bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Paget's Disease of Bone with Salmon Calcitonin Nasal Spray
Authors: Gagel Robert F. , Logan Cheri , Mallette Lawrence E.
Published: April 2015

Subcutaneous daily or bidaily administration of synthetic salmon calcitonin is an effective form of therapy for Paget's disease, but the requirement for parenteral injection deters geriatric patients from using the drug. This study compares a new intranasal preparation of salmon calcitonin to subcutaneous drug in 18 patients with Paget's disease using two different protocols. In the first protocol, 15 patients not previously treated with salmon calcitonin were given the agent for 3 months by either the intranasal or subcutaneous route. Seven patients treated with intranasal calcitonin had a mean fall in the serum alkaline phosphatase of 33% over a 3‐month period compared to a fall of 40% in the subcutaneously treated group; the difference between the two treatment groups was not statistically significant. In the second protocol, three patients previously stabilized on subcutaneous calcitonin were switched to the nasal spray with no subsequent change in alkaline phosphatase values during 6 months of treatment. These results demonstrate that intranasal salmon calcitonin is effective in lowering the serum alkaline phosphatase in Paget's disease. Ease of administration and patient acceptance make intranasal calcitonin a reasonable alternative for geriatric patients.
Elders' Nonadherence, Its Assessment, and Computer Assisted Instruction for Medication Recall Training
Authors: Von Leirer O. , Morrow Daniel G. , Pariante Grace M. , Sheikh Javaid I.
Published: April 2015

This study investigates three questions related to the problem of medication nonadherence among elders. First, does recall failure play a significant role in nonadherence? Recent research suggests that it may not. Second, can the new portable bar code scanner technology be used to study nonadherence? Other forms of monitoring are obtrusive or inaccurate. Finally, can inexpensive computer assisted instructions (CAI) be used to teach mnemonic techniques specifically designed to improve medication schedule recall? Current research on memory training teaches nonspecific mnemonics and uses the expensive classroom approach. Results of the present study suggest that physically active and cognitively alert elders do have significant nonadherence (control group — 32.0%) problems related to forgetting and that CAI courseware can significantly reduce (medication recall training group = 10.0%) this form of nonadherence. Portable bar code technology proved easy to use by elderly patients and provided detailed information about the type of forgetting underlying nonadherence. Most significant recall failure was in the complete forgetting to take medication rather than delays in medicating or overmedicating.
Forgetting Falls
Authors: Cummings Steven R. , Nevitt Michael C. , Kidd Sharon
Published: April 2015

To determine how accurately elderly subjects recall recent falls, we studied 304 ambulatory men and women over the age of 60 years who completed a 12‐month prospective study of risk factors for falling. We developed a system of weekly follow‐up and home visits to record and confirm all falls. During the study, 179 participants suffered at least one fall that was confirmed by home visit. At the end of the study, all subjects were interviewed by telephone about whether they had suffered a fall during the preceding 3, 6, or 12 months. Depending on the time period of recall, 13% to 32% of those with confirmed falls did not recall falling during the specific period of time. Recall was better for the preceding 12 months than for 3 or 6 months. There were only weak correlations (r = 0.28 to 0.59) between the number of falls that were documented and the number that the subjects recalled during each of these periods. Those with lower scores on the Mini‐Mental State Examination were more likely to forget falls. We conclude that elderly subjects often do not recall falls that occurred during specific periods of time over the preceding 3 to 12 months. Researchers and clinicians should consider using methods besides long‐term recall for ascertaining and counting falls over specific periods of time.
Clinical Correlates of Bacteremia in a Veterans Administration Extended Care Facility
Authors: Rudman Daniel , Hontanosas Alfred , Cohen Zev , Mattson Dale E.
Published: April 2015

Little is known about bacteremia in long‐term care facilities. We have conducted a retrospective study during a 12‐month period analyzing the clinical correlates of bacteremia in 533 chronically institutionalized, predominantly male patients, with an average age of 69 years. Thirty‐four men had forty‐two bacteremic illnesses during this period. The incidence rate was 0.30 episodes per WOO patient care days, and the mortality rate was 21%. The urinary tract was the most frequently identified tissue source (56%), followed by respiratory tract (7%) and skin (7%). Providencia stuartii was the most common gram‐negative organism, while Staphylococcus aureus, Streptococcus pneumoniae and enterococcus were the frequent gram‐positive microbes. Gram‐negative bacteremia accounted for 63% of the episodes (15% mortality rate), and gram‐positive bacteremia accounted for 27% (18% mortality rate); 10% of the bacteremias were polymicrobial (25% mortality rate). Most of the isolated organisms were sensitive to available antimicrobial agents. The leading risk factor for bacteremia was an indwelling urinary catheter (odds ratio 39, 95% confidence limits 16 to 97). Patients with urinary catheters at the beginning of the study constituted only 5% of the population, but accounted for 40% of the gram‐negative bacteremias during the year of observation.
Anthropometric Indicators and Hip Fracture
Authors: Farmer Mary E. , Harris Tamara , Madans Jennifer H. , Wallace Robert B. , Cornoni‐Huntley Joan , White Lon R.
Published: April 2015

A cohort of 3,595 white women aged 40–77 years was followed for an average of 10 years during which 84 new cases of hip fracture were identified. Triceps skinfold thickness and arm muscle area measured at baseline were examined as possible risk factors for hip fracture controlling for physical activity, height, menopausal status, calcium consumption, and smoking. Of these variables only arm muscle area, triceps skinfold thickness, and activity in recreation were independent predictors of hip fracture incidence using the Cox proportional hazards model. After adjustment, the estimated relative risk of hip fracture was approximately two for an increment of each anthropometric indicator (adjusted for the other) equivalent to comparing those at the 25th percentile to those at the 75th percentile (maximum width of 95% confidence intervals, 1.2–2.9). Risk of hip fracture was approximately two‐fold for persons who reported little recreational exercise compared to persons who reported much recreational exercise (95% confidence interval, 1.2–3.2).

Our findings are the first evidence from a prospective study that anthropometric indicators besides body mass index may have an independent relationship to risk of hip fracture.
Caregiving Spouses Physical and Mental Health in Perspective
Authors: Pruchno R. A. , Potashnik S. L.
Published: April 2015

The self‐reported physical and mental health of 315 persons caring for a spouse who had been diagnosed with Alzheimer's disease or a related disorder was compared with general population norms for existing data bases controlling for age and gender. Results suggest that across all indicators of mental health, spouse caregivers are more depressed, express higher levels of negative affect, are more likely to use psychotropic drugs, and have more symptoms of psychological distress than the general population. In terms of physical health, caregivers report higher than expected rates of diabetes, arthritis, ulcers, and anemia, yet they use medical services at rates which are similar or lower than those reported by the general population. Since no simultaneous control group was studied, these results suggest, but do not prove, the presence of differences between caregivers and non‐caregivers.
Vasopressin Response to Dehydration in Alzheimer's Disease
Authors: Albert Stewart G. , Nakra B. R. S. , Grossberg George T. , Caminal Eduardo R.
Published: April 2015

Alzheimer's disease is a progressive deterioration of neuropsychological functioning. One of the main neuropathological correlates of the disease is a drop‐out of cholinergic neurons within the central nervous system. The neuropeptide that is responsible for water homeostasis and defense against dehydration, vasopressin, is also under direct cholinergic control. Several studies have suggested that in Alzheimer's disease there has been a trend toward lower vasopressin levels than in age‐matched controls. In order to improve discrimination of normal from diminished vasopressin levels, nine subjects with Alzheimer's disease (mean age 65 ± 2 years) and nine age‐ and sex‐matched controls (68 ± 3 years) underwent a mild provocative challenge of overnight fluid restriction. Individuals with Alzheimer's disease had a greater degree of dehydration, with overnight serum osmolality of 313 ± 4 vs 300 ± 3 Mosmol/kg, P = .01, and diminished “thirst” as measured by water ingested in one hour of ad libitum water intake. Eight of the nine with Alzheimer's disease had levels of vasopressin which, by extrapolation, appear to be subnormal for their serum osmolalities, whereas seven of the nine control subjects has vasopressin levels within or above the reference range (P < .05). Elderly individuals with Alzheimer's disease may be at increased risk of dehydration during periods of fluid restriction due to the loss of normal physiological responses of “thirst” and vasopressin secretion.
The EASI: A Self‐Administered Screening Test for Cognitive Impairment in the Elderly
Authors: Horn Lucille , Cohen Carl I. , Teresi Jeanne
Published: April 2015

The Early Assessment Self Inventory (EASI), a rapid self‐administered screening test for cognitive impairment in the elderly, was constructed to permit individuals to be assessed in a group or singly without examiner intervention. This paper‐and‐pencil device requires a fourth‐grade reading level and makes minimal demands on literacy while assessing orientation, recent and remote memory, language, visual‐construction, calculation, and attention. In the present study, the EASI was group‐administered to 146 elderly persons attending senior centers and completed individually without examiner intervention by 19 outpatients at a memory disorders clinic. Participants were 60 to 95 years old with 5 to 18 years of education. The EASI demonstrated good internal consistency and test‐retest reliability and was significantly correlated with the Mini‐Mental State Exam and the Mattis Dementia Rating Scale, both widely used screening instruments. Neuropsychological measures of memory, attention, and verbal fluency correlated as well with the EASI as with the examiner‐administered screening instruments, suggesting that the EASI may provide an efficient method of screening for cognitive impairment.
Use of the Geriatric Depression Scale in Dementia of the Alzheimer Type
Authors: Burke William J. , Houston Michael J. , Boust Susan J. , Roccaforte William H.
Published: April 2015

The Geriatric Depression Scale (GDS) has been shown to be an effective screening test for depression in selected geriatric populations. However, it has not been evaluated as a screening test for depression among elderly adults with dementia of the Alzheimer type. Over a two‐year period 283 patients were seen in a geriatric assessment center and were screened for depression using the Geriatric Depression Scale. They also received a clinical psychiatric diagnosis by one of two geropsychiatrists. Patients with a Clinical Dementia Rating (CDR) of 0 (cognitively intact) (n = 70) and those with mild Alzheimer's disease (CDR of 1) (n = 72) were selected for comparison. The data were analyzed using Receiver Operating Characteristic Curves (ROCs) in order to compare the utility of the Geriatric Depression Scale in these two groups. ROC curves, which plot sensitivity against false positives, have come into increasing use as a method of examining the clinical performance of tests. The area lying beneath the curve (AUC) can be estimated and used as a quantitative measure of test performance (equivalent to the Wilcoxon rank sum). In the intact group, the Geriatric Depression Scale produced a ROC curve with an AUC of 0.85 (percent score = 1), which is significant (z = 7.28, P < .0001). In the group composed of those with Alzheimer's disease, the Geriatric Depression Scale yielded a ROC curve with an AUC of 0.66, which was not significantly different from chance (z = 1.92, P = NS). This study provides empirical evidence that while the Geriatric Depression Scale is an accurate screening test for depression in cognitively intact geriatric populations, it does not maintain its validity in populations that contain large numbers of patients with dementia of the Alzheimer type.
Clinical Aspects of Pneumonia in the Elderly Veteran
Authors: Harper Cynthia , Newton Patricia
Published: April 2015

While atypical presentation of pneumonia in elderly patients is thought to be common, its incidence and factors predisposing to it are unknown. This study documents presenting symptoms of pneumonia in 48 patients, aged 65 or older, admitted to the medical service at a Veterans Administration Medical Center. Seventeen subjects (35%) had a classic constellation of symptoms which included both fever and cough. A chief complaint suggestive of pneumonia, defined as cough, fever, or shortness of breath, occurred in 27 subjects (56%). Five subjects (10%) had no symptoms suggestive of pneumonia even with a detailed history. Absence of a classic constellation of pneumonia symptoms correlated with advanced age (P = .0045), cognitive impairment at admission (P = .022), and baseline functional impairment (P = .028). Neither nutritional status as measured by serum albumin nor medical status as measured by number of medical problems and number of medications predicted an atypical presentation of pneumonia. Nineteen subjects (39%) did not have a documented fever, and 15 subjects (31%) did not have a leukocytosis. Absence of fever or leukocytosis did not correlate with age, number of medical problems, number of medications, cognitive status, functional status, or serum albumin. We conclude that a classic constellation of symptoms, signs and laboratory findings is frequently absent but some suggestive symptom is usually present in this population of elderly veterans with community‐acquired pneumonia. Patients with advanced age, cognitive impairment at admission, and baseline functional impairment are most likely to have an atypical presentation of pneumonia.
Effectiveness of Influenza Vaccine When Given During an Outbreak of Influenza A/H3N2 in a Nursing Home
Authors: Meiklejohn Gordon , Hoffman Richard , Graves Patricia
Published: April 2015

An explosive outbreak of influenza A/H3N2 began in a nursing home in the Denver area early in November, 1987. Residents had not been vaccinated at that time. Vaccine was administered on November 11th. Two weeks after the vaccine was given, the attack rate differed between the vaccinated and unvaccinated individuals. There were 40 cases of influenza among the 98 elderly residents, 12 cases of pneumonia, and seven deaths. Vaccine efficacy two weeks after it was given was estimated to be 65.4% in preventing clinical illness. There were no cases of pneumonia and no deaths among people who were vaccinated more than two weeks before. The virus was identified as influenza A by complement fixation tests with convalescent sera from 16 individuals who had been ill. Many also had hemagglutination inhibition titers for A/Colorado/1/87, which were as high as titers for A/Leningrad/87. A/Colorado/1/87 closely resembled A/Sichuan/87.
Prescribing of Psychotropics in Elderly Nursing Home Patients
Authors: Beardsley Robert S. , Larson David B. , Burns Barbara J. , Thompson James W. , Kamerow Douglas B.
Published: April 2015

This study examined the prescribing of psychotropic drugs for patients 65 years of age and older in nursing homes using data from the 1984 National Nursing Home Survey pretest. The most frequently used antipsychotic, anxiolytic, antidepressant, and sedative/hypnotic medications were respectively: haloperidol, hydroxyzine, doxepin, and temazepam. Results indicate that more than one‐fifth of the patients having orders for psychotropic medications did not have a documented mental disorder. More than one‐fourth of the study patients had orders for more than one psychotropic medication. Nursing home patients who received psychotropics had concurrent orders for an average of 3.3 nonpsychotropic medications, many of which could increase the possibility of drug interactions and potential side effects.
The Influence of Age and Blood Pressure on the Hemodynamic and Humoral Response to Head‐Up Tilt
Authors: Jansen René W. M. M. , Thien Theo , Hoefnagels Willibrord H. L. , Lenders Jacques W. M.
Published: April 2015

It has been reported that postural hypotension in the elderly is common. However, these studies included institutionalized and more or less disabled persons. Furthermore, postural hypotension may be related to baseline blood pressure. In this study, the influence of age and blood pressure on the hemodynamic and plasma catecholamine responses to orthostatic stress was investigated in young and old normotensive and hypertensive healthy subjects. In normotensive and hypertensive elderly persons, the percentage blood pressure responses during tilt were not significantly different from that seen in young normotensives. We measured a slight decrease of systolic blood pressure and a slight increase of diastolic blood pressure. The hypertensive young patients showed an enhanced diastolic blood pressure response with no fall in systolic blood pressure, in contrast to the normotensive young subjects. Both elderly groups had a lower increase of heart rate than the young subjects. The percentage increase in norepinephrine after tilting was significantly lower in elderly hypertensives than in elderly normotensives and young hypertensives. The presence of hypertension was associated with a decrease in blood pressure, but age had no influence on the change in blood pressure during tilt. In this group of healthy elderly subjects, there was no significant orthostatic hypotension when the blood pressure course of the entire tilt test was taken into account.
Accuracy of Diagnosis of Pancreatic Cancer Decreases with Increasing Age
Authors: Nieman John L. , Holmes Frederick F.
Published: April 2015

Pancreatic cancer is common in the elderly and often is diagnosed clinically without pathologic confirmation. We compared age distribution and survival of 240 elderly patients with clinically diagnosed pancreatic cancer and 712 elderly patients with pathologically confirmed adeno‐ and ductal pancreatic carcinoma. All patients were registered by the Kansas state cancer registry from 1975–1984. The percentage of clinical diagnoses increased significantly from 12% in those aged in their 60s to 59% for those in their 90s (P < .005). Observed 5‐year survival for all of the clinically diagnosed patients was 8.4% compared with 0.6% for those pathologically confirmed. When locally confined disease only was considered, 5‐year survival was 27% for patients clinically diagnosed and 4% for those pathologically confirmed. Given the fact that long survival from pancreatic carcinoma is a rare event, these findings suggest that in many elderly patients clinical diagnoses of pancreatic cancer are wrong. The findings have implications for the statistics on increasing incidence of pancreatic cancer (particularly in the elderly) and in discussion of prognosis with elderly patients diagnosed with pancreatic cancer without pathologic confirmation.
Correlation of Estimated Renal Function Parameters Versus 24‐Hour Creatinine Clearance in Ambulatory Elderly
Authors: Friedman Jon R. , Norman Dean C. , Yoshikawa Thomas T.
Published: April 2015

This study evaluates the correlation between estimated renal function parameters (ie, creatinine clearance by the Cockcroft‐Gault and Lott‐Hayton formulas, serum creatinine and blood urea nitrogen) and 24‐hour creatinine clearance in 15 young and 15 elderly subjects. Correlation coefficients (r) for the elderly group comparing Cockcroft‐Gault and Lott‐Hayton against 24‐hour creatinine clearance were 0.73 (P < .005) and 0.60 (P < .02) respectively, and r for the young subjects were 0.37 (P > .05) and 0.57 (P < .05), respectively. In 13 elderly subjects with creatinine clearance of 60 mL/minute or less, four (31%) had blood urea nitrogen of 20 mg/dL or less and 13 (100%) had serum creatinine between 1.0–1.5 mg/dL. We conclude that the formulas of Cockcroft‐Gault and Lott‐Hayton are valid in ambulatory elderly patients who are functionally independent without severe underlying disease, have normal body weight and are not on medication affecting renal function. Furthermore, in this select elderly population, an apparently normal serum creatinine (1.0–1.5 mg/dL) and blood urea nitrogen (20 mg/dL or less) may frequently represent a 24‐hour creatinine clearance of 60 mL/minute or less.
Musical Hallucinations
Authors: Wengel Steven P. , Burke William J. , Holemon Dawn
Published: April 2015

Hallucinations may occur in any sensory modality. Auditory hallucinations, usually ascribed to psychiatric illness, take various forms including the perception of voices, cries, noises, or rarely, music. Formed musical hallucinations, (ie, the perception of either vocal or instrumental melodies), reported in the English literature to date have typically been associated with marked hearing loss, advanced age (average 67.8 years), female sex (71%), lack of response to treatment, and general lack of associated psychopathology. We have collected data on seven additional patients with musical hallucinations. The average age of these patients was 72.9 years; all were women. Six had significant hearing problems. All reported onset of musical hallucinations after the age of 60. Interestingly, all seven had major psychiatric illnesses. Four had major depression, two had late‐onset schizophrenia, and one had multi‐infarct dementia. Of the five who had CT scans, one was normal and the rest demonstrated varying degrees of brain pathology. Neuroleptics were used with varying results in three cases; antidepressants were used in two depressed patients and were temporally related to the onset of musical hallucinations in one patient. Electroconvulsive therapy (ECT) was very effective in treating depression and musical hallucinations in the three patients for whom it was used, usually providing relief from hallucinations after only two treatments.

Our collection of cases demonstrates that musical hallucinations can occur in association with psychiatric illness, and perhaps unlike the hallucinations associated with isolated hearing loss, may respond to conventional treatments for the underlying psychiatric disorder. Hearing loss is neither a necessary nor sufficient condition for the occurrence of musical hallucinations.
Functional Status and Cognitive Impairment in Alzheimer's Patients With and Without Depression
Authors: Pearson Jane L. , Teri Linda , Reifler Burton V. , Raskind Murray A.
Published: April 2015

Cognitive impairment and depression each compromise functional status in the elderly, but it is not known whether their coexistence is associated with additive functional impairment. The effect of the presence or absence of a diagnosis of major depression on functional status was examined in a group of 50 community‐residing patients with dementia of the Alzheimer's type (DAT). Patients were diagnosed as depressed (N = 20) or not (N = 30) according to DSM‐III criteria. Cognitive status was assessed with the Mini‐Mental State Exam (MMSE), and functional status was assessed by family report of Instrumental Activities of Daily Living (IADLs). Consistent with previous reports, patients with a depression diagnosis were less cognitively impaired than their nondepressed counterparts. When cognitive status was controlled for, depression diagnosis was found to have a main effect on functional impairment. Although the direction of effects between depression and functional limitations was not determined here, these results suggest that alleviating depression may decrease functional limitations in DAT patients.
Influence of Octreotide (SMS 201–995) and Insulin Administration on the Course of Blood Pressure After an Oral Glucose Load in Hypertensive Elderly Subjects
Authors: Jansen Rene W. M. M. , de Meijer Paul H. E. M. , van Lier Henk J. J. , Hoefnagels Willibrord H. L.
Published: April 2015

Pretreatment with a somatostatin analogue, octreotide (SMS 201–995), prevents postprandial blood pressure reduction in the elderly. We hypothesized that this beneficial effect on blood pressure is caused by an octreotide‐induced suppression of insulin secretion. We studied the effects of octreotide and insulin administration on the course of blood pressure after oral glucose loading in 10 healthy hypertensive old persons (mean age 73 ± 3 years). Octreotide was given in a dose of 50 μg subcutaneously (sc) (time = −30 minutes). Insulin was given sc in a dose of 0.3 U/kg body weight (time = −10 minutes) and glucose was given orally in a dose of 75 g in 300 mL water (time = 0 minutes). Plasma insulin concentrations remained essentially unchanged after placebo and rose to a maximum level of 58 ± 6 mU/L following insulin administration. The course of blood pressure was not different following glucose loading with high or low plasma insulin levels. These data indicate that the effects of octreotide on postprandial blood pressure reduction in the elderly are unrelated to the inhibition of insulin secretion.
The First Certifying Examination in Geriatric Medicine
Authors: Steel Knight , Norcini John , Brummel‐Smith Kenneth , Erwin Donald , Markson Lawrence
Published: April 2015

On April 22, 1988, the first Certifying Examination in Geriatric Medicine was administered jointly by the American Board of Internal Medicine and the American Board of Family Practice to 4,282 diplomates (ABIM = 2,202; ABFP = 2,080). This paper addresses both an analysis of the examination and the relationship between performance on that examination and a group of characteristics of the examinees, collected as part of the registration process. The pass rate was 56%. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine. Data provided by the candidates in an addendum to the application were also available for analysis and were used to derive correlations with groups of questions. The performance of candidates was positively correlated with seeing large numbers of elderly in hospitals, nursing homes, or home settings, working in a University Hospital, teaching and research, and the size of the community in which the candidate practiced. Physicians from long‐term care settings did exceptionally well. Working in a solo practice setting was negatively correlated with performance on the examination as was working in a for‐profit setting.
Total Hip Replacement in Patients Aged 80 Years and Older
Authors: Petersen V. S. , Solgaard S. , Simonsen B.
Published: April 2015

Total hip replacement was performed in 27 patients aged 80 years and older. In the early postoperative period, medical complications occurred in 13 patients and arthroplasty‐related complications in 5 patients. At the time of the follow‐up, after an average of 31 months, there was one case of acetabular cup loosening, which was revised. Twenty of 22 patients were free from pain at rest, and the social function of the patients had remained almost unchanged.
Ethical Constraints on Rationing Medical Care by Age
Authors: Jecker Nancy S. , Pearlman Robert A.
Published: April 2015

In a statement published in this issue, the Public Policy Committee of the American Geriatrics Society endorses the view that chronological age should not be a criterion for exclusion of individuals from medical care. This article aims to amplify the Committee's position by placing it within a broader context and identifying its justification in ethical argument. The paper is divided into three parts. The first part clarifies the difference between allocation (the distribution of funds between categories) and rationing (the distribution of funds within a single category). It is argued that given the current allocation of funds to medical care, some form of rationing is unavoidable. As others have noted, rationing is already occurring in an informal and piecemeal fashion. However, ethically sound rationing requires publicly debated and defensible policies. The second section of the paper reviews a number of arguments advanced in favor of rationing medical care on the basis of age. Objections to these arguments are carefully set out. The final part of the paper details and defends a series of positive arguments establishing special duties to the elderly. The paper concludes that to the extent that scarcity forces rationing, older persons should not be excluded because they are old.
Physician Payment Reform: Implications for Geriatrics
Authors: Hammons Glenn T. , Pawlson L. Gregory
Published: April 2015

A consensus has developed on the need for a major revision of physician reimbursement in the Medicare program. The Physician Payment Review Commission has recommended to Congress a series of far‐reaching changes in the payment system, based on the development of a fee schedule using a Resource Based Relative Value System (RBRVS). This article explores the rationale for the recommendations and the probable impact on Medicare beneficiaries and their physicians if the changes are enacted. Special consideration is given to unique aspects of geriatric medicine, including comprehensive geriatric assessment.
Manual Dexterity as a Correlate of Dependency in the Elderly
Authors: Ostwald Sharon K. , Snowdon David A. , Rysavy S. Del Marie , Keenan Nora L. , Kane Robert L.
Published: April 2015

Physical and mental correlates of dependent living were determined in 128 Catholic sisters (nuns), aged 75 to 94 years, who had similar social support systems and lifestyles. The primary a priori hypothesis was that poor manual dexterity would correlate strongly with living in the nursing home. Stepwise discriminant analysis indicated that manual dexterity explained 51% of the variance in the sisters' residential living site (ie, nursing home, retirement home, or living in community). The discriminant analysis equation using manual dexterity predicted living site correctly for 63% of the sisters in the nursing home with a specificity of 99%, a positive predictive value of 96% and a negative predictive value of 84%. The addition of age and mental status to the equation improved the prediction only slightly.
Epidural Methadone for Analgesic Management of Patients with Conservatively Treated Proximal Femoral Fractures
Authors: Nyska M. , Shapira Y. , Klin B. , Drenger B. , Margulies J. Y.
Published: April 2015

Epidural methadone analgesia was initiated soon after admission to emergency room in elderly patients who sustained osteoporotic proximal femoral fracture and who were considered to be high surgical risks. The severe pain was significantly reduced, enabling early mobilization of the patients. The analgesia was discontinued only when nonnarcotic analgesia sufficed. The treatment lasted for about 3.5 weeks. One minor complication was observed during the treatment period. We concluded that patients who have femoral neck fracture who are at high risk for operation and have to be observed and stabilized before operation can be managed by continuous epidural methadone analgesia.
The Senior Care Study
Authors: Fretwell Marsha D. , Raymond Patricia M. , McGarvey Stephen T. , Owens Norma , Traines Mark , Silliman Rebecca A. , Mor Vincent
Published: April 2015

Successful models of inpatient geriatric assessment have often involved long hospital stays, specialized interdisciplinary care, and prolonged follow‐up, which are difficult to achieve within a prospective payment system. A randomized clinical trial was undertaken to evaluate the efficacy (maintenance or improvement in mental, emotional, and physical function) of using a geriatric assessment process in acute hospital care without increasing hospital charges or lengths of stay. Four hundred thirty‐six patients ≥ 75 years of age were randomly allocated to treatment (n = 221) or control (n = 215) conditions. Patients in the treatment group were admitted to a special unit and evaluated on admission by an interdisciplinary team, which developed a care plan. Although primary care was provided by the patient's own physician, the team followed the patients as consultants on the unit in the hospital, and by telephone for 2 months after discharge. The control group was placed on other units and received usual hospital care. The treatment and control groups were similar at study entry. At follow‐up, there were no significant differences between the groups with respect to lengths of stay, hospital charges, mortality, change in physical function, or change in mental function. The treatment group changed more often in measured emotional function (χ2 = 6.213, P = .045). This study indicates that it is feasible to implement consultative interdisciplinary team care in the acute‐care hospital, but that its efficacy may be limited when applied to an unselected group of older patients.
Foci of Increased T2 Signal Intensity in MR Images of Healthy Elderly Subjects
Authors: Austrom Mary Guerriero , Thompson Richard F. , Hendrie Hugh C. , Norton James , Farlow Martin R. , Edwards Mary K. , Dean Raymond
Published: April 2015

An 18‐month follow‐up study was conducted on 26 healthy elderly subjects with and without foci of increased T2 signal intensity on MR imaging. The subjects did not differ with respect to health status or cognitive performance as measured by the Cognitive Subscale of the Cambridge Mental Disorders of the Elderly Examination and the Mini Mental State Examination at follow‐up. There was a significant decline in performance on the Digit Symbol Substitution Test in subjects who had evidence of T2 foci compared to the performance of subjects without T2 foci. This may indicate that the presence of T2 foci is correlated with subtle difficulties in learning and memory.
Factors Associated with Short‐ Versus Long‐Term Skilled Nursing Facility
Authors: Bonar Susan K. , Tinetti Mary E. , Speechley Mark , Cooney Leo M.
Published: April 2015

Characteristics associated with long‐term placement among community‐living patients admitted to a skilled nursing facility (SNF) after a hip fracture were identified. Subjects were 151 consecutive, elderly, community‐living persons discharged from two acute hospitals to SNFs after surgery for a hip fracture. Medical, functional, psychological, social, and outcome data were collected from hospital and nursing home charts. Ninety‐seven subjects (64%) were discharged home within 6 months; 50 (33%) became permanent SNF residents; and four died. Multiple logistic regression identified orientation, younger age, ability to bathe independently, family involvement, ability to ambulate or transfer independently, and greater number of available physical therapy hours as factors contributing independently to returning home. Likelihood of returning home increased from 7% among subjects with fewer than two of the patient characteristics to 82% among subjects with four or more characteristics (P < .0005). These results suggest that hip fracture patients at high risk of permanent SNF placement can be identified at time of hospital discharge. Investigations are needed to determine whether more intensive rehabilitation and discharge planning may improve the chance of returning home for a large percent of hip fracture patients.
Characteristics of an Elderly Driving Population
Authors: Carr David , Jackson Thomas , Alquire Patrick
Published: April 2015

A retrospective, case‐control study was performed to determine the characteristics of elderly drivers referred to an outpatient geriatric assessment center. It was hypothesized that the driving population was operating at a higher cognitive and functional level than nondrivers. One hundred eighty‐two subjects meeting the entry criteria were studied. Twenty‐three percent of the subjects were driving at the time of their assessment. Compared to nondrivers, drivers were younger (P = .0001), were more likely to be male (P = .003), scored higher on a mental status examination (P = .0001), and were more independent in Physical and Instrumental Activities of Daily Living (P < .0001). Despite these findings, the mean Folstein Mini‐Mental score for drivers (23.7) was below normal; 40% of drivers were diagnosed as having Alzheimer's dementia at the time of their evaluation, and over 26% of the drivers needed help with either dressing or bathing. The frequency of impaired elderly drivers in this referral setting was high. The authors conclude that conditions that affect the driving task are common in geriatric assessment centers. Prospective studies of elderly drivers are needed to answer the difficult question of who among the elderly should drive.
Are Elderly People Less Responsive to Intensive Care?
Authors: Wu Albert W. , Rubin Haya R. , Rosen Mark J.
Published: April 2015

Older patients may be excluded from intensive care units because of the perception that they will benefit less than younger patients. To determine if advanced age is associated with increased mortality independent of severity of illness, we compared older and middle‐aged patients admitted to a medical intensive care unit. We reviewed the charts of 130 patients age 75 years or older and 135 patients age 55 to 65 admitted over a 30‐month period. We controlled for severity of illness using the Acute Physiology Assessment and Chronic Health Evaluation (APACHE II) system without including points for age (APACHE IIM). The groups were similar with regard to gender, whether or not they had a private attending physician, mean APACHE IIM score, and diagnoses, except that older patients had more chronic obstructive pulmonary disease. Hospital stay was slightly longer in the older group (37 vs. 39 days, rank sum, P < .02). Hospital mortality was significantly greater in the older group (39% vs. 51%, Chi‐square P < .05) with a crude relative risk of 1.31 (95% confidence interval [CI]: 1.01, 1.73). However, the relation of age group to mortality differed for patients with different diagnoses. When we used logistic regression to adjust for APACHE IIM, whether the patient had a private attending physician, primary admitting diagnosis, or presence of cancer, older patients did not have a significantly greater risk of dying (adjusted relative risk, 1.05; 95% CI: 0.97, 1.11). When pulmonary artery catheterization was added to the model, it independently predicted mortality (adjusted relative risk, 1.47; 95% CI: 1.05, 2.06). APACHE IIM (calculated without the inclusion of age) was an excellent predictor of mortality. Older age did not predict mortality once severity of illness, admitting diagnosis, and the presence of underlying malignancy were taken into consideration. Further studies should explore the effects of age separately for patients with different diagnoses as well as control for severity of illness.
Formal Geriatric Assessment Instruments and the Care of Older General Medical Outpatients
Authors: Miller Douglas K. , Morley John E. , Rubenstein Laurence Z. , Pietruszka Fern M. , Strome L. Sandra
Published: April 2015

To improve identification of cognitive, affective, gait, and nutritional problems in older medical outpatients, nonphysician clinic personnel administered formal geriatric assessment tools to 183 medical outpatients age 70 years and older. Definite impairments were demonstrated in 7% to 23% of patients (depending on the function being assessed), and borderline abnormal results were common as well. Overall, 56% of patients had at least one meaningful impairment identified. Few of these problems had been recognized before the survey. Assessment required 10 to 15 minutes of interviewer time per patient (approximately 22 minutes for each problem newly uncovered). A simple education and information intervention led to physicians addressing the newly identified problem in 30% to 55% of cases. These results suggest that formal geriatric assessment instruments provide an efficient mechanism for case finding in older medical outpatients. Further studies are necessary to determine whether such interventions will lead to improved outcomes in older medical outpatients.
Prevalence of Intrinsic Factor Antibodies and Vitamin B12 Malabsorption in Older Patients Admitted to a Rehabilitation Hospital
Authors: Bunting Robert W. , Bitzer Ann M. , Kenney Robert M. , Ellman Leonard
Published: April 2015

It is possible that the commonly measured serum level of vitamin B12 may miss some cases when used to detect vitamin B12 malabsorption and deficiency in older persons. Serum levels of vitamin B12 and intrinsic factor antibody (IFAB) were determined on 250 consecutive patients over the age of 70 admitted to a rehabilitation hospital. Patients with abnormal results on either test were given the standard Schilling test when possible. Eight patients had documented B12 malabsorption. Of these, five had a low serum B12 level alone and one had a low serum B12 level and a positive IFAB level; however, two patients had positive IFAB and normal serum B12 levels. Serum IFAB level may serve as a useful adjunct to serum B12 level in detecting vitamin B12 malabsorption in older patients.
An Exploratory Use of the Symptoms Checklist‐90 in a Mixed Geriatric Study Group
Authors: Agbayewa M. Oluwafemi
Published: April 2015

There are currently no self‐rating scales of general psychopathology in the older population. Such scales can be used to screen patients who may then be referred on for psychiatric assessment. The validity of the Symptoms Checklist‐90 (SCL‐90), a self‐rating scale of general psychopathology widely used in the nongeriatric adult population, was explored in 44 older subjects. It was compared with the Sandoz Clinical Assessment Geriatric (SCAG) scale and a measure of functional disability, the London Psychogeriatric Rating Scale (LPRS). Caregivers to all subjects also rated the degree of difficulty experienced with their care on a four‐point scale. Thirty of the subjects attended a geriatric day hospital, and the remaining 14 were waiting to go into long‐term care facilities. Symptoms Checklist‐90 was not significantly different between the two groups of subjects (day hospital and preinstitutional) after Bonferroni corrections, though SCAG scale and LPRS were (P <.01 for both). Although SCL‐90 was correlated significantly with the SCAG scale (r = .46), it was not significantly correlated with the LPRS. It showed good internal consistency but poor face validity and an inability to differentiate between levels of difficulty for the caregiver. It is concluded that the use of SCL‐90 in older people may be limited because of the lack of sensitivity to functional disability and care difficulty. This nevertheless needs to be further explored, perhaps with some modification of the scale for older people.
Book Review
Authors: Rosenberg Gilbert M.
Published: April 2015

How Should Elderly Hypertensive Patients be Treated? Edited by Omae T and Zanchetti A. Tokyo, Springer‐Verlag, 1989. 250 pages, $58.00.
Are Stressful Life Events Risk Factors for Herpes Zoster?
Authors: Schmader Kenneth , Studenski Stephanie , MacMillan Julia , Grufferman Seymour , Cohen Harvey J.
Published: April 2015

To determine if psychologically stressful life events are risk factors for herpes zoster, we conducted a case‐control study of zoster and self‐reported recent negative life events and major changes in spousal relationships. The subjects were 101 healthy community‐dwelling cases of zoster and 101 healthy controls matched for age, sex, and race and generated by random digit dialing. The Geriatric Scale of Recent Life Events was administered to case and control subjects, and additional questions were asked regarding the perception of the life event. The results showed that case subjects experienced negative life events significantly more often than subjects in the control groups in the 2 months before zoster onset by analysis of discordant pairs (26 versus 10, odds ratio 2.60, 95% confidence interval [CI] 1.13, 6.27, P = .012), 3 months before (29 versus 11, odds ratio 2.64, 95% CI 1.20, 6.04, P = .007), or 6 months before (35 versus 16, odds ratio 2.00, 95% CI 1.04, 3.93, P = .012). The mean number of total life events was significantly higher in cases at 6 months before zoster (case x̄ = 2.64, control x̄ =1.82, P = .008), but there were no signficant differences at 2, 3, or 12 months before. There were no significant differences between case subjects and control subjects for spousal events, or any given single life event. In conclusion, we found that whereas patients with herpes zoster experienced the same kinds of life events in the year preceding the illness as did control subjects, recent events perceived as stressful were significantly more common among patients with zoster. These results provide supportive evidence that stressful life events may be risk factors for the reactivation of varicella‐zoster virus.
Absence of Significant Bacteremia During Urinary Catheter Manipulation in Patients With Chronic Indwelling Catheters
Authors: Polastri François , Auckenthaler Raymond , Loew François , Michel Jean‐Pierre , Lew Daniel P.
Published: April 2015

The objective of this study was to quantify the microorganisms present in blood at urinary catheter removal and at reinsertion in patients with chronic indwelling urinary catheters. This was a prospective study during a 4‐month period at a university‐affiliated geriatric medical center. Our subjects were 33 patients with chronic indwelling urinary catheters and positive urinary cultures; the urinary catheter was usually changed once a month. A peripheral vein line was used for blood withdrawal and urinary cultures and quantitative blood cultures (Isolator) were performed during and shortly after urinary catheter removal and insertion. All patients had significant bacteriuria (> 105 cfu/mL) with an average of 2.3 microorganisms. Among the 46 sequential quantitative blood cultures performed, only two patients had bacteremia from the urinary source and at a very low concentration; one patient had 0.13 cfu/mL Str. faecalis in blood 5 minutes after removal of the urinary catheter, and the other 0.1 cfu/mL Proteus mirabilis 5 minutes after reinsertion of a new urinary catheter. None of the patients had any subjective or objective clinical problem during the 36 hours after the urinary manipulation.

Clinical symptoms and bacteremia are rare events, and prophylactic antibiotics do not appear necessary during urinary catheter removal and reinsertion in elderly institutionalized patients. Further studies are necessary to identify risk factors in the rare instances of patients with bacteremia.
Delirium: Masquerades and Misdiagnosis in Elderly Inpatients
Authors: Lyness Jeffrey M.
Published: April 2015

Delirium is an organic mental disorder defined as transient, fluctuating global dysfunction of cognition. It is common in elderly medical inpatients, yet its varied presentation is often missed or misdiagnosed.