bluuebunny/crossref_metadata_2025 huggingface dataset:
Postural Responses and Effector Factors in Persons with Unexplained Falls: Results and Methodologic Issues
Authors: Studenski Stephanie , Duncan Pamela W. , Chandler Julie
Published: April 2015

Automatic postural responses and effector factors were examined in 10 persons with unexplained falls after clinical examination and 24 older controls. Fallers were more unstable than controls on clinical tests of balance (20% of fallers vs 79.2% of controls were able to stand on one foot (P < .005), 40% of fallers and 100% of controls were stable while turning in place (P < .001), postural stress test median score was 12 for fallers and 20 for controls (P < 0.001). We found prolonged tibialis anterior latency (fallers 158.8 ± 23.7, controls 143.2 ± 15.7 milliseconds, P = 0.03), marked losses in ankle strength (dorsiflexion: fallers 3.2 ± 2.9, controls 8.9 ± 4.2 foot‐pounds, P < 0.001; plantarflexion: fallers 7.9 ± 5.3, controls 21.4 ± 11.1 foot‐pounds, P < 0.001), and decreases in range of motion (ankle plantarflexion: fallers 29.2 ± 7.0, controls 37.8 ± 12.4 degrees, P = 0.02). Gastrocnemius latency and electromyographic (EMG) measures of sequence showed no differences between fallers and controls. Sequence measures were not symmetric between the lower extremities in either fallers or controls. In this population of persons with unexplained falls who demonstrated substantial impairments in functional balance, effector factors appear more impaired than automatic postural responses. Alternatively, contemporary analysis of automatic postural responses may require further development before it can be useful to study balance problems in older persons.
Outpatient Geriatric Assessment: Associations between Referral Sources and Assessment Findings
Authors: Heath John M. , Grant William D. , Kamps Celia A. , Margolin E. Gordon
Published: April 2015

A review of 431 outpatient geriatric assessments conducted over 2 years examined the associations of referral problems, assessment diagnoses, and therapeutic recommendations with the source of patient referral, as well as that referral source's diagnostic accuracy in identifying the referral problems. Families referred 52% of patients, primarily for problems of memory and behavior, whereas social service agencies made 32.9% of all referrals, primarily for bladder control problems or safety‐related concerns. Physicians made only 6% of referrals in this setting. Referral source was found not to be associated with any of the seven categories of medical diagnoses resulting from the assessment process and was associated with only two of the functional diagnostic categories. Therapeutic recommendations were also broadly distributed among referral sources, though social service agencies did refer more patients who required urgent nursing home placement, financial representation, or adult protective service involvement. The performance of family referral sources in accurately referring patients with dementia and psychiatric impairment was comparable to that of physicians, though all referral sources frequently missed patients with incontinence. Non‐physician referral sources appear to serve as important and quite valid case‐finders for outpatient geriatric assessment.
Sampling Issues in Nursing Home Research
Authors: Wayne Sharon J. , Rhyne Robert L. , Thompson Robert E. , Davis Mary
Published: April 2015

It has been suggested that two common methods of sampling nursing home populations, cross‐sectional sampling and discharge sampling, result in samples with different characteristics and lengths of stay. Comparison of these samples to a sample of nursing home admissions has not been studied. This study compares characteristics and lengths of stay among cross‐sectional, discharge, and admission samples. All current residents of three nursing homes in February 1987 made up the cross‐sectional sample, all admissions in the following year made up the admission sample, and all discharges in the same year made up the discharge sample. The results of comparing these three sampling techniques show that the most striking differences occur between the cross‐sectional sample and the admission sample. Persons in the cross‐sectional sample tended to have longer nursing home stays as well as less social support and more behavioral and functional problems than persons in the admission sample, who tended to have shorter stays and more acute medical problems. The discharge sample was more similar to the admission sample than it was to the cross‐sectional sample; however, some differences were found between the discharge and admission samples. Based on the differences found among the three samples, appropriate uses for each sample are discussed.
Characteristics and Outcomes of Hospitalized Older Patients Who Develop Hypocholesterolemia
Authors: Noel Margaret A. , Smith Thuy K. , Ettinger Walter H.
Published: April 2015

Objectives

This research project was undertaken to determine the clinical characteristics, lipoprotein abnormalities, and outcomes of older hospitalized patients who develop hypocholesterolemia.

Methods

The project had two parts: (1) a retrospective, case‐control study of 50 hospitalized patients ≥65 years old whose serum cholesterol was normal on admission (≥160 mg/dL) and fell to ≤120 mg/dl during hospitalization; (2) a laboratory study of lipoproteins in 17 hospitalized patients ≥65 years old whose cholesterol was normal on admission but fell to ≤120 mg/dL during hospitalization.

Results

Case‐control Study—Nine percent of patients ≥65 years old developed hypocholesterolemia while in the hospital, and these patients were more likely than controls to have undergone surgery and to have nothing by mouth for 5 days or longer. Cases had a longer length of stay, more complications, and were slightly more likely to die in the hospital than controls.

Laboratory Study—Hypocholesterolemic patients had low concentrations of all lipoproteins (VLDL, LDL, HDL), and the LDL and HDL were enriched in triglyceride and depleted of cholesterol ester.

Conclusion

Acquired hypocholesterolemia is a common finding in hospitalized older patients and is associated with poor outcomes. Patients who became hypocholesterolemic in the hospital had both a low concentration of lipoprotein particles and abnormalities in lipoprotein particle composition.
The Use of Armspan in Nutritional Assessment of the Elderly
Authors: Kwok Timothy , Whitelaw Michael N.
Published: April 2015

The use of body mass index (BMI) in the elderly is limited by the measurement of height which is often unreliable. Armspan approximates to height at maturity. It may, therefore, be an alternative to height in calculating BMI. We studied the relationship between height and armspan in 101 elderly men and women. A comparison of BMI by height and armspan was made. The correlation between height and armspan was 0.93. Armspan could be estimated by doubling halfspan (recumbent). The mean difference between BMI by height and armspan was 1.79 (SD 1.11) kg/M2. We concluded that armspan is a reliable and practical estimate of height in the non‐ambulant elderly. There is a case for the use of armspan instead of height in the determination of BMI in the elderly.
Underdiagnosis and Poor Documentation of Acute Confusional States in Elderly Hip Fracture Patients
Authors: Gustafson Yngve , Brännström Benny , Norberg Astrid , Bucht Gustav , Winblad Bengt
Published: April 2015

Study Objective

To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture.

Design

The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies.

Setting

Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital.

Subjects

Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively).

Measurements and Main Results

All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients.

Conclusions

ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.
Does Hypogonadism Contribute to the Occurrence of a Minimal Trauma Hip Fracture in Elderly Men?
Authors: Stanley Holly L. , Schmitt Brian P. , Poses Roy M. , Deiss William P.
Published: April 2015

The risk of MTHF in hypogonadal elderly men was investigated with a case‐control model. Cases and controls were selected from males age 65 years and older residing in the 120‐bed McGuire Veterans Affairs Medical Center Nursing Home Care Unit over a 5‐day interval. Historical data and serum free testosterone (fTe) were available on 17 subjects with MTHF and 61 controls. When groups were compared for differences in age, race, alcohol abuse, cigarette abuse, and diseases or drugs that may be associated with MTHF, only race was significantly different. Although 25.6% of residents were black, 100% of MTHF subjects were white (P = 0.004). Hypogonadism was defined as a random fTe <9 pg/mL (normal 9 to 46 pg/mL) and was found in 21 subjects (26.9%). Of cases with a MTHF, 58.8% were hypogonadal compared with only 18.0% of controls. Utilizing logistic regression, a highly significant association was found between hypogonadism and MTHF (P = 0.008), and using the odds ratio, subjects with hypogonadism were 6.5 times more likely to have a MTHF (95% CI 2.0 to 20.6). To adjust for race, the odds ratio was repeated excluding black subjects, and the results remained highly significant (4.6, 95% CI 1.3 to 16.2). We conclude that hypogonadal elderly white men may be at increased risk for MTHF.
Geriatrics Faculty in the United States: Who Are They and What Are They Doing?
Authors: Reuben David B. , Bradley Thomas B. , Zwanziger Jack , Vivell Susan , Fink Arlene , Hirsch Susan H. , Beck John C.
Published: April 2015

Despite increases in geriatrics training at all levels of medical education, there is a nationwide shortage of geriatrics faculty. This shortage may be due in part to demands for clinical responsibilities that preclude adequate time for teaching and research.

To learn about the professional activities of geriatrics faculty, we conducted a national survey of a 50% sample of all medical schools and their affiliated residency programs that focused on physician and non‐physician geriatrics faculty in internal medicine, family practice, psychiatry, neurology, and physical medicine and rehabilitation. Although we found minor differences across specialties, in general, approximately one‐third of physician faculty time is spent in teaching, the majority of which is clinical teaching. Less than 15% of physician faculty time is spent in research, and fewer than 10% of physician geriatrics faculty devote over half of their time to research. The percentage of time that non‐physician faculty (other than “Research Only” faculty) spend in research is only slightly higher. These findings suggest that efforts to increase geriatrics education at all levels and promote research advances will be limited unless geriatricians devote substantially more of their time to these responsibilities.
BOOK REVIEWS
Authors: Rossman Isadore
Published: April 2015

Geriatric Medicine: Problems and Practice. By Pathy MSJ and Finucane P., London, Springer‐Verlag, 1989. 383 pages. PNS
Prevalence of Postural Hypotension at Baseline in the Systolic Hypertension in the Elderly Program (SHEP) Cohort
Authors: Applegate William B. , Davis Barry R. , Black Henry R. , Smith W. McFate , Miller Stephen T. , Burlando Alfredo J.
Published: April 2015

Objective: The objective of this study was to examine the prevalence and correlates of postural hypotension (defined as a drop in systolic blood pressure of ≥20 mm Hg) in a cohort of elderly persons with isolated systolic hypertension (ISH).

Design: Baseline cross‐sectional analysis of the 4,736 persons randomized in the Systolic Hypertension in the Elderly Program (SHEP).

Setting: A randomized multi‐center double‐blind outpatient clinical trial of the impact of treating ISH. Participants: Men and women age ≥60 years with the systolic blood pressure (SBP) ≥ 160 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg.

Measures: Medical histories were obtained using interviewer‐administered, standardized clinical history forms. At entry into the study, seated and standing BP was measured by certified BP technicians using a random zero sphygmomanometer. Postural hypotension (PH) was assessed at 1 and 3 minutes after the participant arose from a seated position.

Main results: PH was found in 10.4% of participants at 1 minute and in 12.0% of participants at 3 minutes. 5.3% of participants demonstrated PH at both time intervals while 17.3% demonstrated PH at either or both of the time intervals. Factors significantly (P < 0.05) associated with the presence of PH were higher mean SBP and a lower mean body mass index.

Conclusions: Somewhat different persons were defined as having PH based upon the 1 minute and 3 minute standing measures of BP, and prevalence estimates of PH can vary depending on whether one or more intervals of measurement are used. Cross‐sectional data analysis indicated that PH, in healthy community‐dwelling older persons with ISH, may not be associated with a history of disorders or problems usually thought to be related to PH. However, prospective data are needed to determine the prognostic significance of PH, and whether one or multiple measurements carry more significance.
Effects of Exercise Training on Bone Density in Older Men and Women
Authors: Blumenthal James A. , Emery Charles F. , Madden David J. , Schniebolk Susan , Riddle Margaret W. , Cobb Frederick R. , Higginbotham Michael , Coleman R. Edward
Published: April 2015

Objectives: To determine the effects of up to 14 months of aerobic exercise on measures of bone density in older adults.

Design: Randomized controlled trial with subjects assigned to either an aerobic exercise condition, non‐aerobic yoga, or a wait list non‐exercise control group for 4 months. Aerobic fitness and bone density were evaluated in all subjects at baseline (Time 1) and after 4 months (Time 2). A semi‐crossover design was utilized with all subjects completing 4 months of aerobic exercise, followed by another evaluation (Time 3). All subjects were then given the option of 6 additional months of aerobic exercise, after which they had a fourth evaluation (Time 4).

Setting: An outpatient exercise rehabilitation facility at a large, major medical center.

Subjects: One‐hundred‐one healthy men (n = 50) and women (n = 51) over age 60 (Mean age = 67.0), recruited from the community.

Intervention: The exercise program included stretching, cycle ergometry, and walking three times per week for 60 minutes throughout the course of the study.

Outcome Measures: Aerobic fitness (VO2 max) as assessed by cycle ergometry, and bone density (bone mineral content) measured by single photon absorptiometry.

Results: Subjects achieved a 10%–15% increase in VO2 max after 4 months of exercise training, and 1%–6% further improvement with additional training. Aerobic fitness was associated with significant increases in bone density in men, but not women, who maintained aerobic exercise for 14 months.
Methicillin‐Resistant Staphylococcus aureus in Minnesota Nursing Homes
Authors: Thurn Joseph R. , Belongia Edward A. , Crossley Kent
Published: April 2015

Objective: To assess the experience of Minnesota nursing homes with methicillin‐resistant Staphylococcus aureus (MRSA) and the policies and procedures used for its control.

Design: A 12‐question survey, with primarily categorical responses, was mailed to the Directors of Nursing of all Minnesota long‐term‐care facilities. A follow‐up mailing was sent to non‐responders 5 weeks later. The mailing included a cover letter, a description of the study and its purposes, and a stamped return envelope. Four weeks after the second mailing, all non‐responding institutions were contacted by telephone and invited to participate by mail or by completing the survey by telephone.

Setting: All long‐term‐care facilities in Minnesota licensed for skilled and intermediate care.

Participants: The survey was directed to the Directors of Nursing of the long‐term‐care facilities with the request that, if another individual was better able to complete it, the survey be forwarded to them.

Results: Completed responses were obtained from 88% (395/445) of all long‐term‐care facilities in Minnesota. Forty‐eight institutions (12%) had residents colonized or infected with MRSA. Only four (8%) of these facilities stated that MRSA was a problem; however, 33 (69%) of facilities with MRSA had sought outside help or consultation from a variety of sources for its control. Few facilities (7%) had cultured residents specifically for MRSA. Policies regarding the admission of colonized or infected persons were reported by 14% and 21% of facilities, respectively, and over 40% of these policies stated that persons with MRSA would not be accepted. Policies regarding the care of MRSA‐colonized or ‐infected persons were not uniform. Both metropolitan and non‐metropolitan facilities had residents with MRSA.

Conclusions: Our results suggest that MRSA in long‐term‐care facilities may be a widespread and underrecognized problem. There is a need to develop uniform policies for the control of MRSA in nursing homes. These policies should consider the sources and objectives of long‐term‐care facilities.
Educating the Elderly: Cardiopulmonary Resuscitation Decisions before and after Intervention
Authors: Schonwetter Ronald S. , Teasdale Thomas A. , Taffet George , Robinson Bruce E. , Luchi Robert J.
Published: April 2015

Considering the limited success of cardiopulmonary resuscitation (CPR) in achieving survival to hospital discharge in older persons, it is appropriate to educate, discuss and determine patients' wishes at a time when they are able. Sixty‐four ambulatory, non‐depressed, non‐demented veterans >74 years of age were interviewed and educated. Knowledge of CPR at baseline was variable, and most overestimated their survival chances. Most subjects desired routine CPR discussions with physicians. Only 17% had previously discussed their CPR preferences, and none had done so with physicians. Knowledge of CPR increased (P = 0.01) after educational intervention. There was no change in subjects' CPR decisions after education and presentation of current CPR outcome data. In considering five hypothetical scenarios, 9% never wanted CPR, and 17% always wanted CPR. Those who never wanted CPR were more realistic about their suspected survival chance (P = 0.003) and had higher educational levels (P = 0.03) Folstein (P = 0.05) and Geriatric Depression Scale (P = 0.04) scores. With the dependent variable being the number of hypothetical situations in which the patient desired CPR, a regression analysis (adjusted r2 = 0.72) limited significant variables to the patient's current CPR decision, Folstein score, religion, marital status, and previous ICU admissions. This study emphasizes that most elderly male veterans are willing and want to discuss their CPR attitude with physicians and that most have fixed CPR decisions which may be elicited under stable clinical conditions.
Healthy Elderly Women and Men Have Different Entrained Circadian Temperature Rhythms
Authors: Moe Karen E. , Prinz Patricia N. , Vitiello Michael V. , Marks Alan L. , Larsen Lawrence H.
Published: April 2015

Body core temperature was measured in healthy elderly men and women under entrained conditions. Female subjects showed a larger amplitude and a higher peak temperature than male subjects. In addition, acrophase was advanced for females by an average of 49 minutes. Variability in acrophase was greater for males than females. This pattern of gender differences varies considerably from the pattern others have observed in young subjects, suggesting that aging may affect the circadian timing system of males and females differently.
Clinical Significance of Primitive Reflexes in Alzheimer's Disease
Authors: Molloy D. William , Clarnette Roger M. , McIlroy William E. , Guyatt Gordon , Rees Linda , Lever Judy
Published: April 2015

Study Objective: To establish the relationship between cognition, behavior, function, and clinical characteristics on the one hand, and the presence of primitive reflexes (PR) (pout, snout, palmomental and grasp) in patients with Alzheimer's disease (AD).

Design: Cross‐sectional survey.

Setting: Secondary care geriatric practice specializing in the assessment of cognitive impairment.

Subjects: 136 consecutive patients presenting with AD.

Measurements: PR were assessed in standardized fashion by a single clinician. Cognitive function was measured using the Standardized Mini‐Mental Status Examination, activities of daily living (ADL) and instrumental activities of daily living (IADL) were measured using the Lawton scale, and behavior was measured using the Behavioural Problem Checklist.

Results: There was no difference in age or duration of dementia in those with and without PR, nor was there any difference in cognitive function. Despite this, patients with PR showed a greater degree of functional limitation and dysfunctional behavior. There was also a higher incidence of rigidity, gait abnormalities, and apraxia in patients with PR.

Conclusions: Patients with primitive reflexes had more severe impairment in ADL function and dysfunctional behavior for an equal level of cognitive function.
The Utilization of Fecal Occult Blood Testing in the Institutionalized Elderly
Authors: Klos Steven E. , Drinka Paul , Goodwin James S.
Published: April 2015

Objective: To examine physician use of stool guaiac testing in order to determine indications for testing, how the test was used, and the consequences of a particular test result.

Design: Retrospective case series.

Setting: Large midwestern inpatient nursing home facility.

Patients: All patients with positive fecal occult blood tests (FOBT) and one‐third of patients with negative FOBT.

Results: In an 18‐month period, 916 occult blood tests were performed on 339 patients (37% of the nursing home census). Patients over age 90 were as likely to receive FOBT as those under age 70. Fourteen percent of those tested had at least one positive test. Fifty‐eight percent of the patients with positive tests underwent no additional diagnostic testing. No cause for the positive FOBT was found for 68% of patients receiving the test for routine screening. Physician estimates of how frequently they employed FOBT for these patients correlated very poorly with their actual practices (r = .17).

Conclusion: There is a high prevalence of positive results from FOBT among nursing home patients. In most cases, such results do not cause a change of therapy or result in additional workup. Lack of information on the role of FOBT in nursing home patients contributes to the great diversity in utilization of this test by nursing home physicians.
Survival of Patients with Dementia
Authors: van Dijk Pieter TM , Dippel Diederik WJ , Habbema J Dik F
Published: April 2015

The evidence on survival in dementia is summarized. There are no reliable data on survival after onset of dementia or after first contact with medical services. People with dementia in outpatient clinics and nursing homes have 2‐year survival rates of 75% (range 60%‐95%) and 50% (range 30%‐65%), respectively. Differences in survival between patients with senile dementia of the Alzheimer's type (SDAT) and multi infarct dementia (MID) are small. Women in nursing homes have a better prognosis than men (2‐year survival rates, 60% vs 40%). Dementia patients have a considerable excess mortality when compared to the vital statistics. There is no evidence for improvement of survival rates during recent decades. Recommendations for future studies are made
Survival in a Residential Home: An Eleven‐Year Longitudinal Study
Authors: Dontas Anastasius S. , Tzonou Anastasia , Kasviki‐Charvati Popi , Georgiades George L. , Christakis George , Trichopoulos Dimitrios
Published: April 2015

The length of survival and various risk factors were studied utilizing 408 residents (141 men, 267 women) of a large residential home. The subjects, aged 68 years or more at entry, admitted between 1978 and 1983, were physically independent, continent, and non‐diabetic. They were followed until December 31, 1988, by which time 78% had died. The multivariate proportional hazard analysis showed the following entry variables to have the indicated effects on relative mortality rate ratios: 5‐years' higher age (+10%, NS), persistent bacteriuria (+13%, NS), abnormal ECG (+26%, NS), current smoking (+63%, P < 0.01), mildly impaired mobility (+96%, P < 0.001), higher levels of in‐study systolic pressure in 10‐mm Hg steps (‐4%, NS), higher entry serum cholesterol in 1‐mmol/L steps (‐7%, NS), and higher hematocrit in 5% steps (‐14%, P < 0.02). Female sex was associated with a +25% (NS) rate ratio; socioeconomic status and body weight were without effect.

These data highlight the relative importance of specific factors associated with survival of persons within retirement homes and indicate that: (1) the presence of mild impairment of mobility at entry is by far the strongest predictor of early death; (2) smoking and lower hematocrit also exert important adverse effects; and (3) certain “risk factors”, ie elevated systolic blood pressure and serum cholesterol, have a minimal protective effect, if any, in this age group.
Cardiovascular and Catecholamine Responses to Head‐Up Tilt in the Diagnosis of Recurrent Unexplained Syncope in Elderly Patients
Authors: Hackel Andrea , Linzer Mark , Anderson Norman , Williams Redford
Published: April 2015

To increase understanding of the mechanisms causing syncope in patients over the age of 60, hemodynamic and hormonal responses to 60 minutes of 60 degree head‐up tilt were examined in 10 patients with recurrent syncope of unknown origin and five controls with no history of syncope. Nine of 10 patients and all five controls experienced orthostatic intolerance on the tilt table. Syncope or pre‐syncope occurred later in controls than in those syncope patients who had exact reproduction of their clinical symptoms (median time 52 versus 22 minutes, P = 0.05). Three different mechanisms of orthostatic intolerance were identified in the 14 subjects: (1) vasovagal syncope, n = 9 (sudden hypotension ± bradycardia); (2) dysautonomic syncope, n = 3 (immediate and gradual parallel declines in both systolic and diastolic pressures with blunted increase in heart rate); (3) psychogenic or vestibular reaction, n = 2 (orthostatic intolerance without hemodynamic changes). Vasovagal syncope patients showed a significant increase in plasma norepinephrine from baseline to maximum level during tilt (100 ± 39% increase, P = 0.03) and a subsequent decrease at the time of syncope (30 ± 5% decrease, P = 0.01), while plasma epinephrine increased markedly from baseline to the time of syncope (827 ± 154% increase, P = 0.0003). Dysautonomy syncope patients had lower supine levels of norepinephrine compared to vasovagal syncope patients (182 ± 30 versus 614 ± 146 pg/mL, P = 0.008) and no significant change in norepinephrine over time; epinephrine levels increased significantly less than in vasovagal patients (net change 38 ± 8 versus 189 ± 56 pg/mL, P = 0.008). Psychogenic and vestibular reactions were distinguished by rising levels of norepinephrine at the time of symptoms. The 50% (5 of 10) prevalence of vasovagal reactions found in the syncope patients suggests that vasovagal syncope may be more common among the elderly than previously recognized.
Daytime Sleepiness in the Healthy “Old Old”: A Comparison with Young Adults
Authors: III Charles F. Reynolds , Jennings J. Richard , Hoch Carolyn C. , Monk Timothy H. , Berman Susan R. , Hall Florence T. , Matzzie Jeanette V. , Buysse Daniel J. , Kupfer David J.
Published: April 2015

Objective: To determine if excessive daytime sleepiness is an inevitable consequence of aging.

Methods: Daytime sleepiness was measured using Multiple Sleep Latency Tests (MSLT's) before and after a night of total sleep deprivation in a sample of 22 healthy men and women in their eighties and 29 men and women in their twenties.

Results: Young adults were somewhat sleepier than elders, as measured by rapidity of sleep onset during daytime nap recordings using the MSLT, and showed a higher incidence of REM sleep during naps. However, recovery from the effects of acute sleep loss was slower in the elderly, judging from the presence of more daytime sleepiness 2 days after a night of total sleep deprivation. Such persistent sleepiness was absent in the young adult control group.

Conclusions: Healthy persons in late old age may have a level of daytime sleepiness no greater than, and perhaps even less than, that seen in healthy young adults.
Low Body Mass Index in Demented Outpatients
Authors: Berlinger William G. , Potter Jane F.
Published: April 2015

In order to determine the association between dementia and low body weight in outpatients, Body Mass Index (BM1) was evaluated prospectively in 346 frail elderly outpatients presenting for comprehensive geriatric assessment. Patients were categorized into four groups (cognitively intact, dementia of the Alzheimer's type (DAT), other dementia, and patients with depressive symptoms). Patients were assessed for severity of dementia by the Clinical Dementia Rating scale. Differences between groups for various clinical parameters were evaluated using an analysis of variance and Duncan's Multiple Range Test. Patients with dementia, regardless of etiologic type or severity, and patients with depressive symptoms had BMI's ≥10% lower than the cognitively intact patients. BMI was positively correlated with Instrumental Activities of Daily Living (IADL) but not Activities of Daily Living (ADL) or Mini‐Mental State Exam (MMSE) score. Low BMI was not associated with increased physical illness. In fact, in the subset of patients with DAT, lower BMI correlated with significantly lesser amounts of comorbid physical illness. Finally, compared to cognitively intact outpatients, patients with DAT appeared to be physically healthier despite their having a lower BMI.

These results suggest an association between dementia and low BMI. On the other hand, the presence of comorbid physical illness, a common focus of evaluation in these patients, was not more common in those patients with lower BMI's.
A Randomized Study of Ciprofloxacin versus Ceftriaxone in the Treatment of Nursing Home‐Acquired Lower Respiratory Tract Infections
Authors: Hirata‐Dulas Cheryl A. I. , Stein Daniel J. , Guay David R. P. , Gruninger Robert P. , Peterson Phillip K.
Published: April 2015

Objective: To compare the efficacy and safety of ciprofloxacin and ceftriaxone in patients with nursing home‐acquired lower respiratory tract infections requiring initial hospitalization.

Design: Prospective, randomized trial.

Setting: Extended care nursing homes affiliated with a teaching hospital.

Patients: Fifty patients aged 60 years or older with normal or mildly impaired renal function admitted to the hospital for treatment of lower respiratory tract infections.

Interventions: Twenty‐four patients received initial therapy with intravenous ciprofloxacin, 200 mg every 12 hours (19 patients) or 400 mg every 12 hours (5 patients) during the acute phase followed by 750 mg orally every 12 hours during the convalescence phase. Twenty‐six patients received initial therapy with intravenous ceftriaxone, 2 g every 24 hours during the acute phase followed by 1 g administered intramuscularly every 24 hours during the convalescent phase. The total duration of therapy was 14 days.

Main Outcome Measurements: Successful outcome was defined as resolution or marked improvement in clinical signs and symptoms of lower respiratory tract infection upon completion of the treatment course.

Results: Twelve (50%) of the ciprofloxacin‐treated and 14 (54%) of ceftriaxone‐treated patients had successful outcomes. Recurrent oropharyngeal aspiration was the reason for treatment failure in most patients refractory to either antibiotic. Mortality during therapy was 8% in each group. From 21 satisfactory sputum specimens collected, S. pneumoniae was the most common isolate, followed by H. influenzae and other Gram‐negative bacteria. Ciprofloxacin therapy was well tolerated; ceftriaxone therapy was discontinued in two patients (8%) due to adverse reactions (intramuscular pain and drug fever).

Conclusions: Sequential intravenous/oral ciprofloxacin appears to be as safe and effective as sequential intravenous/intramuscular ceftriaxone. The optimal dosage of intravenous ciprofloxacin in this patient population appears to be 400 mg every 12 hours; however, additional clinical and pharmacokinetic studies with this regimen are warranted.
Trends in Elderly Hospitalization and Readmission Rates for a Geographically Defined Population: Pre‐ and Post‐Prospective Payment
Authors: Leibson Cynthia L. , Naessens James M. , Campion Mary E. , Krishan Iqbal , Ballard David J.
Published: April 2015

To address the paucity of patient‐level data regarding the effectiveness of Medicare's prospective payment system (PPS), we conducted a population‐based study of inpatient hospitalizations among individually identified elderly residents of Olmsted County, Minnesota, 1970–1987.

A 4.3% increase in total days of care/1000 population from 2,652/1,000 in 1970 to 2,766/1,000 in 1980 was followed by a 9.8% decline from 1980 to 1987 (2,495/1,000). The decline was due primarily to a 13.4% decrease in mean length stay (9.7 days in 1980 to 8.4 days in 1987). The number of hospitalizations/1,000 Olmsted County elderly in 1980 was already below 1987 U.S. figures and did not exhibit the decline evidenced nationally between 1980 and 1987. A 4.6% decline in the proportion of county residents age 65–74 years who were hospitalized (174/1,000 in 1980 to 166/1,000 in 1987) was offset by an 8.3% increase for persons age ≥ 75 (252/1,000 to 273/1,000) and by a 5.7% increase in the number of hospitalizations per individual hospitalized for persons age 65–74 years (1.34 to 1.42).

Using a time‐dependent Cox model, which adjusted for differences in patient characteristics between years, there was a significantly higher risk of readmission within 14 days in 1987 vs 1980 (hazard ratio (HR) = 1.33, 95% confidence interval (CI) = 1.05–1.70). The difference between years was no longer evident at 30 or 60 days (HR = 0.84, 95% CI = 0.63–1.11 between 15 and 30 days; HR = 1.12, 95% CI = 0.84–1.49 between 31 and 60 days).

This study suggests that initial effects of PPS on utilization may be temporary and that more research is needed to appreciate the impact of cost‐containment on patient outcome.
Shoe Sole Thickness and Hardness Influence Balance in Older Men
Authors: Robbins Steven , Gouw Gerard J. , McClaran Jacqueline
Published: April 2015

Objective

To test the hypothesis that shoes with thick, soft midsoles, such as modern running shoes, provide better stability in older individuals than those with thin‐hard midsoles. In addition, we examined the relation between footwear comfort and stability and stability when barefoot.

Design

Randomized‐order, cross‐over, controlled comparison.

Setting

Subjects were drawn from an internal medicine practice.

Participants

A random sample of 25 healthy men, minimum age 60 years. Additional selection criteria were absence of disabilities influencing ability to walk and lack of history of frequent falls.

Measurements

Balance failure frequency, which was defined as falls from the beam per 100 meters of beam walking when 10 passes were made down a 9 M long balance beam. Comfort rating was based on an ordinal scale.

Results

Contrary to the hypothesis: (1) midsole softness was associated with poor stability (F(2,48) = 17.9, P < 0.0001); (2) thick midsoles also provided poor stability (F(1,24) = 7.36, P < 0.01). When barefoot, subjects showed 19% higher balance failure frequency than with the poorest shoe and 171% greater than the best shoe (t = 5.33, P < 0.0001). Higher comfort was generally found in shoe types associated with higher balance failure frequency.

Conclusions

For optimal stability, shoes with thin, hard soles are preferable for older individuals. Health professionals should exercise caution when recommending shoes with thick, yielding midsoles, such as running shoes, to unstable elderly individuals. Older men and women with a history of falls or who are obviously unstable, should avoid barefoot locomotion.
Development of Scoring Criteria for the Clock Drawing Task in Alzheimer's Disease
Authors: Mendez Mario F. , Ala Thomas , Underwood Kara L.
Published: April 2015

Objective

To investigate the reliability and validity of freehand clock drawings, a frequently used measure of constructional apraxia, in patients with Alzheimer's disease.

Design

Survey for the purpose of testing reliability and validity of a new scale.

Setting

Memory Disorder Clinic at a university‐affiliated hospital in the Upper Midwest.

Patients

Forty‐six patients were diagnosed with clinically probable dementia of the Alzheimer type after a dementia evaluation, and 26 normal elderly controls were research volunteers without a history of cognitive dysfunction.

Measurements

Neuropsychological tests, dementia‐related scales, and clock drawings rated by a new 20‐item Clock Drawing Interpretation Scale. Reliability measures, correlations, and clustering of items in the CDIS.

Results

The CDIS had inter‐rater reliability (r = .94), internal consistence (rtt = .95), and reproducibility over a 6‐month interval. CDIS scores were significantly correlated with two dementia‐related scales and all neuropsychological tests and had the highest correlations with other measures of constructional apraxia. All but four Alzheimer patients (91%) and none of the controls had CDIS scores of 18 or less.

Conclusion

Clinicians may reliably screen patients with Alzheimer's disease with the clock‐drawing task, a measure sensitive to deficits in constructional apraxia.
Driving in Alzheimer's Disease
Authors: Dubinsky Richard M. , Williamson Annette , Gray Carolyn S. , Glatt Sander L.
Published: April 2015

Objective

To determine if the impaired mental skills in Alzheimer's Disease (AD) may adversely affect driving ability.

Design

Retrospective survey.

Setting

The Alzheimer's Clinic of the University of Kansas Medical Center.

Patients

We interviewed 67 AD patients and their families and compared them with 100 elderly, non‐spousal controls.

Measures

The questionnaire was designed to obtain information on their driving habits, with emphasis placed on whether they were still driving, and the number of accidents per year for the past 10 years.

Results

Forty‐six of the AD subjects had stopped driving because of safety concerns expressed by the subjects, their families, or health care providers, and two had stopped for other reasons. Only two of the normal controls had stopped driving (P < 0.0001, Chi‐square test). Over the past 3 years, the 19 AD subjects who were still driving had 263.2 motor vehicle accidents per million vehicle miles of travel compared with 14.3 for the controls (P < 0.002, Mann‐Whitney U test) and 5.7 for the general driving population age ≥ 55 years (P < 0.05, Students one group, two‐tailed t test).

Conclusion

This study suggests that a significant traffic safety problem exists in subjects with AD who continue to drive. Efforts should be directed to detect patients with AD whose driving presents a traffic safety problem.
Instrumental Activities of Daily Living as a Screening Tool for Cognitive Impairment and Dementia in Elderly Community Dwellers
Authors: Barberger‐Gateau Pascale , Commenges Daniel , Gagnon Michèle , Letenneur Luc , Sauvel Claire , Dartigues Jean‐François
Published: April 2015

Objective

To identify which Instrumental Activities of Daily Living (IADL) are related to cognitive impairment, independent of age, sex, and education; to assess the performance of an IADL score using these items in screening for cognitive impairment and dementia in elderly community dwellers.

Design

Survey based on the baseline interview of the PAQUID study on functional and cerebral aging.

Setting

Community survey in 37 randomly selected parishes in Gironde, France.

Subjects

Random sample of 2,792 community dwellers aged 65 and over (participation rate: 69%).

Measurements

Two‐phase screening: (1) functional assessment, Mini‐Mental State Examination (MMSE) and DSM‐III criteria for dementia; (2) in DSM‐III‐positive patients, NINCDS‐ADRDA criteria applied by a neurologist. Functional assessment: IADL scale of Lawton and Brody. Criterion standards: cognitive impairment: MMSE score lower than 24; dementia: DSM‐III and NINCDS‐ADRDA criteria.

Results

Four IADL items are correlated with cognitive impairment independent of age, sex, and education: telephone use, use of means of transportation, responsibility for medication intake, and handling finances. A score adding the number of IADL dependencies has a sensitivity of 0.62 and a specificity of 0.80 at the lowest cut‐off point (score > 0) for the diagnosis of cognitive impairment. The same score at the same cut‐off has a sensitivity of 0.94 and a specificity of 0.71 for the diagnosis of dementia. The prevalence of dementia (2.4%) is reduced by a factor of 12 in subjects independent for the four IADL.

Conclusion

The four IADL score could be incorporated into the screening procedure for dementia in elderly community dwellers.
Treatment of Hypercholesterolemia: Comparison of Younger versus Older Patients Using Wax‐Matrix Sustained‐Release Niacin
Authors: Keenan Joseph M. , Bae Chul‐Young , Fontaine Patricia L. , Wenz Joyce B. , Myers Shepherd , Huang Zhiquan , Ripsin Cynthia
Published: April 2015

Objective

Compare lipid response, side effect profile and toxicity of younger (<50 years) versus older (50 to 70 years) hypercholesterolemic subjects taking wax‐matrix sustained‐release niacin (Endur‐acin®).

Study Design

An 8‐week randomized double‐blind placebo controlled trial.

Setting

General community.

Participants

Volunteers from community cholesterol screening programs and chart review of patients at family practice clinics. Male and female subjects, age 20 to 70, with baseline low density lipoprotein cholesterol level within the 75th to 95th percentile, excluded if on medications that affect lipids or if a history of diabetes, gout, peptic disease, or liver disease is present.

Intervention

Nicotinic acid dosage schedules were 1,000 mg/day, 1,250 mg/day, 1,500 mg/day, or 2,000 mg/day for 8 weeks.

Main Outcome Measures

Change in blood lipids and blood chemistries, side effects, and pill compliance.

Results

158 subjects (79%) completed the study. Higher dose groups (1,500 mg and 2,000 mg) demonstrated improvements in total cholesterol, LDL‐cholesterol, HDL cholesterol, and total‐to‐HDL‐cholesterol ratio (P < 0.05) compared to baseline and controls. Higher‐dose older subjects demonstrated significantly greater improvements than younger subjects on comparable doses for total cholesterol, HDL cholesterol, total‐to‐HDL‐cholesterol ratio, and triglycerides, P < 0.02). Adherence to medication schedules was better and incidence of side effects and toxicity no greater in older subjects compared to younger.

Conclusion

Wax‐matrix niacin (Endur‐acin®) was shown to be effective and well tolerated for the pharmacological treatment of hypercholesterolemia. Older persons, ages 50 to 70, appear to experience greater benefits with no greater side effects when compared to younger subjects on similar doses.
Dementia and the Nursing Home: Association with Care Needs
Authors: Aronson Miriam K. , Cox Donna , Guastadisegni Paul , Frazier Cynthia , Sherlock Lila , Grower Ronnie , Barbera Arlene , Sternberg Marc , Breed Joseph , Koren Mary Jane
Published: April 2015

Objective

To determine whether RUG reimbursement categories accurately predict requirements for care in nursing homes.

Design

Prospective descriptive study of residents in lower reimbursement categories according to RUG.

Setting

Three nursing homes in New York City.

Participants

Convenience sample of 173 residents who agreed to participate, not significantly different from 201 who did not agree to participate.

Main Measures

Chart review; assessment of residents' cognitive and functional abilities; nursing assistants' ratings of residents' functional abilities, behavioral problems, the amount of effort required in care; and time‐motion studies of staff‐resident interactions.

Results

Both the residents' RUG classification (P < 0.01) and the level of ADL independence (P < 0.001) had significant impacts on the staff effort required in their care, with more dependent residents requiring greater effort. The residents' level of cognitive impairment also had a significant impact on the staff effort, with the severely impaired requiring greater effort (P < 0.05). The time‐motion analysis indicated that residents within the same RUG category differed in the number of staff‐resident interactions based on their level of cognitive impairment.

Conclusions

Cognitive impairment is a significant morbidity (or co‐morbidity) in determining the quantity of staff effort required by the resident, and behavioral interventions are an important care component. There is marked heterogeneity within lower (RUG) reimbursement categories which translates into strikingly different care requirements.
A Simple Method of Recognizing Geriatric Patients at Risk for Death and Disability
Authors: Incalzi Antonelli R. , Capparella O. , Gemma A. , Porcedda P. , Raccis G. , Sommella L. , Carbonin P. U.
Published: April 2015

Objective

To identify prognostic indicators for geriatric patients discharged from an acute care hospital.

Design

Prospective observational study.

Setting

Base line assessment at discharge from an acute care hospital; reassessment after 1 year at home.

Patients

One hundred‐seventy‐eight consecutive patients over 70 years of age (mean age ± SD = 75.6 ± 13.1 years, range 70–95 years, 52% males); 56% were dependent in one or more Activities of Daily Living, 21% had abnormal Mini Mental State Scores.

Main Outcome Measures

mortality, increasing physical dependence, health care utilization.

Results

Mortality was directly related to a low ADL score at hospital discharge (Odds Ratio = 3.31, Confidence Limits = 1.91–5.75), neoplastic diseases (OR = 3.59, CL = 2.01–6.43), cardiovascular diseases (OR = 2.47, CL = 1.40–4.36), and drug use, expressed as the total number of individual preparations prescribed at discharge (OR = 1.72, CL = 1.05–2.83). Low ADL score, cardiovascular and neoplastic diseases were also predictive of increasing physical dependency. The use of health care services, quantified by an appropriately designed score, did not correlate with any of the baseline variables, with the implication that the use of the health care services was not proportional to the need for care. Conclusions: Elderly subjects at major risk of death and disability can be easily identified at discharge by a simple assessment of their medical and functional state.