bluuebunny/crossref_metadata_2025 huggingface dataset:
Literacy and Performance on the Mini‐Mental State Examination
Authors: Weiss Barry D. , Reed Richard , Kligman Evan W. , Abyad Abdul
Published: April 2015

OBJECTIVE: Mini‐Mental State Examination (MMSE) scores are associated with age, education, and ethnicity. The objective of this research was to determine the relationship between MMSE and literacy.

DESIGN: Cross‐sectional.

SETTING: A Community population in Tucson, Arizona.

PARTICIPANTS: Senior citizens in public assistance housing.

MEASUREMENTS: MMSE score, reading level, and socio‐demographic variables.

MAIN RESULTS: A total of 214 subjects were tested. The mean age was 72.3 (±8.01), and the mean education level was 10.3 years (range 0–20 years). Reading levels ranged from grade 0 (non‐reader) to 8 (maximum value for the test used), with a mean of 4.8 (±2.8). MMSE scores ranged from a mean of 21.9 (±4.6) for non‐readers to a mean of 28.0 (±2.0) for subjects with ≥8th grade reading skills.

Multiple regression using reading level, education, age, and ethnicity as independent variables, and MMSE score as the dependent variable, showed the highest correlation was between MMSE and reading level (R2 = .265). Education level made only a small additional contribution; age and ethnicity did not enter the regression equation. Correlations between reading level and individual MMSE subsections were highest between reading level and MMSE language items (r = .499).

CONCLUSIONS: The correlation between MMSE score and reading skills is stronger than the correlation with other sociodemographic variables. Proper interpretation of MMSE scores requires knowledge of patients' reading levels.
Factors Influencing Users' Return Home on Discharge from a Geriatric Intermediate Care Facility in Japan
Authors: Ishizaki Tatsuro , Kai Ichiro , Hisata Mitsuru , Kobayashi Yasuki , Wakatsuki Ken‐ichi , Ohi Gen
Published: April 2015

OBJECTIVES: To determine the factors that influence users' destinations on discharge from Geriatric Intermediate Care Facilities (GICFs), which were established in Japan in 1987 to help hospitalized older people return home.

DESIGN: Retrospective chart review.

SETTING: A 94‐bed GICF attached to Saku Central Hospital in Japan.

SUBJECTS: Charts of all users (N = 437) aged 65 years and older, discharged from the GICF between July 1987 and February 1991, were reviewed.

MEASUREMENTS: The independent variables, obtained from users' admission records, were age, sex, place of residence before admission, length of stay, intellectual impairment (assessed by Karasawa's diagnostic criteria for senile dementia), ability to perform activities of daily living (ADLs), and living arrangement of users in the GICF. The dependent variable was destination after discharge from the GICF.

MAIN RESULTS: Multiple logistic regression analyses revealed that, compared with users who were able to successfully return home, users with little ability to perform ADLs, male users, and those admitted from other institutions were more likely to be hospitalized. Such analyses also revealed that users who came from institutions, had low ability to perform ADLs, and lived alone were more likely to be institutionalized in nursing homes.

CONCLUSIONS: Evaluating a user's physical, mental, and socioeconomic conditions at an early stage of admission to a GICF may allow us to predict whether the user can be successfully discharged to his or her home or will have to remain at the GICF for an extended period.
Resilience to Exercise Detraining in Healthy Older Adults
Authors: Sforzo Gary A. , McManis Beth G. , Black Donna , Luniewski Dawn , EdD Kent C. Scriber
Published: April 2015

OBJECTIVE: To determine the effects of stopping and restarting two types of exercise programs in older adults.

DESIGN: A controlled, longitudinal study that utilized random assignment of volunteers. Treatments were exercise programs designed to improve cardiovascular or neuromuscular fitness.

MEASUREMENTS: Dependent variables measured before and after implementation of treatments were: maximum oxygen consumption, oxygen pulse, treadmill and cycle training workloads, quadriceps isokinetic peak torque, quadriceps isokinetic total work, and quadriceps training workload.

MAIN RESULTS: Exercise training was highly effective in improving cardiovascular endurance or muscular strength. Ten weeks of exercise detraining resulted in small losses in newly gained cardiovascular capacity but more noticeable losses in muscular strength. Exercise retraining was accomplished easily using cardiovascular or resistive exercises. The functional benefits of restarting a cardiovascular exercise program appeared additive despite a 10‐week intervening period of exercise detraining. In this age group, cardiovascular exercise produced limited improvements in muscular strength, and resistive exercise training positively influenced cardiovascular exercise performance.

CONCLUSIONS: Older adults are fairly resilient to 10 weeks of cardiovascular detraining and retain newly gained muscular strength for at least 5 weeks, despite an interruption of formal exercise. An occasional missed exercise session or temporary cessation of habitual exercise should not be a cause for distress in exercising older adults. Instead, they should realize the ease with which they may restart their exercise program and also appreciate the generalizable fitness benefits that can be ascribed to becoming more active. J Am Geriatr Soc 43: 209–215, 1995.
Medical Care Utilization Among Older HMO Members With and Without Hypertension
Authors: Ried L. Douglas , Johnson Richard E. , Brody Kathleen K. , Vogt Thomas M.
Published: April 2015

OBJECTIVES: To compare hospital utilization, health status, and sociodemographic characteristics of older persons with and without hypertension and to examine the nature of the association of hypertension with medical care utilization.

DESIGN: A retrospective, nonexperimental study.

SETTING: A large health maintenance organization (HMO), located in the Portland, Oregon and Vancouver, Washington areas, that provides comprehensive, prepaid benefits to its members.

PARTICIPANTS: Approximately 4200 older (≥65 years) members enrolled in the Social HMO Demonstration Project.

MEASUREMENTS: The dependent variables were (1) whether a member was hospitalized (0 = no; 1 = yes) and (2) the number of hospitalizations during the 12‐month period before the return of the Health Status Form, a mail questionnaire. The predictor variables were high blood pressure and other medical conditions, health status, and sociodemographic characteristics. Patients classified as hypertensive were those who self‐reported high blood pressure and who received two or more dispensings for antihypertensive medications.

RESULTS: Older hypertensives were more likely than older nonhypertensives to have been hospitalized (odds ratio (OR) = 1.14 (95% CI 1.01,1.27)), self‐report their health as only good or fair (P < .001), self‐report IADL functional limitations (P < .001), and to be younger than nonhypertensives (P < .001). Utilization differences were similar after controlling for patients' age and gender. Factors independently associated with an increased likelihood of hospitalization were: male gender (OR = 1.14 (1.00,1.31)), age (OR = 1.35 (1.00,1.81)), poor (OR = 1.32 (1.02,1.72)) or fair (OR = 1.20 (1.01,1.44)) self‐rated health status, functional limitations in activities of daily living (OR = 1.74 (1.48,2.03), and self‐reported heart trouble (OR = 1.50 (1.34,1.68)), stroke (OR = 1.37 (1.15,1.64)), or cancer (OR = 2.89 (1.72,4.84)). Factors independently associated with a decreased likelihood of hospitalization were excellent self‐reported health (OR = 0.65 (0.47,0.90)), no physical impairments (OR = 0.59 (0.48,0.72)), and no circulation problems (OR = 0.85 (0.74,0.98)).

CONCLUSIONS: Older hypertensive patients had poorer self‐reported health, more functional limitations, used more hospital services, and were not as old as nonhypertensive older patients. To the extent that general health is improved by treatment of hypertension, appropriate treatment of high blood pressure may not only improve health, it may also reduce medical care utilization. Our findings offer further support for hypertension prevention, detection, and treatment programs designed to reduce or minimize hypertension's later medical complications and to reduce future utilization. J Am Geriatr Soc 43: 222–229, 1995.
Evidence for Inflammation as a Cause of Hypocholesterolemia in Older People
Authors: Ettinger Walter H. , Harris Tamara , Verdery Roy B. , Tracy Russell , Kouba Ethel
Published: April 2015

Evidence for Inflammation as a Cause of Hypocholesterolemia in Older People
Urinary Incontinence Associated with Dementia
Authors: Skelly Jennifer , Flint Alastair J.
Published: April 2015

Urinary Incontinence Associated with Dementia
Health Outcomes of Post‐Hospital In‐Home Team Care: Secondary Analysis of a Swedish Trial
Authors: Melin Anna Lisa , Wieland Darryl , Harker Judith O. , Bygren Lars Olov
Published: April 2015

Health Outcomes of Post‐Hospital In‐Home Team Care: Secondary Analysis of a Swedish Trial

OBJECTIVE: To determine patient and treatment‐related factors predictive of health outcomes.

DESIGN: Secondary analysis of a randomized trial with 6‐month follow‐up. After using bivariate and three‐way analysis in the total sample to screen outcome predictors and interactions among baseline variables, multivariate logistic regression was used to model outcomes.

SETTING: A county general hospital in central Stockholm, and patients' homes nearby.

PATIENTS: Hospital inpatients stable for discharge from acute care having at least one chronic condition, and dependent in 1 to 5 Katz activities of daily life (ADLs) were included. Subjects (mean age = 81.1 years) were randomized to “team” (n = 150) or “usual care” (n = 99).

INTERVENTIONS: Team patients were eligible for in‐home primary care by an interdisciplinary team that included a physician, physical therapist, and 24‐hour nursing services and geriatric consultation where necessary. “Usual‐care” patients received standard district nurse‐administered services at home upon hospital discharge.

MEASUREMENTS: Demographic, functional status, and medical characteristics were measured at randomization. Outcomes included survival and higher ADL, instrumental ADL (IADL), and outdoor ambulation scores.

CONCLUSIONS: Heterogeneous clinical populations of older patients contain many prevalent characteristics important to outcomes. Secondary analysis of trials including interactions identifies treatable and untreatable risks, what program components may be effective, and who benefits. J Am Geriatr Soc 43: 301–307, 1995.
Increased Mortality in Older Persons with Hypocholesterolemia: Cause or Effect
Authors: Elam Marshall B.
Published: April 2015

Increased Mortality in Older Persons with Hypocholesterolemia: Cause or Effect
Increased Fall Rates in Nursing Home Residents After Relocation to a New Facility
Authors: Friedman Susan M. , Williamson Jeff D. , Lee Ben H. , Ankrom Michael A. , Ryan Stephen D. , Denman Susan J.
Published: April 2015

OBJECTIVE: To examine the change in fall rates after relocation of nursing home residents from one facility to another and to identify resident risk factors for changes in falls following relocation.

DESIGN: Retrospective review of incident reports to identify falls, followed by chart review of a longitudinal cohort.

SETTING: An academic nursing home whose residents and programs moved from a 125‐ year‐old, 233‐bed facility to a newly constructed 255‐bed facility.

PATIENTS: A total of 210 nursing home residents were moved from one facility to the other. Of these, 133 individuals who lived in the old facility for 9 months before the move and in the new facility for 6 months after the move formed the longitudinal cohort.

RESULTS: In the 3 months after the move, the fall rate increased from 0.34 to 0.70 falls per resident per quarter in the entire nursing home population (P < .001) and subsequently returned to baseline. In the longitudinal subgroup the fall rate went from 0.26 to 0.60 (P < .005). Fall‐related injuries in the longitudinal subgroup went from 0.058 injuries per resident per quarter at baseline to 0.15 (P < .001). However, the injury rate per fall did not change. There were no characteristics associated with being a faller in the quarter before the move. Dementia and not being bedbound were associated with being a faller after the move. Individuals who were ambulatory or wheelchair mobile had a significant risk of increasing the number of falls after the move, and individuals with dementia had a strong but insignificant trend in this direction.

CONCLUSIONS: The incidence of falling doubled after relocation of nursing home residents to a new facility. An increase in falls was seen in individuals who were not bed‐bound. Although nursing home relocation may be a relatively uncommon occurrence, it is reasonable to infer that older individuals who change their living environments are at increased risk for falls and fall‐related injuries.
The Neuropsychological Differentiation of Patients with Very Mild Alzheimer's Disease and/or Major Depression
Authors: desRosiers Gabriel , Hodges John R. , Berrios German
Published: April 2015

OBJECTIVE: To evaluate the usefulness of standardized neuropsychological tests in the psychometric differentiation of patients with very mild or mild Alzheimer's Disease (AD) and/or major depression presenting in a tertiary clinic with memory/attention complaints.

DESIGN: Controlled prospective clinicoexperimental design.

SETTING: Multidisciplinary Memory Clinic at Addenbro‐oke's Hospital, Cambridge, England.

PARTICIPANTS: Twenty‐four patients with a clinical diagnosis of Alzheimer's disease (12 with major depression and 12 without), 12 patients with major depressive illness but without AD, and 12 healthy control subjects, all matched for age, sex, education levels, and estimates of premorbid intellectual potential.

MEASUREMENTS: Mini‐Mental State Examination (MMSE), Wechsler's Logical Memory (WLM) and Visual Reproduction (WVR), immediate and delayed reproduction, Wechsler's paired Associate Learning (WPAL), including the Easy and Hard subsets. Warrington's Recognition Memory for Faces (WRMF), Kendrick's Object Learning (KOLT) and Digit Copying (KDCT)Tests.

OUTCOME MEASURES: Minimum 2‐year follow‐up diagnosis.

RESULTS: Statistically, patients with very mild AD were distinguished clearly from those without AD on most tests of memory functions. Psychometrically, only KOLT and an index of retention on WLM and WVR were specific enough to avoid false positives, a requirement for second‐stage tools. They also proved sensitive enough to suggest their role as first‐stage instruments when screening for primary dementia in high‐functioning patients scoring above the cut‐point on MMSE.

CONCLUSIONS: As efforts intensify to develop more powerful means to identify patients with Alzheimer's disease in its earliest stages, inclusion of specialist tests posing greater cognitive challenge than standard mental status scales has been one strategy. Our study explored how some of these neuropsychological tools behave psychometrically when analyzed on a single‐case basis, and the results suggest a few are sensitive enough to boost detection above base rates alone while also being specific enough to reduce false alarms. Retention on Wechsler's Logical Memory and Visual Reproduction tasks and scores on Kendrick's Object Learning Test helped decrease the degree of ambiguity when cognitive profiles were used to distinguish depressed patients with Alzheimer disease from those without.
Cognitive Impairment and Risk of Stroke in the Older Population
Authors: Verruca Luigi , Guralnik Jack M. , Salive Marcel E. , Pahor Marco , Corti Maria‐Chiara , Baroni Alberto , Havlik Richard J.
Published: April 2015

OBJECTIVE: Recent studies have suggested that vascular dementia in older persons is more common than previously hypothesized. A substantial proportion of dementia in old age may be an early manifestation of cerebrovascular disease (CVD), that eventually becomes clinically evident as an acute cerebrovascular accident. This study was aimed at assessing whether cognitive impairment and cognitive decline in older persons free of stroke are associated with higher risk of future stroke, independently of other risk factors.

DESIGN: Population‐based prospective study.

PARTICIPANTS: A total of 5024 subjects from the Established Populations for Epidemiologic Studies of the Elderly, who were alive and had no history of previous stroke at the sixth follow‐up visit. Subjects who had reported a stroke in a previous interview or with a diagnosis of cerebrovascular disease in a hospitalization record during the previous 3 years were excluded.

MEASUREMENTS: Cognitive function was assessed by the Short Portable Mental Status Questionnaire (SPMSQ). Occurrence of a stroke was prospectively assessed by examining hospital discharge diagnoses and death certificates.

RESULTS: During 19,533 person‐years of follow‐up, 259 strokes were recorded (13.3/1000 person‐years). Stroke incidence was lowest in those with normal SPMSQ score (12.1/1000 person‐years), intermediate in those with moderate impairment (16.3/1000 person‐years), and highest in those with severe impairment (30.9/1000 person‐years). Adjusting for age, education, smoking, history of hypertension, blood pressure, heart attack, diabetes, and disability, the relative risks of stroke for moderate and severe cognitive impairment were 1.2 (0.9–1.6) and 2.2 (1.2–3.8), respectively. The association between cognitive impairment and incident stroke was not mediated by hypertension or diabetes. Compared with subjects with stable or improved SPMSQ score in the previous 3 years, those who declined had higher risk of stroke.

CONCLUSIONS: The elevated risk of subsequent strokes in older persons with cognitive impairment suggests that CVD may play a larger role in causing cognitive impairment then previously suspected. It remains to be demonstrated whether reducing modifiable risk factors for CVD decreases the burden of cognitive impairment in older persons without stroke. J Am Geriatr Soc 44:237–241, 1996.
Weight Change in Alzheimer's Disease
Authors: White Heidi , Pieper Carl , Schmader Ken , Fillenbaum Gerda
Published: April 2015

PURPOSE: To determine the natural history of weight change and the occurrence of clinically significant weight loss in subjects with Alzheimer's disease (AD).

PATIENTS AND METHODS: Subjects with AD and cognitively normal older controls were recruited from 21 U.S. university medical centers that were participating in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Annual assessments were performed. Subjects with AD (n = 362) and controls (n = 317) with two or more weight measurements taken a year or more apart were included in this analysis. The average period of follow‐up was > 2 years for both subjects with AD and controls. Four variables describing different aspects of weight change were defined: ≥ 5% weight loss, percent weight change/year, maximum percent weight loss over 1 year, and standard deviation of measurements/subject.

RESULTS: Nearly twice as many subjects with AD experienced a weight loss of 5% or more when compared with controls (men P = .003, women P = .001). Surprisingly, a weight gain of 5% or more was also more common among AD cases. Overall, there was a tendency toward weight loss for both subjects with AD and controls, as measured by percent weight change/year. When other possible causes of weight loss were controlled using a multivariate model, a diagnosis of AD remained a significant predictor of ≥5% weight loss (P ≪ .001), maximum percent weight loss over 1 year (P ≪ .001), and standard deviation of measurements/subject (P ≪ .001). A trend toward significance was noted for percent weight change/year (P = .07). Other than AD, very few of the possible confounders of this association remained significant predictors of weight change. In bivariate analysis, the severity of AD at entry correlated with percent weight change/year and standard deviation of measurements/subject. Additionally, the functional status of subjects with AD correlated with all four measures of weight change.

CONCLUSION: Clinically important weight loss occurs more frequently among patients with AD than among cognitively normal control subjects. Instances of weight gain, periods of acute weight loss, and greater fluctuations in weight suggest that the natural history of weight change in AD may be characterized by dysfunction in body weight regulation. Further analysis is warranted regarding the relationship of severity of dementia, functional status, and other specific aspects of AD to weight change. J Am Geriatr Soc 44:265–272, 1996.
An Assessment of Surgery for Spinal Stenosis: Time Trends, Geographic Variations, Complications, and Reoperations
Authors: Ciol Marcia A. , Deyo Richard A. , Howell Eric , Kreif Suzanne
Published: April 2015

OBJECTIVE: To study temporal trends and geographic variations in the use of surgery for spinal stenosis, estimate short‐term morbidity and mortality of the procedure, and examine the likelihood of repeat back surgery after surgical repair.

DESIGN: Cohort study based on Medicare claims.

SETTING: Hospital care.

SUBJECTS: All Medicare beneficiaries 65 years of age or older who received a lumbar spine operation for spinal stenosis in 1985 or 1989 were followed through 1991 (10,260 patients from the 1985 cohort and 18,655 from the 1989 cohort).

MAIN OUTCOME MEASURES: Two outcomes were measured: (1) rates of operation for spinal stenosis by state and (2) on an individual level, operative complications (cardiopulmonary, vascular, or infectious), postoperative mortality, and time between first operation and any subsequent reoperation.

RESULTS: Rates of surgery for spinal stenosis increased eightfold from 1979 to 1992 for patients aged 65 and older and varied almost fivefold among US states. Mortality and operative complications increased with age and comorbidity. Complications were more likely for men and for individuals receiving spinal fusions. The 1989 cohort experienced a slightly higher probability of reoperation than the 1985 cohort for the first 3 years of follow‐up.

CONCLUSIONS: A rapid increase in surgery rates for spinal stenosis was identified over a 14‐year period. The wide geographic variations and substantial complication rate from this elective surgical procedure (partly related to patient age) suggest a need for more information on the relative efficacy of surgical and nonsurgical treatments for this condition. The risks and benefits of particular surgical procedures for specific clinical and demographic subgroups as well as individual patient preferences regarding surgical risks and possible outcomes should also be evaluated further. These issues are likely to become increasingly important with the aging of the US population. J Am Geriatr Soc 44:285–290, 1996.
Can a Physician Recognize an Older Driver with Increased Crash Risk Potential?
Authors: Johansson Kurt , Bronge Lena , Lundberg Catarina , Persson Anders , Seideman Marianne , Viitanen Matti
Published: April 2015

OBJECTIVE: To identify factors in a medical examination that distinguish convicted older drivers with traffic violations from other drivers.

DESIGN: Matched case‐control study.

SETTING: Two counties in Sweden.

SUBJECTS: Thirty‐seven drivers older than age 65, whose driving licenses have been temporarily suspended, each matched to one control subject based on age, sex, type of driving license, year of first license, living area, educational level, and annual distance driven.

MEASUREMENTS: Case and control subjects were compared with respect to medical history, medication use, blood tests, drawing and memory tests, Mini‐Mental State Examination, medical status findings, visual acuity, and brain imaging procedures.

MAIN RESULTS: The group of drivers with suspended driving licenses did not differ from matched controls with respect to visual acuity or presence of cardiovascular diseases. However, persons with suspended driving licenses were more likely than control subjects to have suspected or mild dementia (P < .010) and to perform less well on two easily administrated screening tests: copying a cube (P < .010) and 5‐item recall (P < .010). Case subjects with crashes had significantly more cardiovascular diseases than case subjects with other moving violations (P < .050). These case subjects with crashes also had significantly more cognitive impairments than control subjects without crashes as shown by a higher clinical dementia rating score (CDR) (P < .001), lower score on the Mini‐Mental State Examination (MMSE) (P < .050), and lower level of performance in the copying task (cube) (P < .050) and 5‐item recall test (P < .010). They also had evidence of greater cognitive impairment than those case subjects with other moving violations.

CONCLUSIONS: Visual acuity and common medical examination did not distinguish convicted older drivers with crashes or other moving violations from controls. There was evidence that even mild cognitive impairment contributed to the risk of losing a driving license because of crashes.
Suicidal Ideation Among Older Primary Care Patients
Authors: Callahan Christopher M. , Hendrie Hugh C. , Nienaber Nancy A. , Tierney William M.
Published: April 2015

OBJECTIVE: To describe the prevalence and sociodemographic and clinical correlates of suicidal ideation among older primary care patients.

DESIGN: Baseline screening for depressive symptoms, functional status, and suicidal ideation, with prospective assessment of mortality.

SETTING: An academic primary care group practice at an ambulatory care clinic.

PARTICIPANTS: 301 patients who screened positive for depression and a random sample of 101 patients who screened negative from among 3767 patients aged 60 and older who completed screening for depression during routine office visits.

MEASUREMENTS: Centers for Epidemiologic Studies Depression (CES‐D) scale, Hamilton Depression Rating (HAM‐D) scale, Sickness Impact Profile (SIP), structured psychiatric interview, sociodemographic and clinical variables, and mortality.

RESULTS: Among the 301 patients with CES‐D scores ≥16, 14 (4.6%) reported suicidal ideation and received urgent evaluation by mental health professionals. The estimated prevalence of suicidal ideation in this cohort of older primary care patients was 0.7 to 1.2%. All patients with suicidal ideation had evidence of a current affective disorder, and nearly all had moderate to severe functional impairment. However, even though all 14 patients endorsed suicidal ideation, corresponding HAM‐D scores ranged from 3 to 40, and only four of 14 met diagnostic criteria for major depression. The most common suicide plan involved use of a hand gun. Depressed patients with suicidal ideation did not differ significantly from depressed non‐suicidal patients on any of the following variables: age, gender, race, education, alcohol abuse, cognitive impairment, or mean CES‐D, HAM‐D, or SIP scores. None of the suicidal patients had died within 12 months of the screening date.

CONCLUSION: The prevalence of suicidal ideation was about 1% among this cohort of older primary care patients, and the prevalence approaches 5% among those older adults who report significant symptoms of depression. However, asking patients directly about the presence of active suicidal ideation appears to be the only effective means of identifying those at risk.
Physician Responses to a Hospital Policy Allowing Them to Not Offer Cardiopulmonary Resuscitation
Authors: Swig Louise , Cooke Molly , Osmond Dennis , Luce Judith A. , Brody Robert V. , Bird Carol , Luce John M.
Published: April 2015

OBJECTIVE: To determine whether physicians followed a hospital policy permitting them to not offer cardiopulmonary resuscitation (CPR) to patients considered unlikely to benefit from this therapy.

DESIGN: Prospective series.

SETTING: San Francisco General Hospital, a university‐affiliated public hospital.

PATIENTS: Attending physicians were interviewed about patients admitted over a period of 5 consecutive months for whom do‐not resuscitate (DNR) orders were written. Only the first patient for whom each physician wrote a DNR order was included.

MAIN OUTCOME MEASURES: Responses of physicians to questions regarding their initiation of DNR orders for these patients.

RESULTS: Sixty‐nine physicians responded to questions about DNR orders written for 69 patients. Fifty‐seven of these physicians said that they were aware of the hospital policy, and 49 of the 57 physicians said that they generally agreed with it. Thirty‐three physicians felt that CPR should be offered only to patients likely to benefit from it. In contrast, 36 physicians said that CPR should be offered to all patients, regardless of benefit. CPR was offered to 41 patients and 15 surrogates; 27 of these patients were considered to be unlikely to benefit from CPR.

CONCLUSION: Despite a policy that allows them to do otherwise, physicians usually offered CPR to patients, regardless of benefit. Most physicians believed that CPR should be offered to all patients. These findings suggest that policies such as that of San Francisco General Hospital may not be compelling because physicians hold attitudes that are inconsistent with the policies.
Five‐Year Performance Trends for Older Exercisers: A Hierarchical Model of Endurance, Strength, and Flexibility
Authors: Morey Miriam C. , Pieper Carl F. , Sullivan Robert J , Crowley Gail M. , Cowper Patricia A. , Robbins Michael S.
Published: April 2015

OBJECTIVE: To examine 5‐year trends in measures of physical performance, and the impact of disease upon performance, in three domains: cardiovascular fitness, musculoskeletal strength, and flexibility among older adults participating in a medically supervised exercise program.

DESIGN: Longitudinal analyses of data obtained in an observational cohort study.

SETTING: Department of Veterans Affairs Medical Center in Durham, North Carolina.

PARTICIPANTS: Seventy‐three community‐dwelling veterans between 64 and 90 years of age.

INTERVENTION: Voluntary participation in a medically supervised outpatient exercise program meeting 3 days per week for 90 minutes per session.

MAIN OUTCOME MEASURES: Changes over time in cardiovascular fitness, musculoskeletal strength, and flexibility.

RESULTS: Forty‐nine percent of the original study participants remained in the program for a full 5 years. They had lower baseline rates of cardiorespiratory and musculoskeletal diseases than did the dropouts. Dropouts were significantly more impaired in baseline measures of cardiovascular fitness (P = .038) and strength (P = .007). Changes over time for cardiovascular fitness and strength were similar. Only linear (P < .05) and quadratic time (P < .001) were significant. Only linear time was significant for measures of flexibility (P < .05). Baseline cardiorespiratory disease, baseline musculoskeletal disease, and interaction terms were not significant. Overall, measures of physical performance demonstrated gradual improvement for 2 to 3 years, followed by a gradual decline in performance irrespective of baseline disease status.

CONCLUSION: Older adults who exercise regularly, including those with multiple chronic diseases, can achieve significant gains in measures of physical performance, and these gains can be sustained for 2 to 3 years.
Management of Complicated Urinary Tract Infection in Older Patients
Authors: Yoshikawa Thomas T. , Nicolle Lindsay E. , Norman Dean C.
Published: April 2015

Urinary tract infection (UTI) in older persons is a common medical problem that is seen in both the ambulatory and institutional settings. It affects older women and men with a gender prevalence ratio of 2:1, respectively. UTI in older persons can be a complex problem in terms of the approach to diagnosis, treatment, and prevention. In this report the discussion will begin with the unique aspects of UTI in older persons, particularly as they relate to UTI in the younger, general population. The remaining discussion will then focus on three complicated clinical circumstances and conditions of UTI in the geriatric population: non‐catheter recurrent UTI, asymptomatic bacteriuria, and catheter‐related bacteriuria and UTI.
Breathing Disorders During Sleep and Cognitive Performance in an Older Community Sample: The EVA Study
Authors: Dealberto Marie‐José , Pajot Nicole , Courbon Dominique , Alpérovitch Annick , Group EVA Study
Published: April 2015

OBJECTIVES: To determine whether poor cognitive performance was associated with symptoms related to the sleep apnea syndrome, snoring, and breathing stoppage during sleep.

DESIGN: Cross‐sectional analysis of data collected at baseline in the EVA Study, a 4‐year cohort study.

SETTING: The city of Nantes in western France.

SAMPLE: A total of 1389 persons, aged 60 to 70 years, recruited from the electoral rolls of the city of Nantes.

MEASUREMENTS: Demographic characteristics and data on drug use and tobacco and alcohol consumption were collected using a standardized questionnaire. Weight and height were measured. Individuals completed a previously validated sleep questionnaire about nocturnal sleep characteristics, snoring, breathing stoppage during sleep, and day‐time sleepiness. Trained psychologists administered eight neuropsychological tests: The Mini‐Mental State Examination, Trail Making Test, Digit Symbol Substitution Test of the WAIS‐Revised, Benton Visual Retention Test, Paced Auditory Serial‐Addition Task, Auditory Verbal Learning Test, Raven Progressive Matrices, and Word Fluency Test. Depressive symptomatology was assessed by the Center for Epidemiologic Studies‐Depression scale.

MAIN RESULTS: In this older sample, 49.5% of subjects reported snoring, and 10.8% reported breathing stoppage during sleep. Both respiratory disorders were associated significantly with male gender and high body mass index. In men, prevalence of snoring was increased significantly in those with alcohol consumption greater than 40 mL per day. Breathing stoppage during sleep was associated with depressive symptoms in women. Logistic regression models adjusted for age, gender, educational level, tobacco status and alcohol consumption, depressive symptomatology, and number of medications found that both snoring and breathing stoppage were associated with low scores (≤10th percentile) in tests requiring visual attention skills, the Trail Making Test (OR = 2.14, 95% CI = 1.24–3.69 and OR = 1.88, 95% CI = 1.04–3.39, respectively), and the Digit Symbol Substitution Test (OR = 1.80, 95% CI = 1.09–2.99 and OR = 1.58, 95% CI = .87–2.89, respectively). These relationships were significant only when either snoring or breathing stoppage was associated with daytime sleepiness.

CONCLUSIONS: This cross‐sectional analysis suggested that in community‐dwelling individuals 60 to 70 years of age, snoring and breathing stoppage during sleep associated with daytime sleepiness were risk factors for low cognitive performance in tests requiring visual attention skills. J Am Geriatr Soc 44:1287–1294, 1996.
Sleep‐Disordered Breathing and Systemic Hypertension in the Older Male
Authors: Stoohs Riccardo A. , Gingold Jeffrey , Cohrs Stefan , Harter Richard , BA Emily Finlayson , Guilleminault Christian
Published: April 2015

OBJECTIVE: To investigate the relationship between sleep‐disordered breathing (SDB) and essential hypertension in a population of older male hypertensives.

PATIENTS: One‐hundred forty consecutive older hypertensive males.

MEASUREMENTS: Monitoring of sleep‐related breathing abnormality with a portable sleep apnea monitor (level III device). Assessment of complaints related to sleep quality using a validated questionnaire. Systemic arterial blood pressure according to WHO standards and biochemical analyses. SDB was defined as more than 10 abnormal respiratory events per hour of sleep.

DESIGN: Prospective investigation on a retrospective cohort.

SETTING: Veterans Administrations hypertension clinic.

MAIN RESULTS: SDB was diagnosed in 80% of this older, hypertensive, male population. Thirty‐four percent of all study subjects presented with severe SDB, with more than 30 abnormal respiratory events per hour of sleep. Subjects with SDB were significantly heavier (BMI = 30.0 ± 5.2 kg/m2) than subjects without SDB (BMI = 26.8 ± 5.1 kg/m2, P = .004). Furthermore, subjects with SDB slept significantly longer (by a mean of 46 minutes/night, P = .027) and complained significantly more often of daytime sleepiness than subjects without SDB (P = .018). Fifty percent of all 140 subjects snored more than 10% of the total sleep time, and 26% snored for more than one‐third of the night. No significant differences in blood pressure values were observed in subjects with compared with subjects without sleep‐disordered breathing. However, a considerable number of subjects presenting with hypertensive blood pressure values despite treatment could be identified. Subjects presenting with hypertensive blood pressure values had a significantly higher severity index of SDB than subjects with normotensive blood pressure values (P = .047).

CONCLUSIONS: This investigation supports data showing that undiagnosed SDB is a common phenomenon in older male individuals, leading to impaired daytime functioning and impairment of overall quality of life. More importantly, our data suggests that untreated SDB may have an adverse effect on the efficacy of antihypertensive treatment in hypertensive individuals with sleep‐disordered breathing. J Am Geriatr Soc 44:1295–1300, 1996.
Quality of Life in Patients with Alzheimer's Disease as Reported by Patient Proxies
Authors: Albert S. M. , Del Castillo‐Castaneda C. , Sano M. , Jacobs D. M. , Marder K. , Bell K. , Bylsma F. , Lafleche G. , Brandt J. , Albert M. , Stern Y.
Published: April 2015

OBJECTIVE: To measure behaviors indicative of quality of life (QOL) in patients with Alzheimer's disease and to examine correlates of patient QOL.

DESIGN: Cross‐sectional investigation.

SETTING: Multi‐center study.

PARTICIPANTS: Sample of 130 diagnosed patients.

PRINCIPAL OUTCOME MEASURES: Proxy ratings of (1) the frequency, opportunity, and enjoyment of 15 non‐ADL activities potentially within the capacity of a demented person, and (2) the frequency of a series of positive and negative affects, evident in clearly demarcated facial and bodily expressions.

RESULTS: QOL ratings were reliably elicited. Family and institutional caregivers differed only in reports of opportunity for patient activity. Frequency of activities declined with increasing severity of dementia. The frequency of negative affects increased and positive affects declined with increasing severity of dementia, but correlations were weak. High QOL, defined by frequent activity and positive affect, was evident in a quarter of the sample. In multivariate models, functional and cognitive status independently predicted QOL among community‐resident older adults; only absence of antipsychotics was related to QOL among older people in nursing homes. Patient education, a marker of premorbid state, independently predicted some activity patterns.

CONCLUSIONS: Although the subjective world of the demented patient is not directly accessible, readily observable behaviors offer a basis for assessing QOL. J Am Geriatr Soc 44:1342–1347, 1996.
Cognitive and Functional Status of the Oldest Old
Authors: Corey‐Bloom Jody , Wiederholt Wigbert C. , Edelstein Sharon , Salmon David P. , Cahn Deborah , Barrett‐Connor Elizabeth
Published: April 2015

OBJECTIVE: To compare the cognitive performance and functional status of the normal oldest old (85+ years) with that of normal older persons aged 65 to 84 years to identify age‐associated changes in cognition in individuals considered clinically normal.

BACKGROUND: Advancing age appears to be a risk factor for dementia.

DESIGN/METHODS: Analysis of performance on an extensive neuropsychological battery and the Pfeffer Outpatient Disability Scale in 243 normal individuals age 65 to 99 years.

RESULTS: Fifty‐two normal subjects who were 85 years of age and older (mean age 88.2 ± 3.1) and 191 normal subjects aged 65–84 years (mean age 75.8 ± 5.0) were compared. Mean education for both groups was not statistically different. No significant differences in functional disability were found between the two groups. Normal subjects aged 85 years and older performed significantly less well than their younger counterparts on verbal and nonverbal memory, psychomotor/executive tasks, and category verbal fluency.

CONCLUSIONS: Advancing age in normal subjects is accompanied by a decrease in cognitive function, measured by various neuropsychological tests, but is not accompanied by functional impairment.
Utility of Clysis for Hydration in Nursing Home Residents
Authors: Hussain Naaz A. , Warshaw Gregg
Published: April 2015

OBJECTIVES: To determine the utility of hypodermoclysis in the management of dehydration in nursing home residents and to review the recent literature on the use of clysis in older adults.

DESIGN: A retrospective chart review.

SETTING: Two continuing care retirement community nursing home units in Cincinnati.

PARTICIPANTS: Thirty‐six nursing home residents with a mean age of 85 years.

MEASUREMENTS: A standard chart auditing form was used to collect demographic and clinical data from the patients' nursing home charts. Clinical outcomes were assessed at 1 week following the cessation of clysis.

RESULTS: The study subjects were functionally impaired, with 86% having significant cognitive impairment and 81% totally dependent with transfer. The most common indication for clysis was in association with an infection. Clysis was frequently initiated upon nursing observation of inadequate oral intake before obtaining laboratory results and discontinued upon resumption of adequate oral intake. The use of clysis was associated with the return to clinical/functional baseline in 71% of the cases. In the subset of subjects with pre‐ and post‐clysis measurements of serum sodium and BUN/creatinine ratios, improvement in laboratory values was not significant. The use of clysis was not associated with significant complications, but in nine cases minor local skin reactions were documented.

CONCLUSIONS: Hypodermoclysis is a relatively safe and effective procedure in a nursing home. The use of clysis in the nursing home is an alternative to intravenous hydration. The use of clysis for short‐term hydration has the potential to reduce cost and transfers to the hospital. J Am Geriatr Soc 44:969–973, 1996.
Circulatory Responses to Weight Lifting, Walking, and Stair Climbing in Older Males
Authors: Benn Sally J. , McCartney Neil , McKelvie Robert S.
Published: April 2015

OBJECTIVES: To compare the heart rate and intra‐arterial blood pressure responses during weight lifting, horizontal and uphill walking, and stair climbing in older male subjects.

DESIGN: We used intra‐brachial artery catheterization to compare the arterial blood pressure (ABP) and heart rate (HR) responses during 10 repetitions (˜40 s) of single‐arm curl (SAC) and single‐arm overhead military press (SAMP) (70% of the one repetition maximum–1RM); 12 repetitions (˜50 s) of single‐ (SLP) and double‐leg press (DLP) weight‐lifting exercises (80% of 1RM); 10 minutes of horizontal treadmill walking (T10) at 2.5 mph holding a 20‐pound weight in minutes 4 to 6 (T104–6) and 30 pounds in minutes 8 to 10 (T108–10); 4 minutes of treadmill walking (T4) at 3.0 mph up an 8% incline; and 12 flights (192 steps) of stair climbing (STR) at 60 to 65 steps/minute on a Stairmaster 6000 ergometer (˜3 minutes).

SETTING: McMaster University, Hamilton, Ontario, Canada.

PARTICIPANTS: Seventeen healthy males aged (X̄ ± SE) 64.4 ± 0.6 years.

MEASUREMENTS: Continuous intra‐arterial measurements of systolic, diastolic, and mean arterial pressure and heart rate and rate‐pressure product.

RESULTS: The peak values of HR, ABP and rate‐pressure product (HR · BPs/1000;(RPP,103)) were not systematically ordered among the various activities. The lowest peak values for all variables were recorded during the initial 4 minutes of horizontal treadmill walking. The STR and T4 walking exercises elicited higher HRs (151 ±3.2 and 121 ± 3.4 bpm) than the weight lifting (range from 100 ± 4.8 (SAC) to 113 ± 3.8 bpm (SAMP)), but the converse was true for diastolic pressure (range from 128 ± 6.3 (SAC) to 151 ± 4.8 mm Hg (SAMP) versus 101 ± 2.5 (T4) to 118 ± 3.4 mm Hg (T108–10) and mean arterial pressure (range from 145 ± 4.5 (SAC) to 158 ± 4.8 mm Hg (SAMP) versus 129 ± 3.4 in T4 to 148 ± 3.8 (T108–10) and 157 ± 4.1 mm Hg (STR)). The peak systolic pressure was greatest in STR (271 ± 9.6 mm Hg) followed by SAMP (261 ± 9.3 mmHg) and T108–10 (244 ± 6.4 mm Hg) and was lowest in SAC (224 ± 10.5 mm Hg) and T104–6 (220 ± 5.7 mm Hg). The peak RPP descended in sequence from STR (41 ± 1.8), SAMP (29.8 ± 1.7), T4 (28.1 ± 1.3), DLP (27.2 ± 1.3), T108–10 (27.1 ± 1.4), SLP (25.4 ± 1.7), T104–6 (22.7 ± 1.2) and SAC (22.0 ± 2.2).

CONCLUSION: We concluded that older adults who engage in weight lifting with heavy submaximal loads are exposed to no more peak circulatory stress than that created during a few minutes of inclined walking. Moreover, climbing only three to four flights of stairs at a moderate pace (–50–70 s) elicits peak circulatory demands similar to, but at a much more rapid rate of adjustment than, 10 minutes of horizontal walking at 2.5 mph intermittently carrying a 30‐pound weight or 4 minutes of walking up a moderately steep slope. J Am Geriatr Soc 44:121–125, 1996.
Prevalence of Dementia and Distribution of ApoE Alleles in Japanese Centenarians: An Almost‐Complete Survey in Yamanashi Prefecture, Japan
Authors: Asada Takashi , Yamagata Zentaro , Kinoshita Toru , Kinoshita Akemi , Kariya Tetsuhiko , Asaka Akio , Kakuma Tatsuyuki
Published: April 2015

OBJECTIVE: To determine the prevalence and types of dementia in centenarians and to examine whether the ApoE 4 allele has significant impact on the development of Alzheimer's disease (AD) in the population.

DESIGN: Cross‐sectional study and a 6‐month prospective study.

SETTING: Yamanashi Prefecture, Japan

PARTICIPANTS: Forty‐seven centenarians participated in the study to determine the prevalence and types of dementia. Thirty‐three of the 47 participated in the study of ApoE genotyping. As controls, 224 demented older adults participated in the genetic study. Their age at onset was <90 years.

OUTCOMES: Prevalence of dementia based on DSM‐III‐R; types of dementia based on NINCDS‐ADRDA and ICD‐10; distribution on ApoE alleles in the centenarians and in the controls; and the 6‐month mortality rate of the subjects.

MAIN RESULTS: Of 47 centenarians, 70.2% had dementia, and AD accounted for the majority (75.8%) of the dementia cases. The distribution of ApoE alleles in all the subjects and the AD subjects was ε2: 4.6% vs. 0%; ε 3: 90.1 % vs. 94.1%; ε 4: 4.6% vs. 5.9%. The frequency of the ε 4 allele in the AD patients showed a tendency to decrease with increasing age, ranging from 38% for those with an age at onset of <60 years to 22% for those with an age at onset of ranging from 80 to 89 years. The 6‐month mortality rate was 27% (9/33) for the demented centenarians, whereas none of the 14 nondemented centenarians died.

CONCLUSION: This almost‐complete survey, conducted in a prefecture of Japan, revealed a high prevalence of dementia in centenarians. The ApoE ε 4 allele does not have an impact on the development of AD in centenarians. J Am Geriatr Soc 44:151–155, 1996.