease may reduce albumin in any age group. Other studies have shown no association between age and albumin. To investigate the association of age and albumin, albumin levels were determined in 241 apparently healthy subjects aged 55 to 101. A small but consistent negative regression slope of about 4% per decade was found for those aged over 70. Because the relationship to age was small, the finding of hypoalbuminemia in an elderly patient generally should be attributed to disease rather than age alone.
Risk Factors for Pressure Sores
Authors: Berlowitz Dan R. , Wilking Spencer Van B.
Published: April 2015

The purpose of this study was to identify prospectively risk factors for pressure sores and to compare these results with a cross‐sectional analysis in the same population. Medical records on all admissions to a chronic care hospital over a 13‐month period were reviewed. Data on potential risk factors were abstracted from the initial history, physical examination, nursing assessment, and laboratory studies. Pressure sore status on admission and at three weeks was determined from a standardized form completed on all patients with a sore. The cross‐sectional analysis was performed by comparing patients with and without a pressure sore at the time of admission. The cohort analysis used patients initially without a pressure sore and monitored for a new sore at three weeks. Factors associated with pressure sores on univariate testing were entered into a stepwise logistic regression model. One hundred of the 301 admissions presented with a pressure sore. Factors significantly associated with the presence of a sore were altered level of consciousness (OR = 4.1), bed‐ or chair‐bound (OR = 2.4), impaired nutritional intake (OR = 1.9), and hypoalbuminemia (OR = 1.8 for 10 mg/mL decrease). Of the 185 patients without a pressure sore, 20 (10.8%) developed a sore. Factors significantly associated with the development of a new pressure sore were a history of cerebrovascular accident (OR = 5.0), bed‐ or chair‐bound (OR = 3.8), and impaired nutritional intake (OR = 2.8). Neither urinary nor fecal incontinence, nor the presence of hypoalbuminemia, was associated with sore development. We have prospectively identified risk factors for pressure sores. Although cross‐sectional studies may identify several of these risk factors, important differences exist. Cohort studies should be used in future research.
Age‐Related Changes of Thyroid Function and Immunologic Abnormalities in Patients with Hyperthyroidism Due to Graves' Disease
Authors: Aizawa Torn , Ishihara Masaki , Hashizume Kiyoshi , Takasu Nobuyuki , Yamada Takashi
Published: April 2015

In order to clarify the reasons why hyperthyroidism due to Graves' disease is mild in aged patients compared to young patients, we examined the degree of hyperthyroidism and immune abnormalities in 371 untreated patients. The patients were divided into nine groups based on their age; groups A to I consisted of patients aged 0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and 80–89 years, respectively. Serum thyroxine (T4), triiodothyronine (T3), and thyroglobulin levels were highest in group B (patients aged 10–19 years) and decreased progressively with advancing age. T3/T4 ratio was also highest in group B and decreased progressively with age. These data reconfirmed that the degree of hyperthyroidism is milder in older patients. The prevalence of positive microsomal and thyroglobulin antibodies was highest in group B (patients aged 10–19 years) and progressively lower in older groups, suggesting that an association with Hashimoto's thyroiditis is less prevalent in aged patients. We suggest that hyperthyroidism due to Graves' disease is mild in aged patients because responsiveness of the thyrocyte to the abnormal stimulator, thyrotropin‐receptor antibody, may be reduced. Such reduced responsiveness may not be due to Hashimoto's thyroiditis, since the prevalence of antithyroid antibodies is lower in aged than in younger patients with hyperthyroidism due to Graves' disease.
Effects of Age, Education, and Physician Advice on Utilization of Screening Mammography
Authors: Coll Patrick P. , O'Connor Patrick J. , Crabtree Benjamin F. , Besdine Richard W.
Published: April 2015

We investigated the utilization of mammography as a screening test for breast cancer in a middle‐income Connecticut suburban community of 30,000 people. The sampling frame was community‐dwelling women aged 30 years and over who had telephones. Random digit telephone survey methods were used to identify a sample of 470 eligible subjects. Of those eligible to be included, 350 or 74.4% completed the interview. Analysis of data from the 171 respondents aged 50 years or greater indicated that women aged 65–80 years had a significantly lower rate of screening mammography than did women aged 50–64 years (χ2 = 6.6, P = .01). When further analysis was done to take into account the effects of education and of income on these rates, the association of age with mammography utilization was no longer statistically significant. Among women who recalled their physician advising a mammogram, 88% had had one performed. Among women who could not recall their physician advising a mammogram, 7% had had one. The impact of physician advice was statistically significant (χ2 = 110.3, P < .001). Physicians recommended screening mammography less often for patients with low level of education (χ2 = 21.6, P < .001), low income (χ2 = 7.8, df = 2, P = .02) and greater age (χ2 = 14.2, P = .003). We conclude that utilization of screening mammography in the community studied is related more strongly to education and to income than to age. The bivariate association of mammography utilization with age may be attributable to a cohort effect, rather than an age effect. Physician advice appears to be an important factor influencing the decision to have the procedure.
Severe Head Injury Hastens Age of Onset of Alzheimer's Disease
Authors: Gedye A. , Beattie B.L. , Tuokko H. , Horton A. , Korsarek E.
Published: April 2015

Head trauma has been found with greater frequency in the histories of Alzheimer patients than age‐matched controls in some studies, but not in others. We hypothesized that events that accelerate neuron loss, such as significant head trauma, hasten the onset of symptoms of Alzheimer's disease in persons vulnerable to the disorder. Retrospective data on 148 probable Alzheimer patients and 33 demented controls were examined. Alzheimer patients with severe head injury before the age of 65 showed onset of symptoms at an earlier age than Alzheimer patients without head trauma.
Reference Values for the Mini‐Mental
Authors: Heeren Th. J. , Lagaay A. M. , Beek W. C. A. V. , Rooymans H. G. M. , Hijmans W.
Published: April 2015

The Mini‐Mental State Examination (MMSE) was used in a population survey of all inhabitants of Leiden, the Netherlands, over 85 years (n = 1258). In this paper we report on 532 subjects without neurological or psychiatric disease. Results show that the median score and lowest quartile cut‐off score remain high until the tenth decade (median score = 28, lowest quartile cut‐off score = 26). Thus age, in itself, is not a major limitation in using the MMSE. In this study a comparatively low level of education (the majority had 6 to 7 years of education) did not affect the results on the MMSE in a negative way, nor did we find an association with the use of psychoactive drugs.
Assessing Treatment Decision‐Making Capacity in Elderly Nursing Home Residents
Authors: Fitten L. Jaime , Lusky Richard , Hamann Claus
Published: April 2015

Clinicians usually employ indirect measures of cognitive and physical function in order to assess medical decision‐making capacity. We tested a reference group of well elderly (Mini‐Mental State Exam [MMSE] score = 29.1 ± 0.8, mean ± SD), for their understanding of three increasingly complex, hypothetical treatment situations or “vignettes”—use of a hypnotic, need for thoracocentesis, and desire for CPR. From this, we have developed a more direct, Guttman‐like assessment of decision‐making capacity. Of 51 Veterans Affairs nursing home residents (MMSE score = 22.4 ± 6.9), only 33.3% demonstrated intact decision‐making capacity by this method, whereas 77% were felt by their primary physicians to be capable of giving consent for oral surgery; 37.3% had very impaired decision‐making capacity; and 29.4% were intermediate in this ability.

Judged against our more direct assessment of decision‐making capacity, primary physicians' judgment of capacity for consent was 31% to 39% sensitive in identifying impaired decision‐making and the MMSE was 53% to 63% sensitive. These measures were 100% and 82% to 83% specific in identifying intact decision‐making capacity, respectively. We conclude that (1) more directly assessed decision‐making capacity varies noticeably among elderly nursing home residents and correlates in only limited fashion with frequently used cognitive screening methods; and (2) cognitive screening tests underestimate the prevalence of impaired decision‐making capacity in this population. For informed consent and advance directives, our study suggests that decision‐making capacity should be directly, rather than indirectly, assessed.
BOOK REVIEWS
Authors: Kaplan Cyril J. , Barzel Uriel S.
Published: April 2015

Comprehensive Care of Orthopaedic Injuries in the Elderly. Edited by Zuckerman JD. Baltimore, MD, Urban & Schwarzenberg, 1990. 699 pages, PNS.
BOOK REVIEWS
Authors: Kapp Marshall B.
Published: April 2015

Everyday Ethics: Resolving Dilemmas in Nursing Home Life. Edited by Kane RA and Caplan AL. New York, Springer Publishing Company, 1989. 331 pages. #34.95.
Effect of Aging on Vasopressin, Catecholamines, and Alpha2‐Adrenergic Receptors
Authors: Bursztyn Michael , Bresnahan Margaret , Gavras Irene , Gavras Haralambos
Published: April 2015

To characterize normal changes with aging, we measured plasma levels of epinephrine, norepinephrine, and vasopressin, as well as alpha2‐adrenergic receptor numbers (Bmax) and the antagonist dissociation constant (Kd) from platelet‐derived membranes of white, younger (aged 28 ± 6 years, n = 30) and older (aged 70 ± 4 years, n = 41) normotensive, healthy volunteers. There were no differences in resting vasopressin or epinephrine levels at 0.83 ± 0.83 and 360 ± 120 pmol/L in the younger versus 1.0 ± 0.2 and 450 ± 420 in the older subjects, respectively. However, plasma norepinephrine was significantly higher in the older (2.87 ± 1.34 nmol/L) versus the younger subjects (1.50 ± 0.53 nmol/L, P < .01). Platelet alpha2‐receptor numbers were significantly lower in the older subjects at 289 ± 79 fmol/mg protein versus 388 ± 81 fmol/mg protein in the younger subjects (P < .01), compatible with but not proof of down‐regulation by norepinephrine. However, Kd, representing receptor affinity, was similar in both groups. Therefore, studies of hormone and receptor status in various pathologic conditions should always take into account the normal changes attributable to the age of the subject population.
Age‐Related Decline in Interleukin 2 Production in Response to Influenza Vaccine
Authors: McElhaney Janet E. , Beattie B. Lynn , Devine Robert , Grynoch Richard , Toth Ellen L. , Bleackley R. Christopher
Published: April 2015

Articles in the recent literature document an abnormal antibody response in elderly persons to influenza vaccination. Several studies have presented evidence to show that immune dysfunction in aged mice and humans may be due to a defect in the production of interleukin 2 (IL2) by helper T cells (TH). Cultures of peripheral blood mononuclear cells (PBMC) were prepared from blood samples taken at eight weeks after vaccination (0.5 mL of Armand‐Frappier, 15 μg/0.5 mL each of A/Taiwan/1/86, A /Leningrad/360/86, and B/Ann Arbor/1/86 administered in the fall of 1987) from a group of elderly men and a young control group. Peripheral blood mononuclear cells were frozen in 10% dimethyl sulfoxide (DMSO) until all the cells were cultured. After stimulation with a 1/320 dilution of the same influenza vaccine, cultures of PBMC from young controls showed a significantly greater increase in IL2 production than the cultures of PBMC from the elderly group of patients. This was statistically significant at both day 3(P < .01) and day 5(P < .05) of culture using the Mann‐Whitney U test. Previous experiments that have shown defective IL2 production related to aging have used potent mitogens such as concanavalin A and phytohemagglutinin to stimulate TH. This study provides evidence that defective IL2 production may also occur in response to physiologic antigenic stimulation and may be one explanation for the reduced efficacy of influenza vaccination in elderly persons.
Effects of Three Liquid Diets on Nutrition‐Sensitive Plasma Proteins of Tube‐Fed Elderly Men
Authors: Feller Axel G. , Caindec Norma , Rudman Inge W. , Rudman Daniel
Published: April 2015

The effects on three nutrition‐sensitive plasma proteins of isocaloric feedings with three enteral formulas were compared in 10 tube‐fed male nursing home residents. The enteral products were Isocal (based on whole protein), Peptamen (based on a mixture of oligopeptides), and Vivonex T.E.N. (based on free amino acids). The nutrition‐sensitive plasma proteins were albumin, transferrin, and retinol‐binding protein. After observation during four weeks of feeding with Isocal, each subject was then monitored during four weeks of Peptamen and four weeks of Vivonex T.E.N. The latter two products were alternated in a crossover design.

The shift of Isocal to Peptamen did not significantly (P > .05) influence the serum level of albumin, transferrin, or retinol‐binding protein. In contrast, the shift of Isocal to Vivonex T.E.N. or of Peptamen to Vivonex caused a significant (P < .05) decline in all three plasma proteins, the kinetics of their reductions corresponding to their known half‐lives.

The behavior of the three nutrition‐sensitive plasma proteins suggests that in elderly nursing home men without gastrointestinal disease the nutritional value of the protein component of the three formulas follows the order Isocal = Peptamen > Vivonex T.E.N. However, this conclusion will require confirmation by nitrogen balance studies.
Financing Long‐Term Care An Insurance‐Based Approach
Authors: Pawlson L Gregory , Mourey Risa J. Lavizzo
Published: April 2015

A joint public‐private insurance program is the best approach to resolving the problem of financing long‐term care. In this report, we describe one possible approach in detail. A modest expansion of the current (ie, after repeal of the Medicare Catastrophic Coverage Law of 1988) Medicare benefit for persons needing relatively short‐term nursing home and home care services would be a first step. For those with extended long‐term service needs, a non‐means tested, publicly funded program with joint federal – state financing and administration would provide coverage after a substantial elimination period and with an income‐related copayment. Private long‐term care insurance purchased through employers before retirement or in the periretirement period, through use of income or equity accumulated in life insurance, pension funds, or home ownership, would be used to fund the exclusionary period or copayments of the public program by those who wish to have greater protection for income or assets. The role of Medicaid would be limited to paying for the deductible, copayments, and initial long‐stay expenses of those with low incomes and limited assets.
Rethinking Long‐Term Care
Authors: Kane Robert L.
Published: April 2015

In the context of several proposals for financing long‐term care (LTC), this article suggests three areas in which reform of the structure of LTC is needed to create more appropriate incentives for better care. The interfaces between short‐ and long‐term care can be addressed by either a number of specific changes or more global approaches, such as one or another form of capitated care. Using the ratio of achieved/expected outcomes as a prominent part of a regulatory strategy offers a means to increase the flexibility of regulation to encourage innovation while retaining meaningful accountability. New combinations of housing and nursing care offer a way for both a better and more flexible way of living in the context of an approach that guarantees universal coverage of care together with an incentive to save to afford better accommodations.
The Short‐Term Outcome of Pressure Sores
Authors: Berlowitz Dan R. , Wilking Spencer Van B.
Published: April 2015

Patients with pressure sores have been observed to have a poor prognosis. The short‐term outcome of pressure sores at a long‐term care hospital was therefore evaluated. Medical records on the 301 admissions to this hospital over a 13‐month period were reviewed. One hundred patients (33%) had a pressure sore present on admission. Using ordinary therapies, 79% of these pressure sores improved and 40% completely healed during the 6‐week follow‐up period. Remaining bed‐ or chair‐bound was the sole patient characteristic associated with a failure of the pressure sore to improve. Mortality rates were significantly increased in patients with a pressure sore present on admission (relative risk [RR] = 1.9), in patients who developed a new sore (RR = 3.1), and in patients in whom the pressure sore failed to improve (RR = 3.3). However, the pressure sores did not appear to be the direct cause of this increased mortality. These data suggest that the majority of pressure sores encountered at a long‐term care hospital can be successfully managed in this setting. Although patients with pressure sores have an increased mortality rate, this is most likely due to coexisting medical conditions.
Cognitive Impairment and Length of Hospital Stay in Older Persons
Authors: Binder Ellen F. , Robins Lee N.
Published: April 2015

We looked at performance on the Folstein Mini‐Mental State Exam (MMSE) as a predictor of hospitalization and length of stay in the coming year in community‐dwelling older persons from the National Institute of Mental Health Epidemiologic Catchment Area program. They had been assessed with the MMSE at the outset and were reevaluated with the MMSE and a Health Services Questionnaire 1 year later. Subjects were more likely to be hospitalized in the subsequent year if they were older than 75 years or if they scored poorly on the MMSE. Severe cognitive impairment increased the risk more than mild impairment. Multivariate analyses that controlled for demographic variables demonstrate that MMSE performance is a significant predictor of any subsequent hospitalization (medical or psychiatric) among whites and among those at both high and low educational levels. This effect was not explained solely by the increased rate of psychiatric hospitalizations. We also determined that a decline in MMSE score over 1 year was associated with an increased risk of hospitalization, more hospital days, longer average length of stay, and a prolonged (> 20 days) hospital stay.

We conclude that both initial poor performance on the MMSE and deterioration increase the risk of hospital use and lead to more extended hospital stays. However, even with poor MMSE performance, most older persons remain out of the hospital and most of those hospitalized do not have prolonged stays; thus, MMSE score alone is insufficient as a predictor of impending hospitalization. Further studies are needed to add other measures of risk for hospitalization and prolonged hospital stays.
Pygmalion in the Nursing Home The Effects of Caregiver Expectations on Patient Outcomes
Authors: Learman Lee A. , Avorn Jerry , Everitt Daniel E. , Rosenthal Robert
Published: April 2015

Several characteristics of nursing home care can diminish rather than enhance the clinical status of older residents. In view of evidence from other settings that “interpersonal expectancy effects” can influence outcomes in a variety of relations, we conducted a randomized controlled trial to test the effects of caregiver expectations on the clinical status of nursing home residents. Within 2 weeks of admission, 63 older residents at six nursing homes were given a comprehensive assessment of cognitive, functional, and emotional status. Residents were then randomly assigned to a “high‐expectancy” or “average‐expectancy” condition. Nurses and aides were told that, in comparison with other residents having similar problems, residents in the high‐expectancy group were predicted to perform above average in their rehabilitation. The assessment was repeated 3 months later; information on the health and psychosocial status of residents was drawn from their medical records covering the same period.

Aides reported having higher expectations for treatment group residents. When assessed by a blinded research assistant, residents in the high‐expectancy group experienced greater relief of depressive symptoms but showed greater decrements in functional independence in comparison with control residents. Treatment group residents were admitted significantly less frequently to hospitals despite a comparable number of emergency ward visits, suggesting a lower incidence of severe illness despite comparable medical surveillance. There was also a trend toward improved performance in mental status testing among the high‐expectancy residents compared with controls (P = .08). Additional research is needed to define further the magnitude and mechanisms of expectancy effects in relations between nursing home caregivers and residents.