bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Hormone Replacement Therapy for Menopause on the Mechanical Properties of Skin
Authors: Piérard Gérald E. , Letawe Caroline , Dowlati Afshin , Piérard‐Franchimont Claudine
Published: April 2015

OBJECTIVE: To evaluate the effect of hormone replacement therapy (HRT) for menopause on the mechanical properties of the skin in healthy women.

DESIGN: A group of 114 women, including 43 nonmenopausal controls, 46 menopausal women with HRT and 25 menopausal women without HRT, participated in the study. Mechanical properties of the skin were measured on the volar forearm using a computerized suction device.

SETTING: University medical center. Research laboratory in bioengineering and biometrology.

RESULTS: Computerized measurements of skin deformability and viscoelasticity revealed differences between the three groups of women. A steep increase in skin extensibility was evidenced during the perimenopause in untreated women. HRT appeared to limit the age‐related increase in cutaneous extensibility, thereby exerting a preventive effect on skin slackness. No effect of HRT was found on other parameters of skin viscoelasticity.

CONCLUSION: HRT has a beneficial effect on some mechanical properties of skin and thus may slow the progress of intrinsic cutaneous aging.
The Reliability and Validity of the Geriatric Depression Rating Scale Administered by Telephone
Authors: Burke William J. , Roccaforte William H. , Wengel Steven P. , Conley Deborah M. , Potter Jane F.
Published: April 2015

OBJECTIVE: To evaluate prospectively the reliability and validity of the Geriatric Depression Scale administered by telephone (T‐GDS) in patients undergoing outpatient comprehensive geriatric assessment.

SUBJECTS: A total of 101 geriatric patients were evaluated in a 1‐year period at the outpatient Geriatric Assessment Center of the University of Nebraska Medical Center.

METHODS: The 30‐item GDS was completed by all patients on three occasions: by telephone several days before their assessment, face‐to‐face during their assessment visit, and several days later, again by phone. During their assessment, all patients were evaluated by one of three geriatric psychiatrists who were blind to all GDS results.

The test‐retest reliability of the T‐GDS was measured by comparing the results of the two phone interviews. The construct validity of the T‐GDS was estimated by comparing the results of the initial T‐GDS to the GDS obtained during the comprehensive assessment. The criterion validity of the T‐GDS was estimated by comparing the results of the T‐GDS with the clinical diagnosis of depression assigned by the psychiatrists.

RESULTS: The individual items of the initial T‐GDS showed substantial concordance with the second T‐GDS (kappa range 0.35–0.7, mean = 0.52), and with the assessment GDS (kappa range 0.29–0.75, mean = 0.52). One item showed evidence of bias when comparing the two T‐GDSs, and two items when comparing the initial T‐GDS to the GDS done during the assessment. The mean number of symptomatic responses was not significantly different for the T‐GDS versus assessment administration but did decline slightly when comparing the two T‐GDSs. ROC curve analyses showed good agreement between the clinical diagnosis and the T‐GDS.

CONCLUSION: The GDS appears to maintain its reliability and validity when administered via telephone and thus may be useful for a variety of epidemiological and clinical purposes.
Predicting Bacteremia in Older Patients
Authors: Pfitzenmeyer P. , Decrey H. , Auckenthaler R. , Michel J. P.
Published: April 2015

Predicting Bacteremia in Older Patients

OBJECTIVE: To evaluate potential clinical predictors of bacteremia in hospitalized geriatric patients and to propose an individual risk score as an alternative to “subjective” clinical judgment for a more efficient approach in early recognition and treatment of bacteremia.

DESIGN: A 16‐month prospective study.

SETTING: The University Geriatric Hospital of Geneva, Switzerland.

PATIENTS: Four hundred thirty‐eight patients aged 62 years or older in whom 558 episodes of bacteremia were suspected.

MEASUREMENTS: The unit of evaluation was the blood culture episode, which was defined as a 48‐hour period beginning with the drawing of the first blood for culture. An extensive precoded protocol, including clinical and biological data, was completed by the resident who requested the blood cultures. For each episode, the resident also provided a subjective assessment of the probability of bacteremia. Odds ratios and their variances were used to estimate the relative risks of potential predictors of bacteremia. The performance of a predictive clinical model based on risk score threshold was evaluated by means of a receiver‐operating characteristic analysis.

RESULTS: Of the 558 potentially bacteremic episodes investigated, 46 (8.2%) yielded positive blood cultures. The bacteremia rate was strongly associated with the type of episode: it reached 15.6% among the community‐acquired (CA) episodes (those occurring within 48 hours of hospital admission) and 6.0% only among the hospital‐acquired (HA) episodes (those occurring after the first two days of hospitalization). Predictors of bacteremia with highest relative risks included: bladder catheter removal, fever (≥38.5°C), rigors, shock, total band count ≥ 1500/mm3, and lymphocyte count ≤ 1000/mm3. When assessed by episode type, it appeared that bladder catheter removal and rigors were good predictors of bacteremia in HA episodes only, whereas fever (≥38.5°C) had a good predictive value in CA episodes only. The performance of the clinical model was two times better than the physician's subjective ability to predict bacteremia when the threshold of the risk score was fixed at two or more predictors per episode.

CONCLUSIONS: These findings provide means to identify older hospitalized patients at high risk of bacteremia. Although the proposed predictive model will need further validation and more precise evaluation of the potential benefits, it may nevertheless be of some help in early recognition and treatment of bacteremia. J Am Geriatr Soc 43: 230–235, 1995.
Elevated Plasma Levels of Interleukin‐6 in Postmenopausal Women Do Not Correlate with Bone Density
Authors: Kania D. M. , Binkley N. , Checovich M. , Havighurst T. , Schilling M. , Ershler W. B.
Published: April 2015

Elevated Plasma Levels of Interleukin‐6 in Postmenopausal Women Do Not Correlate with Bone Density

OBJECTIVE: To determine if plasma levels of Interleukin‐6 (IL‐6) across the lifespan correlate with bone density or plasma osteocalcin.

DESIGN: Cross‐sectional study.

PARTICIPANTS: Forty‐five healthy community‐dwelling volunteers aged 25–74 years. Exclusion criteria were smoking, use of medications known to affect bone metabolism (corticosteroids, heparin, thyroxine, thiazides, and anticonvulsants), and presence of chronic inflammatory disease.

MEASUREMENTS: Bone density was measured by dual‐energy X‐ray absorptiometry at the femoral neck and lumbar spine. Plasma levels of IL‐6 and osteocalcin were determined by ELISA and RIA, respectively.

RESULTS: Plasma levels of IL‐6 increased with advancing age (P <.0001) and correlated with postmenopausal status (P < .0001). No correlation was observed between plasma IL‐6 level and bone mineral density at either the lumbar spine or femoral neck, and none was observed with plasma osteocalcin.

CONCLUSIONS: The elevation of plasma IL‐6 observed following menopause is consistent with the proposed importance of estrogen in the regulation of IL‐6. These findings do not provide support for a role of IL‐6 in determination of peak bone density or subsequent development of osteoporosis. However, it is possible that plasma levels of IL‐6 differ from those in the bone microenvironment. J Am Geriatr Soc 43: 236–239, 1995.
Clinical Spectrum of Tuberculosis in Older Patients
Authors: Liaw Yuang‐Shuang , Yang Pan‐Chyr , Yu Chong‐Jen , Wu Zen‐Guang , Chang Dun‐Bing , Lee Li‐Na , Kuo Sow‐Hsong , Luh Kwen‐Tay
Published: April 2015

Clinical Spectrum of Tuberculosis in Older Patients

OBJECTIVE: To investigate the clinical differences between old and young patients infected with Mycobacterium tuberculosis in a developing country.

DESIGN: Retrospective chart and chest radiograph review.

SETTING: A university‐affiliated teaching hospital.

PATIENTS: The medical records of patients with documented tuberculosis (TB) from January 1990 through December 1991 were analyzed. Clinical assessment included sex, age, diagnosis at first visit, past history, symptoms and signs, laboratory data, X‐ray findings, bacteriological examinations, outcome, time elapsed from first visit to initiation of anti‐TB therapy and the major determinants for starting anti‐TB therapy. Statistical significances were analyzed by Student's t test and χ2 tests.

RESULTS: Among 205 patients with culture‐proven TB, 57 were 65 years of age and older (range, 65 to 91; mean, 73) and 148 under 65 years of age (range, 16 to 64; mean, 41). There was a higher incidence of previous TB (26.3% vs. 16.2%) and diabetes mellitus (24.5% vs. 14.3%) in the elderly patients. Initial diagnosis of TB at first visit was less frequent in the elderly than in the young group (38.6% vs. 47.3%), although symptoms and signs at first visit were similar in each of the age groups. Radiographic presentation with mass lesions was more frequently encountered in elderly patients (10.5% vs. 2.1%, P <.05). Elapsed time from the first visit to suspicion of TB and the initiation of anti‐TB therapy was frequently delayed in elderly patients (22 ± 23 vs. 13 ± 20 days, P <.05). The incidence of drug‐resistance (39% vs. 16%, P <.05) and unfavorable response to anti‐TB therapy (17.5% vs. 3.4%, P <.05) were significantly higher in the older patients.

CONCLUSIONS: Although clinical presentation of TB in the elderly did not differ significantly from that in younger patients, this study showed that diagnosis and treatment were more often delayed in the elderly, and there was a higher incidence of treatment failure. J Am Geriatr Soc 43: 256–260, 1995.
Predictors of Pap Smear Screening in Socioeconomically Disadvantaged Elderly Women
Authors: Weinrich Sally , Coker Ann L. , Weinrich Martin , Eleazer G. Paul , Greene Frederick L.
Published: April 2015

Predictors of Pap Smear Screening in Socioeconomically Disadvantaged Elderly Women

OBJECTIVE: The objective for this study was to identify predictors for participation in Pap smear screening in a socioeconomically disadvantaged older population.

DESIGN AND SAMPLE: A cross‐sectional survey design was used to examine data from 238 southern women 50 years of age and older who were recruited from 24 randomly selected congregate meal sites of the Council on Aging.

MEASUREMENTS: The 45‐item questionnaire covered demographics, Pap smear screening history, and colorectal cancer screening history.

RESULTS: Among this older, very low income population, women who had never had Pap smears (17.2%) were significantly more likely to have no phone or to be unable to use a phone (adjusted odds ratio (aOR) = 4.1; 95% confidence interval (CI) 1.6–10.6), to have annual incomes of less than $5,800 (aOR = 3.1; 95% CI 1.1–9.0), to be widowed (aOR = 2.8; 95% CI 1.1–7.3), to have no family history of cancer (aOR = 3.3, 95% CI 1.3–10.0), to report having never had a rectal examination (aOR = 5.4, 95% CI 1.8–16.0), and not to have participated in a free fecal occult blood testing program (aOR = 5.0, 95% CI 2.0–10.0).

CONCLUSIONS: These data, unique in including very low income (<$10,000) and older women (65 and over), found that income and access to a phone were strongly correlated with cervical cancer screening participation. Women who lacked external incentives for screening (being widowed and not having a family history of cancer) were less likely to obtain screening. This study's finding that “not having a phone” was a strong predictor for nonparticipation in cervical cancer screening has implications for national telephone‐derived estimates of cervical cancer screening. J Am Geriatr Soc 43: 267–270, 1995.
The Contribution of Predisposing and Situational Risk Factors to Serious Fall Injuries
Authors: Tinetti Mary E. , Doucette John T. , Claus Elizabeth B.
Published: April 2015

OBJECTIVES: The objectives were to identify situational risk factors associated with suffering a serious fall injury and to determine whether, and to what extent, predisposing and situational risk factors contributed independently to risk of suffering a serious fall injury.

DESIGN: Nested cohort study.

SETTING: General community.

PARTICIPANTS: 568 members of a representative sample of community‐living persons 72 years of age or older who fell during a median follow‐up of 36 months.

MEASUREMENTS: Candidate predisposing factors, identified during a baseline face‐to‐face home assessment, were the demographic, cognitive, medical, and physical performance measures associated with an increased risk of serious injury among fallers in a previous analysis of the cohort. Acute host, behavioral, and environmental factors present at the time of the participants' first reported fall constituted potential situational risk factors. The primary outcome was occurrence of a serious fall injury, defined as a fracture, joint dislocation, or head injury resulting in loss of consciousness and hospitalization, during the first fall recorded during follow‐up.

RESULTS: Sixty‐nine subjects (12%) suffered a serious injury during their first reported fall. No acute host factor was associated with increased risk of injury. The environmental and activity factors associated independently with serious injury in multivariate analysis included falling on stairs (adjusted relative risk 2.0; 95% confidence intervals 1.1 – 3.5), during displacing activity (1.8; 1.0 – 3.0), and from at least body height (2.1; 1.0 – 4.7). The independent predisposing factors included female gender (2.1; 1.0 – 4.4), low body mass index (1.8; 1.2 – 2.9), and cognitive impairment (2.8; 1.7 –4.7). Although 12% of first falls resulted in a serious injury overall, this percentage ranged from 0% to 36% as the number of predisposing risk factors increased from zero to three and from 5% to 40% as the number of situational risk factors increased from zero to three. Further, for any given number of predisposing risk factors, the percentage of fallers suffering a serious injury increased with the number of situational risk factors

CONCLUSIONS: Several environmental and behavioral factors contributed to the risk of serious fall injury; this contribution was independent of the effect of chronic predisposing risk factors. Preventive programs that address both predisposing and situational risk factors may result in the greatest injury reduction. These findings support previously recommended multicomponent intervention programs that combine medical, rehabilitative, and environmental components. J Am Geriatr Soc 43:1207–1213,1995.
The Event‐Related P300 Potential Approach to Cognitive Functions of Nondemented Patients with Cerebral and Peripheral Arteriosclerosis
Authors: Kiigler Christian F.A. , Vlajic Predrag , Funk Harald , Raithel Dieter , Platt Dieter
Published: April 2015

OBJECTIVES: To detect subtle cognitive dysfunction in non‐demented patients with either cerebral (cAD) or peripheral (pAD) arteriosclerotic disease, and to evaluate in these patients the effects on cognitive functions of carotid endarterec to my and bypass surgery, respectively.

DESIGN: Case‐control study.

SETTING: Tertiary care referral center.

PARTICIPANTS: Eighty consecutive patients with moderate to high‐grade stenosis of the internal carotid artery (ICA) (mean age plusmn SD, 62plusmn 8 years), 53 patients with stenoses of the peripheral arteries (60plusmn10 years), and 80 healthy volunteers (58plusmn15 years) enrolled in a study on healthy aging. Cerebral and peripheral arteriosclerotic disease was verified by digital subtraction angiography, and all patients were screened for confounding effects of concomitant diseases.

MAIN OUTCOME MEASURES: Cognitive functions by event‐related visual P300 potentials.

RESULTS: Patients with cAD showed prolonged P300 latencies and reduced P300 amplitudes, whereas pAD patients had reduced P300 amplitudes only. On an individual scale, 25% of cAD patients, but only 6% of pAD patients, revealed P300 abnormalities. In the cAD, but not in the pAD patients, the P300 latencies were especially prolonged in the older patients, but other factors such as sex, cerebral symptoms, degree of ICA stenosis, and premorbid intelligence did not play any role in either group. Within 1 to 2 weeks of surgery, the P300 latencies shortened in both cAD and pAD patients with high initial values.

CONCLUSIONS: As demonstrated by P300 potentials, even nondemented arteriosclerotic patients reveal signs of subtle cognitive dysfunction affecting especially the older cAD patient. In the short‐term, carotid endarterectomy presumably improves cognitive functions unspecifically in nondemented patients with a higher initial degree of P300 abnormality.
Measuring the Psychosocial Impact of Urinary Incontinence: The York Incontinence Perceptions Scale (YIPS)
Authors: Lee Paul S. , Reid David W. , Saltmarche Anita , Linton Lyn
Published: April 2015

OBJECTIVE: The York Incontinence Perceptions Scale (YIPS) was developed to measure the psychosocial aspects of urinary incontinence and its management.

DESIGN: Testing of internal consistency and validity of the YIPS.

SETTING AND PARTICIPANTS: Subjects were 101 female rural community residents (mean age = 67.4 years) diagnosed with urinary incontinence and participating in a 25‐week longitudinal randomized control study testing the efficacy of treating incontinence with a behavioral/educational intervention.

MEASUREMENTS: Participants completed the YIPS, a bladder chart monitoring daily incontinence episodes, the Aids to Living Scale, the Incontinence Impact Questionnaire, and single‐item ratings of self‐perceptions of amount of leakage, continence status, and overall health status.

MAIN RESULTS: The YIPS had high internal consistency (a = .78). Positive adjustment on the YIPS was correlated with lower frequency of incontinence (r = ‐.44), and self‐ratings of improvement in amount of leakage (r = .60), improved continence status (r = .38), and overall health status (r = .32). At the end of the 25‐week treatment period, the participants in the treatment group reported a more positive adjustment on the YIPS than did participants in the control group (t[99] = 4.78, P < .001), which was concordant with a reduction in the incidence of incontinence in the treatment group (F [l, 91] = 6.95, P<.01).

CONCLUSIONS: The YIPS is a brief, yet reliable, instrument that addresses such psychosocial issues as coping, control, and acceptance of incontinence.
Causes of Increasing Mortality in a Nursing Home Population
Authors: Holtzman Jeremy , Lurie Nicole
Published: April 2015

OBJECTIVE: To examine the roles played by changes in case‐mix, quality of care, and aggressiveness of care in explaining the 42% increase in mortality of the Medicaid nursing home population of Hennepin County, Minnesota, between 1984 and 1988.

DESIGN: Retrospective chart review.

SETTING: All nursing homes in Hennepin County, MN, that care for Medicaid patients.

PATIENTS: A random sample of 1605 Medicaid nursing home residents from 1984 and 1988 stratified by year and by whether the resident died in that year. Sampling was disproportionate to allow approximately 400 individuals per stratum. A total of 1405 charts (87%) were reviewed; the remainder were either lost or destroyed.

MAIN OUTCOME MEASURES: Measures included case‐mix (Charlson index, functional status, implicit reviewer assigned severity [range 1–4]), aggressiveness of care (orders limiting care), quality of care (process of care for tracer conditions [range 1–5], falls), and resident death.

RESULTS: Implicitly rated severity of illness worsened between 1984 and 1988 (2.77 vs 2.91; P = .009), but other measures of case‐mix were unchanged. A greater percentage of residents had a DNR order in 1988 (12% in 1984 vs 37% in 1988; P < .001), and more received less aggressive care (31% vs 40%; P = .006). Overall process of care improved between 1984 and 1988 (2.88 vs 3.01; P < .05). With adjustment of the mortality rates and with logistic regression controlling for age and gender, changes in quality of care alone accounted for less than 5% of the mortality rate change between 1984 and 1988, case‐mix alone accounted for 49%, and aggressiveness of care alone accounted for nearly 100%.

CONCLUSIONS: The nursing home population became sicker between 1984 and 1988, but process of care improved. These changes had a modest effect on the mortality rate. The increase in less aggressive care between 1984 and 1988 accounts for nearly all of the increase in mortality. J Am Geriatr Soc 44:258–264, 1996.
Focused Assessment of Foot Care in Older Adults
Authors: Plummer E. Sharon , Albert Stewart G.
Published: April 2015

OBJECTIVES: The purpose of this study was to investigate the prevalence and characteristics of foot problems in non‐diabetic individuals compared with those in a diabetic population in order to develop recommendations for preventive foot care in older people.

DESIGN: Retrospective review of a convenience sample of all patients referred to a Foot Care Service during a 24‐month period.

SETTING: University Health Sciences Center.

PARTICIPANTS: A total of 308 patients aged 33 to 95 years (176 women and 132 men), of whom 183 had diabetes mellitus (DM) and 125 were without DM.

INTERVENTION: Each subject had a detailed history of foot care behavior and a thorough foot examination for peripheral neuropathy (PN), peripheral vascular disease (PVD), and foot deformities. PN was evaluated using the Semmes‐Weinstein monofilament test. PVD was graded by clinical measures and Doppler examination (ankle: brachial index < 0.8).

MEASUREMENTS: Forty‐three percent of subjects with diabetes had PN, 32% had PVD, and 19% had both conditions. Eighteen percent of subjects without diabetes had PN, 21% had PVD, and 6% had both. The risk of foot abnormalities in those without DM increased with age (r = .99, P = .0002). Thirty‐eight percent of non‐diabetic patients older than age 60 had one or more of these major risk factors and would be considered at high risk for the development of foot ulcers or amputation. Ninety percent of the subjects reported inappropriate foot care practices. Forty‐seven percent of non‐diabetic individuals with PN or PVD wore inappropriate shoes.

CONCLUSION: Older individuals without DM are at high risk for foot‐related disease and should receive the same foot care screening, education, and follow‐up as those with DM. Older people who have PN, PVD, or physical and psychosocial limitations, may require referral to foot care specialists. J Am Geriatr Soc 44:310–313, 1996.
The Relationship Between Alcohol Consumption, Cognitive Performance, and Daily Functioning in an Urban Sample of Older Black Americans
Authors: Hendrie Hugh C. , Gao Sujuan , Hall Kathleen S. , Hui Siu L. , Unverzagt Frederick W.
Published: April 2015

OBJECTIVE: To report on moderate alcohol consumption and measurements of cognitive function and activities of daily living in an older, urban, community‐dwelling sample of black Americans.

DESIGN: As part of a community prevalence study of dementia, information on alcohol consumption and cognitive performance was collected on 2040 randomly selected black subjects living in Indianapolis.

MEASUREMENTS: From questions in the screening interview, alcohol consumption was grouped into four categories: lifetime abstainers, regular drinkers less than 4 drinks per week, 4 to 10 drinks per week, and more than 10 drinks per week. Current and past drinkers were analyzed separately. Three measurements were used: (1) a total cognitive score; (2) the delayed recall score from the East Boston Memory Test; (3) a score for daily functioning based upon information from the informant. Multiple regression models were fitted with drinking variables as the major predictor, including covariates of age, gender, education, history of stroke, hypertension, being treated for depression, and a family history of dementia.

MAIN RESULTS: In all analyses, there was a very consistent pattern for both current and past drinkers. There was a small but significant dose effect of drinking for the drinkers, with subjects in the heaviest drinking category scoring poorest, i.e., lowest scores in cognitive tests and highest scores in scales of daily functioning indicating more impairment. The scores of abstainers were worse than those of subjects in the lightest drinking category. The pattern of scores for cognitive performance and daily functioning was similar between current and past drinkers. These patterns remained the same even after potential confounders were included.

CONCLUSIONS: Previous research on effects of alcohol on health indices have suggested a J‐shaped relationship between amounts of alcohol consumption and measurements of heart disease, stroke, and mortality rates. Our study provides some support for the concept of a similar J‐shaped relationship between cognitive performance and alcohol consumption, but the differences between drinking categories were modest and the clinical significance of these findings uncertain.
No Evidence for a Higher Resting Metabolic Rate in Noninstitutionalized Alzheimer's Disease Patients
Authors: Donaldson Kendall E , Carpenter William H , Toth Michael J. , Goran Michael I. , Newhouse Paul , Poehlman Eric T.
Published: April 2015

OBJECTIVE: It has previously been suggested that Alzheimer's disease patients have higher resting energy requirements than healthy individuals, which may contribute to their unexplained weight loss. We examined whether resting metabolic rate, the largest component of daily energy expenditure, is elevated in Alzheimer's patients compared with healthy older controls.

DESIGN: Cross‐sectional

SETTING: General Clinical Research Center and Baltimore VA Medical Center

PATIENTS: Twenty‐five noninstitutionalized demented patients (74 ± 8 years; mean ± SD) with a wide range of Mini‐Mental Examination scores (1 to 20) and 73 healthy older individuals (69 ± 7 years).

MEASUREMENTS: Resting metabolic rate was measured by indirect calorimetry, fat‐free mass and fat mass by dual energy X‐ray absorptiometry, and daily energy intake by food diaries.

RESULTS: No differences in fat‐free mass and fat mass were noted between Alzheimer's disease patients and healthy older controls. Resting metabolic rate was similar in Alzheimer's disease patients (5446 ± 962 kJ/day) and healthy older individuals (5647 ± 887 kJ/day). These results persisted when resting metabolic rate was statistically adjusted for differences in body composition and age.

CONCLUSION: These results provide no evidence for an elevation in resting energy requirements in noninstitutionalized demented patients.
The Significance of Subnormal Serum Vitamin B12 Concentration in Older People: A Case Control Study
Authors: Metz J. , Bell A.H. , Flicker L. , Bottiglieri T. , Ibrahim J. , Seal E. , Schultz D. , Savoia H. , McGrath K.M.
Published: April 2015

OBJECTIVES: To determine the clinical significance of subnormal serum vitamin B12 concentration in older people by comparing the hematological, neurological, and biochemical findings in patients with subnormal serum B12 with a control group with normal B12 levels.

DESIGN: Clinical and laboratory assessment of hospital patients selected to represent a wide range of serum B12 levels.

SETTING: Patients in the medical wards of two hospitals, one a general hospital and the other a geriatric hospital.

PARTICIPANTS: Ninety‐four older patients, 43 with subnormal (<150 pmol/L) and 51 with normal serum B12 concentrations.

MEASUREMENTS: Mini‐Mental State Examination, neurological score, full blood examination, mean neutrophil lobe count; serum B12, holotranscobalamin II, total homocysteine, folate, creatinine and gastrin red cell folate; parietal cell antibodies, intrinsic factor antibodies.

RESULTS: Of all the measurements, only mean neutrophil lobe count and mean serum total homocysteine were significantly different in the low serum B12 compared with the control group. There was a significant correlation between serum B12 and homocysteine levels. Eighty‐eight percent of patients in the test group compared with 76% in the control group showed at least one of the following; elevated serum total homocysteine, neutrophil hypersegmentation, or elevated MCV. This overlap was much reduced when patients with borderline values for serum B12 (150–250 pmol/L) were included in the low B12 group. Most of the older subjects had little or no B12 on transcobalamin II, irrespective of the serum B12 level.

CONCLUSION: Almost 90% of older patients with serum B12 < 150 pmol/L show evidence of tissue vitamin B12 deficiency. Deficiency becomes manifest in older patients at relatively higher concentrations of serum B12 than in younger subjects, possibly because of lower levels of holotranscobalamin II in the older patients. J Am Geriatr Soc 44:1355–1361, 1996.
Clinical Variables Influencing Treatment Decisions for Agitated Dementia Patients: Survey of Physician Judgments
Authors: Colenda Christopher C. , Rapp Stephen R. , Leist James C. , Poses Roy M.
Published: April 2015

OBJECTIVE: To better understand primary treatment recommendations and the variables that might influence treatment decisions of physicians who treat agitated dementia patients.

DESIGN: A written cross‐sectional survey of three physician groups (geriatric psychiatrists, primary care physicians, and neurologists) who typically treat agitated dementia patients in community settings. We used a written clinical vignette describing a home‐bound, agitated dementia patient to ask respondents to provide information regarding their primary treatment recommendation and to estimate the degree to which clinically relevant variables might influence their treatment recommendation. Using principal component analysis, the original set of clinical variables was collapsed into a smaller set of composite factors that better defined the fundamental constructs of the variables that influenced decision making. Analyses compared primary treatment recommendations and factors influencing treatment recommendations by physician groups.

PARTICIPANTS: The pool of survey respondents consisted of a random selection of 207 primary care physicians from western North Carolina, 147 geriatric psychiatrists obtained from the roster of the 1991 American Association for Geriatric Psychiatry, and 120 neurologists obtained from the roster of the American Board of Medical Specialties. The response rate was 65% for geriatric psychiatrists, 38% for primary care physicians, and 33% for neurologists.

RESULTS: Differences in primary treatment recommendations by physician group were not found. Physicians, regardless of specialty, recommended neuroleptic medications as their primary intervention. When medication classes were collapsed into a single category, medications as a primary intervention exceeded 55% for all physician groups. Twenty‐two percent of all respondents recommended psychosocial interventions as primary treatment strategies. The principal component analysis of clinical variables influencing treatment recommendations solved for five components that accounted for 64% of the variance. Comparing the five components by specialty groups failed to find significant differences, except for Factor 5, the “Hassle Factor.” Primary care physicians were more likely to indicate that this component influenced their decision making than were the other physician groups.

CONCLUSIONS: The findings indicate that physicians, regardless of specialty, are likely to use medication and to weight clinically relevant information in a similar fashion when managing agitated dementia patients. J Am Geriatr Soc 44:1375–1379, 1996.
Do Rehabilitative Nursing Homes Improve the Outcomes of Care?
Authors: Kane Robert L. , Chen Qing , Blewett Lynn A. , Sangl Judith
Published: April 2015

OBJECTIVES: To compare the differences in outcomes of Medicare patients discharged from hospital to two types of nursing homes, rehabilitative and regular, and to rehabilitative facilities.

DESIGN: Criteria for distinguishing rehabilitative nursing homes (RNHs) from ordinary nursing homes (NH), based on staffing criteria, were developed by an expert panel and validated on a national sample of nursing homes. Those criteria that significantly discriminated the two types of NHs were then applied to a sample of nursing homes from a study of the outcomes of care for more than 2500 Medicare patients to classify the nursing homes to which patients were discharged. Actual discharge outcomes were compared with optimal outcomes based on predictive equations for different types of treatment (ordinary NH care, RNH care, and formal rehabilitative care).

PARTICIPANTS: Medicare patients with strokes and hip fractures discharged from 52 hospitals in three cities.

MEASUREMENTS: A disability scale that weights components of ADL measures was used as the primary outcome indicator. Nursing homes were classified as rehabilitative on the basis of the extent of staffing in rehabilitative areas.

RESULTS: Patients discharged to various types of care varied on several parameters. After adjusting for these differences, stroke patients fared better when treated in rehabilitative facilities; there was no substantial benefit for RNH care over NH care. Healthier hip fracture patients who received RNH care fared better, but functional change for sicker hip fracture patients was not different among the three groups.

CONCLUSIONS: The study suggests that at least a preliminary distinction among NHs can be made on the basis of staffing patterns and that the benefits of the additional staffing may vary with the problem under consideration. More work is needed to establish just what sorts of patients are most likely to benefit from the higher level of NH care.
A Home‐based Exercise Program for Nondisabled Older Adults
Authors: Jette Alan M. , Harris Bette Ann , Sleeper Lynn , Lachman Margie E. , Heislein Diane , Giorgetti Marie , Levenson Claudia
Published: April 2015

OBJECTIVES: This paper describes a videotaped, home‐based, strength training program, titled Strong‐for‐Life and reports on its effectiveness in improving muscle strength, psychological well‐being, and health status in a sample of older persons.

DESIGN AND SETTING: We enrolled 102 nondisabled, community‐dwelling older people aged 66 to 87, identified from the Medicare beneficiary list, into a randomized, controlled trial.

MEASUREMENTS: Effectiveness was based on change in isokinetic upper and lower extremity muscle strength, psychologic well‐being, and health status.

RESULTS: Results revealed several statistically significant short‐term benefits after 12 to 15 weeks of exercise, especially for men. Younger older adults demonstrated a 10% improvement in knee extensor strength relative to control subjects. Older male exercisers achieved significant differences relative to controls in perceived anger, tension, and overall social functioning. Male exercisers, in general, achieved significant improvement in perceived vigor. Women did not report psychological benefits following participation in the program.

CONCLUSION: Study results reveal that the Strong for Life program, designed to be widely disseminated to the nondisabled older population, has many short‐term positive benefits.
Medical Screening of Older Drivers as a Traffic Safety Measure—A Comparative Finnish‐Swedish Evaluation Study
Authors: Hakamies‐Blomqvist Liisa , Johansson Kurt , Lundberg Catarina
Published: April 2015

OBJECTIVES: To evaluate the safety effect of age‐related medical screening of older drivers by comparing the licensing laws and accident rates for older road users in Finland and Sweden.

DESIGN: Post hoc comparison of Sweden and Finland with respect to three different risk variables.

SETTING: Nationwide Swedish and Finnish accident, licensing, and population data from the year 1990 were provided for the present study by the local authorities responsible for tabulating these data.

PARTICIPANTS: Data about all citizens born in 1960 or earlier, i.e., aged 30 years or more in the year of measurement, are included.

MEASUREMENTS: Rates of police‐reported private car accidents leading to personal injury, fatality rates of private car drivers and passengers, and fatality rates of unprotected road users.

RESULTS: The age‐related variation in private car accident and private car fatality trends was similar in both countries. Fatalities among unprotected road users (i.e., pedestrians, cyclists, and mopedists) increased more sharply with age among the older Finnish population than among the Swedish population.

CONCLUSION: We found no safety‐related reasons to implement age‐related medical screening of older drivers of the kind practiced in Finland. On the contrary, by producing a modal shift toward a more risky mode of travelling, this screening may indirectly lead to higher fatality rates among older road users.
Measuring Capacity to Complete an Advance Directive
Authors: Molloy D. William , Silberfeld Michel , Darzins Peteris , Guyatt Gordon H. , Singer Peter A. , Rush Bonnie , Bédard Michel , Strang David
Published: April 2015

OBJECTIVE: To validate reference standards for the assessment of capacity to complete an advance directive and to develop and test three simple screening instruments.

METHODS: We administered five measures of capacity to 96 older subjects from nursing homes, retirement homes, and homes for the aged. The measures included two reference standard evaluations: an assessment by a specially trained nurse in collaboration with a multidisciplinary team (Competency Clinic assessment) and geriatrician assessment using a decisional aid. Three screening instruments were also included: a Generic Instrument designed for any advance directive, a Specific Instrument designed for the “Let Me Decide” advance directive, and the Standardized Mini‐Mental Status Examination (SMMSE). The screening instruments and the geriatrician's assessment were administered twice to half of the respondents to determine interrater agreement.

RESULTS: The chance‐corrected agreement for the assessment by two geriatricians was 0.78, and for agreement between the geriatricians and Competency Clinic assessments it was 0.82. Agreement for the Generic and Specific screening instrument assessments by two observers was 0.77 and 0.90, respectively. The areas under the Receiver Operating Characteristic curve relating the results of the three screening instruments to the Competency Clinic assessment were 0.82 for the Generic Instrument, 0.90 for the Specific Instrument, and 0.94 for the SMMSE; chance is an unlikely explanation for the difference between these three values (P ≤ .01).

CONCLUSIONS: Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.
Age, Education, and Changes in the Mini‐Mental State Exam Scores of Older Women: Findings from the Nun Study
Authors: Butler Steven M. , Ashford J. Wesson , Snowdon David A.
Published: April 2015

OBJECTIVE: To describe the relationship of Mini‐Mental State Exam (MMSE) scores and changes over time in MMSE scores to age and education in a population of older women.

DESIGN: A prospective study of a defined population.

SETTING: Various motherhouses and church‐run health care facilities in the Eastern, Midwestern, and Southern regions of the United States.

PARTICIPANTS: Catholic sisters (nuns) participating in the Nun Study, a study of aging and Alzheimer's Disease. The 678 participants were 75 to 102 years old (mean 83.3, standard deviation 5.5, median 82.3) at the time of the first functional assessment. Second assessments were obtained an average of 1.6 years later on 575 survivors.

MEASUREMENTS: The outcome variables were MMSE scores at the first assessment (Time‐one), and MMSE scores at the second assessment (Time‐two). The independent variables were age at Time‐one, and education (bachelor's degree or no bachelor's degree).

RESULTS: Time‐one MMSE scores decreased with age at Time‐one. The decrease in MMSE scores with age was less in sisters with bachelor's degrees than in sisters without bachelor's degrees. The changes in MMSE scores had a “U‐shaped” relationship with Time‐one score, where the greatest declines occurred in sisters with intermediate Time‐one scores. Stratified analysis by age, education, and Time‐one MMSE score was feasible only in sisters with Time‐one MMSE scores of 20 or greater because of the small numbers of sisters with Time‐one scores less than 20. In sisters with Time‐one MMSE scores in the categories 20 to 23, 24 to 26, or 27 to 30, older ages at Time‐one were associated with greater decline in those with bachelor's degrees, but not in those without bachelor's degrees. Also, lower education was associated with greater decline in sisters aged 75 to 84 years at Time‐one, but this education effect disappeared or reversed in sisters who were 85 years of age or older at Time‐one.

CONCLUSIONS: Cognitive function as measured by the MMSE decreased with age at Time‐one, most steeply as a function of age in those without bachelor's degrees. Cognitive function declined over 1.6 years within individuals, and the extent of decline increased with age in the sisters with bachelor's degrees. The extent of decline varied with age and education in an interactive manner, which may have been attributable to a hardy survivor effect in lower educated sisters. It may be necessary to consider such interactions whenever changes in function are studied, particularly when analyses are stratified by the initial level of function.
The Utilization of Antithrombotic Prophylaxis for Atrial Fibrillation in a Geriatric Rehabilitation Hospital
Authors: Lawson Fiona , McAlister Finlay , Ackman Margaret , Ikuta Roland , Montague Terrence
Published: April 2015

OBJECTIVE: To determine the utilization of anticoagulant and antithrombotic agents in older patients with atrial fibrillation.

DESIGN: Retrospective chart review.

SETTING: A geriatric rehabilitation hospital.

PATIENTS: Subjects were 102 patients with atrial fibrillation as an intermittent or prevailing cardiac rhythm during a hospital admission in the 1993 fiscal year.

MEASUREMENTS: Age, sex, and mental status of the patients; duration and etiology of atrial fibrillation; presence of contraindications to anticoagulants or antithrombotic agents; and utilization of these agents in this population.

RESULTS: Of 102 older patients with atrial fibrillation at admission, only 51 were taking some form of anticoagulant or antithrombotic therapy proven effective for stroke prophylaxis (19 warfarin and 32 aspirin). Although 67 patients had relative contraindications to anticoagulation with warfarin, only 25 of the 35 with no contraindications were taking warfarin at the time of discharge. In addition, of the 43 patients with contraindications to warfarin but no contraindications to aspirin, only 28 were prescribed antithrombotic therapy.

CONCLUSIONS: Although anticoagulation or antithrombotic therapies for atrial fibrillation appear to be relatively widely used, there are still significant windows of opportunity for the improvement of clinician practice patterns and clinical outcomes in older patients.
Improved Reliability of the Standardized Alzheimer's Disease Assessment Scale (SADAS) Compared with the Alzheimer's Disease Assessment Scale (ADAS)
Authors: Standish Tim I. M. , Molloy D. William , Bédard Michel , Layne Elizabeth C. , Murray E. Ann , Strang David
Published: April 2015

OBJECTIVES: To compare the interrater and intrarater reliability of the Alzheimer's Disease Assessment Scale (ADAS) with the Standardized Alzheimer's Disease Assessment Scale (SADAS).

DESIGN: A randomized, double blind trial. Sixteen university students were randomized to administer either version of the instrument. Subjects were randomized to three assessments, at 2‐week intervals, using the ADAS or the SADAS. Each subject's first and third tests were administered by the same rater, the second by a different rater.

SETTING: A geriatric outpatient clinic in a university teaching hospital.

PARTICIPANTS: Fifty‐four patients with possible or probable Alzheimer's disease living in the community or in a long‐term care facility.

MEASUREMENTS: The primary outcome was the interrater reliability of total ADAS and SADAS scores. Secondary outcomes were ADAS and SADAS cognitive scores, noncognitive scores, duration of testing, and sample size estimates.

RESULTS: The interrater reliability of the SADAS total score was significantly better than that of the ADAS (interrater ICC 0.93 SADAS vs 0.83 ADAS), and the interrater standard deviation of the total SADAS score was lower than that of the ADAS (38%, P < .05). The SADAS cognitive subscale inter‐ and intrarater reliability, although higher than the ADAS, was not significantly different when used by different raters (interrater ICC 0.91 SADAS vs 0.90 ADAS; intrarater ICC 0.88 SADAS vs 0.86 ADAS). The SADAS noncognitive subscale was significantly more reliable than the ADAS (interrater ICC 0.89 SADAS vs 0.42 ADAS; intrarater ICC 0.87 SADAS vs 0.70 ADAS; P ≤ .05) and had a lower standard deviation between raters (59%; P < .01) and within raters (40%; P < .05) compared with the ADAS.

CONCLUSION: The improved reliability of the SADAS total score means that investigators can now use this score as a primary outcome measure, and important behavioral symptomatology can be included as a marker for treatment efficacy in AD. The smaller standard deviation of the SADAS means that clinical trials using the SADAS as a primary outcome will demonstrate differences, if present, with smaller sample sizes than with the ADAS.
Apolipoprotein‐E Genotyping of Diabetic Dementia Patients: Is Diabetes Rare in Alzheimer's Disease?
Authors: Nielson Kristy A. , Nolan Jennifer H. , Berchtold Nicole C. , Sandman Curt A. , Mulnard Ruth A. , Cotman Carl W.
Published: April 2015

OBJECTIVES: To determine whether diabetes is rare in Alzheimer disease (AD) relative to other types of dementia and whether diabetics with dementia have a low frequency of the Apolipoprotein‐E E4 genotype.

DESIGN: Observational survey study.

SETTING: An Irvine, California, outpatient dementia assessment center.

PARTICIPANTS: A total of 123 patients with AD, 51 with vascular dementia, 57 with “mixed” vascular dementia and AD, and 34 with “other” dementias (non‐vascular non‐AD).

MEASUREMENTS: Demographic data; histories and evidence of diabetes, hypertension, heart disease, stroke; and Apolipoprotein‐E genotype for 95 cases distributed across the groups.

RESULTS: There were 15 diabetics in the sample (5.7%), all of whom had extensive vascular disease. Diabetes was rare in AD patients (0.8%) relative to vascular dementia (11.8%), mixed vascular/AD dementia (8.8%), and “other” dementia patients (8.8%). In addition, the E4 allele of apolipoprotein‐E, associated with high risk for AD, was frequent in the AD group (71.4%), but in the diabetic group it was only as frequent as in the general population (38.5%). In the diabetics with E4, 60% (3/5) had mixed dementia.

CONCLUSIONS: Diabetics with dementia rarely have AD except as a component of mixed dementia. Apo‐E genotyping showed only average E4 allele frequency in diabetics compared with the high E4 frequency found in AD patients. However, mixed dementia in diabetics may be associated with the E4 allele, suggesting that close control of diabetes may be particularly important for those with E4 since they may be more likely than others to develop both diseases. J Am Geriatr Soc 44:897–904, 1996.