bluuebunny/crossref_metadata_2025 huggingface dataset:
Repetitive Nocturnal Arterial Oxygen Desaturation and Silent Myocardial Ischemia in Patients Presenting for Vascular Surgery
Authors: Goldman M. D. , Reeder M. K. , Muir A. D. , Loh L. , Young J. D. , Gitlin D. A. , Casey K. R. , Smart D. , Fry J. M.
Published: April 2015

Objective: To determine whether nocturnal respiratory abnormality (cyclic oxygen desaturation and tachycardia) is associated with nocturnal myocardial ischemia in older individuals with ischemic heart disease.

Design: Non‐invasive monitoring on a single occasion.

Setting: Tertiary care referral hospital.

Patients: Thirty four consecutive older (68.5 ± 6 yrs) patients referred for elective abdominal or carotid reconstructive vascular surgery.

Results: Seven patients (21%) had moderately severe nocturnal respiratory abnormality, defined by more than 50 dips in arterial oxygen saturation and increases in heart rate during the night. Two of these seven had clinical risk factors for ischemic heart disease and had nocturnal myocardial ischemia. Ten patients (29%) developed ischemia at some time during the study, of whom seven hand known ischemic heart disease, hypertension, and/or angina. Those with increased nocturnal ischemia showed very low frequency (1–2 cycles per minute) cyclic heart rate oscillations and repetitive nocturnal episodes of arterial oxygen desaturation, similar to patients with sleep apnea.

Conclusion: Repetitive nocturnal cyclic arterial desaturation and cyclic increases in heart rate are associated with nocturnal myocardial ischemia in individuals with clinical risk factors for ischemic heart disease. Further investigation in a large patient sample utilizing non‐invasive monitoring of saturation, heart rate, and blood pressure may provide definitive evidence regarding causation of some of the nocturnal myocardial ischemia occurring in older individuals with vascular disease.
Attitudes of Physicians toward Elderly Drivers and Driving Policy
Authors: Miller Denver J. , Morley John E.
Published: April 2015

Objective: To examine physicians' attitudes toward and knowledge concerning driving in older persons.

Design: Questionnaire survey.

Measurements: A questionnaire was sent to physician members of the American Geriatrics Society (n = 5009). The questionnaire explored physicians' practice characteristics, general approach to record keeping, frequency of behavior toward educating, counseling, and reporting patients to authorities when deemed appropriate, and their personal understanding of driving issues and physician responsibilities within the state in which they practice.

Results: A response rate of 48% was obtained. There was a lack of consensus among physicians, with a broad range of attitudes and practices dealing with this growing public health concern. Physicians generally believed that they had a legal responsibility to assess driving ability but were uncertain about how to assess driving competence and their responsibility toward their senior patients who drive.

Conclusions: Physician practices concerning the appropriate management of older drivers vary widely. Physicians should be aware that medical literature is available to aid in the evaluation of the elderly driver with medical impairments. In addition, physicians should consider referring their elderly patients to driver refresher courses to improve or maintain their driving skills. More research is needed to help guide health professionals in assessing the frail elder with multiple medical impairments and decreasing the crash risk for the older driver.
Identification of Alcoholism and Depression in a Geriatric Medicine Outpatient Clinic
Authors: Fulop George , Reinhardt Jayne , Strain James J. , Paris Barbara , Miller Myron , Fillit Howard
Published: April 2015

Objective: To examine the utility of brief screening instruments for alcoholism and depression in the frail elderly medical outpatient.

Design: Cross‐sectional examination.

Setting: Coffey Geriatric Outpatient Clinic, The Mount Sinai School of Medicine, New York City.

Subjects: Convenience sample of 84 consenting male and female outpatients over 62 years of age.

Measurements: The Michigan Alcohol Screening Test (MAST), CAGE questionnaire, and the Geriatric Depression Scale (GDS).

Results: Four subjects (5%) scored positive for alcoholism on the MAST, all of whom had been previously identified by the geriatric clinic staff. In contrast, the CAGE only identified 1 (1.4%) alcoholic subject. Thirty‐two percent of subjects scored positive for depression on the GDS, yet only one‐third of these depressed patients had been previously identified by the geriatric team as depressed. Among the depressed outpatients, 19% were labeled anxious and received anxiolytics from the geriatric medical staff.

Conclusions: Whereas brief alcohol screening instruments to detect alcoholism did not augment the geriatrician's clinical assessment, screening for depression with the GDS may be an important adjunct to the identification of depression in geriatric medical patients.
Factors Affecting the Serum Free Thyroxine Levels in Hospitalized Chronic Geriatric Patients
Authors: Szabolcs Istvan , Ploenes Christoph , Beyer Mathias , Bernard Wolfdieter , Herrmann Jorg
Published: April 2015

Objective: Determination of whether nonthyroidal factors affect the diagnostic value of free thyroxine estimation in geriatric patients.

Design: Survey.

Participants: A convenience sample of 381 non‐selected, chronic, hospitalized geriatric patients over 60 years of age (I = relatively good health; II = relatively poor health; III = bad health; subgroups “sine therapia,” ie, patients receiving no drugs that affect FT4) and 180 20–40 year old healthy persons.

Measurements: Thyrotropin‐releasing hormone test; thyrotropin (TSH); free thyroxine (FT4, measured in part by two parallel methods) estimation in a screening study; and thy‐roxine‐binding globulin and thyroxine‐binding‐inhibitor activity measurements.

Results: The normal FT4 ranges of the euthyroid geriatric (n = 210) and healthy young groups were similar. In the “sine therapia” euthyroid patients, FT4 decreased with age but increase with the severity of illness. High FT4 levels with non‐suppressed TSH were more frequent in patients in poor and bad health. (I = 6/112; II = 14/140; III = 13/74; P < 0.01). The serum thyroxine‐binding‐inhibitor activity of euthyroid geriatric patients correlated with the severity of their clinical state (I = 6.22 ± 5.65 (13); II = 7.40 ± 4.33 (23); III = 10.04 ± 5.50 (16) μg merthiolate equivalent/μL; ANOVA with log‐transformed values: F(2.51) = 3.50, P < 0.05). The mean FT4 was higher in 36 heparin‐treated patients (22.81 ± 4.67 pmol/L) than in the 193 “sine therapia” patients (19.03 ± 4.23 pmol/L; ‐ P < 0.001). In a convenience subsample of 240 patients, a weak inverse correlation was found between FT4 and the thyroxine‐binding globulin (r = −0.14, P < 0.02). Only 5/11 patients with low free thyroxine had hypothyroidism, while 11/46 patients with elevated free thyroxine had hyperthyroidism.

Conclusions: There is no need to modify the normal free thyroxine range for hospitalized geriatric patients. Clinical condition, drug treatment, and, to a lesser extent, age are factors that significantly affect the diagnostic value of FT4 in hospitalized chronic geriatric patients, decreasing the specificity of the test in diagnosing clinical hyper‐ and hypothyroidism.
Driving Performance in Persons with Mild Senile Dementia of the Alzheimer Type
Authors: Hunt Linda , Morris John C. , Edwards Dorothy , Wilson Bradley S.
Published: April 2015

Objective: To assess the effect of mild senile dementia of the Alzheimer type (SDAT) on driving ability.

Design: Cross‐sectional study with correlation analysis.

Setting: A university‐based Alzheimer's Disease Research Center, which evaluates community‐living older adult volunteers, and the university's Program in Occupational Therapy.

Participants: Healthy elderly controls (n = 13) and subjects with very mild (n = 12) and mild (n = 13) SDAT. Dementia severity was staged by the Washington University Clinical Dementia Rating.

Measurements: The driving ability of participants on the in‐car road test was scored independently by a driving instructor, blinded to the study design and to the dementia status of the subjects, and an unblinded occupational therapist. Interview‐based perceptions of driving ability were obtained independently from the subjects and their collateral sources. Attentional and visuospatial performances of the subjects were assessed prior to the road test.

Results: All control and very mild SDAT subjects were judged to be “safe” drivers (ie, passed the in‐car road test), but five (40%) of the mild SDAT subjects had driving impairment sufficient to “fail” the road test. Neither subject self‐assessment nor caregiver perceptions of driving ability consistently predicted driving performance. Attentional task performance correlated well with road test results.

Conclusions: Some SDAT subjects retain “safe” driving skills. The greater the dementia severity, the greater the likelihood of poor driving ability. Performance‐based (road test) evaluations are necessary to properly determine driving skills at present, but attention and other cognitive screening measures should be developed.
Does Radiographic Osteoarthritis Correlate with Flexibility of the Lumbar Spine?
Authors: Weiner Debra K. , Distell Bruce , Studenski Stephanie , Martinez Salutario , Lomasney Laurie , Bongiorni Dennis
Published: April 2015

Objectives

To examine the association between radiographic lumbosacral (LS) osteoarthritis (OA) and lumbar flexibility in elders without back pain or known spinal pathology and to develop a reliable grading system for osteoarthritis of the lumbosacral spine.

Design

Cross‐sectional study.

Setting

Durham VA and Duke University Medical Center Department of Radiology.

Participants

35 volunteers aged 64–90 (nursing home residents and community dwellers). Exclusion criteria were known spinal pathology, back pain, inability to stand independently for 1 minute, and >150% of ideal body weight.

Interventions

All subjects underwent LS spine radiographs and flexibility measures (forward flexion, extension, lateral flexion, and axial rotation).

Main Outcome Measures

Reliability of ordinal OA X‐ray grading system, tested using intraclass correlations (ICCs); stability of flexibility measures, using ICCs; and association of disc or facet summary scores (sum of all levels, T12 thru SI) with flexibility measures, using Pearson correlations.

Results

ICCs for interest flexibility measures ranged from 0.72 to 0.94. ICCs for interobserver X‐ray scores were 0.85 for facet disease and 0.93 for disc disease. The correlation of facet disease with forward lumbar flexion was 0.29. The correlation of disc disease with flexibility showed modest correlation for forward (r = 0.34), right lateral (r = 0.36), and left lateral (r = 0.35) flexion. None of the correlations was influenced by age.

Conclusions

We have developed a reliable radiographic scoring instrument for assessing radiographic OA of the LS spine. It appears that painless LS disc OA is one factor that influences spinal motion.
Urinary Incontinence as a Risk Factor for Mortality
Authors: Herzog A. Regula , Diokno Ananias C. , Brown Morton B. , Fultz Nancy H. , Goldstein Nancy E.
Published: April 2015

Objective

To determine whether mortality is independently associated with urinary incontinence.

Design

6‐year prospective study that started in 1983/84.

Setting

A Midwestern County.

Participants

Probability sample of 1956 community‐residing persons 60 years of age and older in 1983/84.

Measurements

The independent variables of urinary incontinence, its types and severity, were measured by survey self‐report, which was validated with clinical exams. The control variables of age, education, and health status were also self‐reported. The dependent variable of death was established during follow‐up interviews from reports of previously designated contact persons.

Results

Neither incontinence status nor its severity level or types were found to be positively associated with 6‐year mortality in logistic regression analyses that adjusted for age, education, and health status.

Conclusion

Whereas urinary incontinence can be an embarrassing and socially debilitating condition, it does not itself predict or contribute to mortality.
Risk of Falls after Hospital Discharge
Authors: Mahoney Jane , Sager Mark , Dunham Nancy Cross , Johnson Jill
Published: April 2015

Objectives

To determine the incidence of falls within the first month after hospitalization and risk factors associated with falling during this period.

Design

Cohort study with 1‐month follow‐up after hospital discharge.

Setting

370‐bed community hospital.

Patients

Consecutive sample of 214 patients, aged 70 years and over, hospitalized for medical illness more than 48 hours and discharged to the community. Exclusion criteria: terminal illness, neurologic diagnosis, discharge to skilled nursing facility.

Measurements

Information was obtained at hospital admission, discharge, and 1 month after discharge. Initial assessment included demographic data, vision, mood, pre‐admission function, and use of assistive device. Discharge assessment included length of hospital stay, use of assistive device, need for professional help after discharge, medications, cognition, and functional status. Patients were assessed 1 month after discharge for history of confusion and falls. Main outcome measure was falls in the first month after discharge.

Main Results

Twenty‐nine patients (13.6%) fell during the month after discharge. Major risk factors for falls included, at discharge, decline in mobility (P = 0.005), use of assistive device (P = 0.002), and cognitive impairment (P = 0.05), and after hospital discharge, self‐report of confusion (P = 0.002). Patients who were functionally dependent and needed professional help after discharge had the highest rate of falls (20.2%). In contrast, only 8.4% of independent patients not requiring professional help fell (P = 0.01).

Conclusions

There is a high incidence of falls after hospital discharge, particularly among patients who are functionally dependent. Further study is needed to determine to what extent acute illness and hospitalization may influence falls risk.
Association of Visual Impairment with Mobility and Physical Function
Authors: Salive Marcel E. , Guralnik Jack , Glynn Robert J. , Christen William , Wallace Robert B. , Ostfeld Adrian M.
Published: April 2015

Objective

To examine the association of distant vision and physical function in the population of older adults.

Design

Cross‐sectional and cohort study.

Participants

5143 older residents of three communities (Established Populations for the Epidemiologic Studies of the Elderly) who were interviewed in 1988–89, including residents of two communities who were re‐interviewed 15 months later (n = 3133, 97% of those eligible).

Measures

Visual acuity screening, self‐reported activities of daily living and mobility, and objective physical performance measures of balance, walking, and rising from a chair.

Results

Limitations in mobility, activities of daily living, and physical performance were associated with worse visual function. In prospective analyses controlling for potential confounders, participants with severe visual impairment had 3‐fold higher odds of incident mobility and activity of daily living limitations than those with acuity of 20/40 or better (P < 0.001). In prospective analyses investigating the relationship of vision with improvement in function, those with poor vision were about half as likely to improve as those with better acuity, but this relationship was only statistically significant for improvement in mobility limitations.

Conclusions

Distant visual function appears to play an important role in physical function, particularly for mobility. An intervention to improve vision in at‐risk elders might preserve function and prevent disability; this warrants further investigation.
Neuropsychological Deficits, Caregivers' Perception of Deficits and Caregiver Burden
Authors: Hadjistavropoulos Thomas , Taylor Steven , Tuokko Holly , Beattie B. Lynn
Published: April 2015

Objective

We tested three hypotheses about the effects of perceived and actual patient deficits on caregiver burden: (1) objective patient deficits directly influence caregiver burden; (2) caregiver burden is the result of caregiver perceptions of patient deficits; (3) objective patient deficits influence caregiver burden indirectly by determining perceived deficits.

Design

Causal modeling.

Setting

A hospital‐based out‐patient diagnostic clinic.

Participants

An elderly sample (n = 136) referred to a diagnostic dementia clinic and their caregivers.

Measurements

Neuropsychological tests of patient functioning, a measure of patient mood (the Geriatric Depression Scale), caregiver perceptions of patient functioning, and a measure of caregiver burden (the Burden Interview).

Results

The Geriatric Depression Scale and neuropsychological battery‐based indices of functioning were not predictive of caregiver burden. Caregiver perceptions of patient dysphoria, and of everyday functioning skills were related to burden. Caregiver perceptions of patient memory, self‐care, and language skills were unrelated to caregiver burden.

Conclusions

The results are consistent with the Lazarus and Folkman model of stress and coping; the caregiver's perceptions of the patient's functioning were the most important determinants of caregiver burden. Objective patient deficits influenced caregiver burden indirectly by influencing caregiver perceptions of patient deficits. These findings suggest that practitioners attempting to assess and manage caregiver burden should attend to the caregivers' perceptions of patient mood and everyday functioning. The relationship of caregiver appraisals with actual patient deficits also sheds light on the nature of caregiver stress.
Permanent Cardiac Pacemakers in the Elderly
Authors: Bush David E. , Finucane Thomas E.
Published: April 2015

Objective

To review (1) Changes in cardiac impulse generation, conduction, and ventricular filling in normal aging and disease; (2) Pacemaker technology and nomenclature; (3) Expert guidelines about pacemaker use; (4) Studies of pacemaker effectiveness and utilization.

Design

Articles were identified through a Medline search, review of articles' bibliographies, and contact with pacemaker manufacturer representatives for information on device features and costs. These articles were reviewed, and the relevant data are presented.

Results

Abnormalities in impulse generation and conduction are common in the elderly. Pacemaker use is higher in the elderly than in other population groups. Hemodynamic changes associated with aging include an increased contribution of atrial contraction to ventricular filling. Pacemakers, which maintain the synchrony between the atria and ventricles, may be particularly advantageous in the elderly for this reason. Rate‐responsive ventricular pacemakers improve the quality of life compared with fixed rate devices in some patients over the age of 75. Dual‐chamber, sequential pacemakers are more likely to reduce symptoms of pacemaker syndrome than ventricular pacemakers and probably also prolong survival and reduce risk of atrial fibrillation in certain groups of patients. However, dual chamber devices are more expensive and require more frequent follow‐up. Pacemaker utilization can vary widely by region. Decisions about pacemakers require explicit tradeoffs between risk and quality of life on one hand and cost on the other. In many clinical situations, there is controversy as to whether pacemakers should be used.

Conclusions

Pacemakers provide definite benefits to some patients, whereas in others, the likelihood of benefit is uncertain. More sophisticated devices may provide some additional benefit, but they are more costly. Further data is still required to define precisely which groups of patients substantially benefit from complex and expensive pacing modalities compared with simpler ones.
The Predictive Power of Self‐Rated Health, Activities of Daily Living, and Ambulatory Activity for Cause‐Specific Mortality among the Elderly: A Three‐year Follow‐up in Urban Japan
Authors: Tsuji Ichiro , Minami Yuko , Keyl Penelope M. , Hisamichi Shigeru , Asano Hirotake , Sato Makito , Shinoda Kazuo
Published: April 2015

Objective:To examine the predictive power of self‐rated health, activities of daily living (ADL), and ambulatory activity for different causes of death in a representative sample of older persons.

Design:Three‐year prospective cohort study.

Setting:Sendai City, Japan.

Participants:2,552 persons 65 years and older at baseline in 1988.

Measurements:Independent variables (measured by self‐report of participants) were age, sex, self‐rated health, ADL, ambulatory activity level, and use of medical care. Dependent variables were mortalities from cancer, stroke, and heart disease.

Main Results:Self‐rated health significantly predicted cancer mortality but not the other two causes of mortality. ADL disability was a significant predictor for stroke mortality, and limitation in ambulatory activity significantly increased the risk of heart disease mortality. The associations between ADL and stroke mortality as well as between ambulatory activity and heart disease mortality remained significant even after excluding those who reported having the index disease in 1988.

Conclusion:The predictive powers of self‐rated health, ADL function, and ambulatory activity varied significantly with the underlying causes of death among the elderly.
Patterns and Predictors of Institutionalization in Community‐Based Dementia Patients
Authors: MA Mary A. Severson , Smith Glenn E. , Tangalos Eric G. , Petersen Ronald C. , Kokmen Emre , Ivnik Robert J. , Atkinson Elizabeth J. , Kurland Leonard T.
Published: April 2015

Objective:To investigate patterns and predictors of institutionalization in a community‐based sample of dementia patients.

Setting:The Mayo Clinic Alzheimer's Disease Patient Registry (ADPR), a community‐based prospective registry.

Patients:Two hundred seventy‐five participants, including 145 dementia patients and 130 controls on whom longitudinal follow‐up data was available. The mean ages were 79.9 and 78.8 years, and the mean Mini‐Mental State Examination (MMSE) scores at enrollment were 22.1 and 28.1 points for the demented cases and controls, respectively.

Measures:Place of residence, marital status, number of direct support providers, global cognitive status, activities of daily living and instrumental activities of daily living were used in hazards modeling of institutionalization.

Results:The results from our community‐based sample suggest a high rate of institutionalization for dementia patients. One‐half of the sample of dementia patients were institutionalized within 2.5 years of enrollment in our patient registry. Identified assistance providers were absent in a significant proportion (36%) of our dementia sample. Marital status, global cognitive function, and functional status were significant terms in hazards models of institutionalization. Age, gender, number of direct caregivers, and dementia etiology were not associated with significant risk. Seventy‐two percent of the dementia patients who died over the course of this study had been placed in nursing home care prior to death (with a mean length of stay of 2.8 years).

Conclusions:Social (marital status) and disease‐related variables (cognitive and functional status) are related to risk for institutionalization. These variables may be useful in estimating time to institutionalization in various clinical and research populations.
Short‐Term Variability of Self Report of Incontinence in Older Persons
Authors: Resnick Neil M. , Beckett Laurel A. , Branch Laurence G. , Scherr Paul A , Wetle Terrie
Published: April 2015

Objective: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self‐reported continence status. The goal of this study was to assess the reliability of this measure in older adults.

Design: Telephone interviews administered approximately 2 weeks apart.

Setting: Community‐based congregate living facility.

Participants: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women >70 years old (79% >80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent.

Measurement: Responses to a structured questionnaire.

Main Results: The prevalence of urinary incontinence was 40% at baseline and 44% on re‐interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67–.69.

Conclusion: Prevalence estimates of incontinence are stable over a 2‐week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community‐dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.
Stepping Responses of Young and Old Adults to Postural Disturbances: Kinematics
Authors: Luchies Carl W. , Alexander Neil B. , Schultz Albert B. , Ashton‐Miller James
Published: April 2015

Objectives: When large disturbances of upright stance occur, balance must usually be restored by taking a step. We undertook this study to examine the biomechanics of stepping responses to sudden backward pulls at the waist. Primarily, response differences between young and old healthy adults were sought.

Design: A controlled laboratory study.

Subjects: Two groups of healthy and physically‐fit adult females, 12 of mean age 22 (Young) and 12 of mean age 73 years (Old).

Measurements: Response kinematics were measured. From them, the stepping strategies of the subjects were derived, including the timing, length, and height of the first step taken and the rotations of major body segments and at major body joints that occurred.

Results: In response to sufficiently large backward pull forces, all subjects responded by taking one or more steps backwards. No significant age group difference appeared in the smallest disturbance for which subjects sometimes used a step response. A significant age group difference appeared in the smallest disturbance at which subjects began consistently to use step responses, and that disturbance was larger for the Old than for the Young. Distinct age group differences were found in stepping strategy. At large disturbance levels, the Young mostly responded by taking a single step, whereas the Old mostly responded by taking multiple steps. The steps taken by the Old, compared with those of the Young, were significantly shorter, had significantly smaller heights, and were taken significantly earlier in the responses. Body segment and joint rotations were generally modest, and few significant age group differences were found in these kinematics.

Conclusions: In restoration of perturbed balance by step‐taking, the responses of the healthy, physically‐fit young and old adults studied here were similar in many respects, but they differed in some important features. Joint range of motion (ROM) limitations are unlikely to explain age group differences in stepping responses to postural disturbances among healthy subjects because the ROM actually used in any of the responses observed were substantially smaller than the ROM available.
Symptom Patterns and Comorbidity in the Early Stages of Alzheimer's Disease
Authors: McCormick Wayne C. , Kukull Walter A. , van Belle Gerald , Bowen James D. , Teri Linda , Larson Eric B.
Published: April 2015

Objective: To learn whether patients with early Alzheimer's disease tend to under‐report or over‐report symptoms and to compare their comorbidity with non‐demented patients.

Design: Case Control Study in a population‐based dementia registry.

Setting and Patients: Three groups of subjects (mean age 76) were enrolled from an HMO base population: 154 cases had clinically diagnosed probable Alzheimer's disease, 92 subjects were found to be not demented although they had complaints of cognitive impairment, and another 129 cognitively intact controls were enrolled after frequency‐matching for age and sex.

Measurements and Results: Medical records were examined for the 2 years prior to enrollment. Symptoms suggestive of cognitive impairment were evident 7.8 months prior to enrollment (median 6 months) in 95% of cases, in 77% of the not demented subjects, and in 6% of controls. After corrections for multiple comparisons, only symptoms of cognitive impairment were more frequent in cases, whereas several common symptoms not suggestive of cognitive impairment (eg, gastrointestinal discomfort, joint pain, vision problems) occurred more often in controls and the not demented group, even though comorbidity was similar among all three groups (Charlson Index mean scores: case = 0.7, not demented = 0.7, control = 0.5).

Conclusions: Persons with Alzheimer's disease do complain of symptoms clearly related to cognitive impairment early in the course of illness, but may under‐report common symptoms not suggestive of cognitive impairment, even though their comorbidity is similar to patients without dementia.
The Timed Manual Performance Test as a Predictor of Hospitalization and Death in a Community‐Based Elderly Population
Authors: Williams Mark E. , Gaylord Susan A. , Gerrity Martha S.
Published: April 2015

Objective: To determine the usefulness of timed manual performance measurements (TMP) as predictors of health outcomes, hospitalization, and mortality in a large, heterogeneous sample of elderly people living in the community.

Design: Prospective cohort study.

Setting: Central North Carolina.

Participants: 1,286 community‐dwelling older people.

Measurements: Demographic background, health problems, number of prescribed medications, perceived health, quality of life, and the TMP, a 27‐item test that has been shown to predict functional dependency and need of health‐care services in older people.

Results: During the 2‐year follow‐up period, 127 people died and 200 were hospitalized. Scores for those who were able to complete the original TMP, as well as scores for two shorter versions of the TMP, predicted mortality and, to a lesser extent, hospitalization within 2 years. For both original and shorter versions of the TMP, relative risk of death was approximately 2.5 times greater for those in the poorest performance quartile, as compared with the best performing quartile, when adjusted for age, gender, race, and number of prescribed medications. TMP tests and an index of IADL were independent predictors of death.

Conclusions: TMP scores may be useful in the clinical setting as a vital sign of functioning, providing a means of targeting those individuals at increased risk of mortality. J Am Geriatr Soc 42:21–27, 1994
A Retrospective Review of Nosocomial Infections in an Acute Rehabilitative and Chronic Population at a Large Skilled Nursing Facility
Authors: Smith Miriam A. , Duke William M.
Published: April 2015

Objective: This study was undertaken to analyze infection rate, risk for acquisition of infection, and spectrum of infectious disease in two distinct sub‐populations within a large, metropolitan, long‐term care skilled nursing facility (LTCSNF).

Design: A retrospective chart review over an 18‐month period.

Setting: A large, metropolitan LTCSNF.

Patients: 786 acute rehabilitative patients and 554 chronic patients.

Measurements: The study compared infection rate, risk for acquisition of infection, and the microbiology of the most common infections in the two sub‐populations. Analyses comparing the infection rate in the rehabilitative population with the infection rate in the chronic population were performed by multiple regression. The dependent variable in these analyses was the number of infections. The length of time that the patient was at risk for infection was included as a covariate.

Main Results: Approximately 75% of patients in both groups were women. The median age was 80 years in the rehabilitative group, 85 years in the chronic group. Urinary tract infection, pneumonia, skin/soft tissue infection were the most common infections in both groups. Five hundred forty‐seven patients in the rehabilitative group and 479 patients in the chronic group had three or more underlying diseases. Enterobacteriaceae organisms were the most common isolates in urinary tract infectious episodes in both groups; mixed flora were the most common isolates for pneumonia and skin/soft tissue episodes in both groups. The calculated rate of infection for the rehabilitative and chronic groups was not significantly different (P = >0.05).

Conclusions: In concordance with other studies, urinary tract infection, respiratory infections, and skin and soft tissue infections were the most common in the long‐term care facility. Analyses of two distinct populations within a single, large, teaching nursing facility revealed, however, that the rate of infection was not significantly different between the groups and that length of stay or presence of underlying disease was not predictive of infection. J Am Geriatr Soc 42:45–49, 1994
Serum Insulin‐Like Growth Factor I in Healthy Older Men in Relation to Physical Activity
Authors: Rudman Daniel , Mattson Dale E.
Published: April 2015

Objective: The serum level of insulin‐like growth factor‐I (IGF‐I) is lower in old men than in young men. It has been theorized that this change may result in part from the lower level of physical activity in the elderly. The objective of the present study was to test this theory.

Design: Cross‐sectional study.

Setting: Community‐dwelling healthy men.

Participants: Twenty‐nine young men aged 21–29 and 120 older men aged 58–98. A wide range of habitual physical activity was assured in the older men by recruiting them both in senior centers and in fitness centers.

Measurements: Serum IGF‐I level was measured by radioimmunoassay. Physical activity was estimated as the sum of moderate, hard, and very hard activities in leisure and occupation during the previous week as determined by the interviewer‐administered Seven Day Physical Activity Recall questionnaire.

Results: IGF‐I was significantly higher (363.7 + 16 ng/mL, avg + SEM) in the young men than in the senior center older men (219.6 + 5 ng/mL) or in the fitness center older men (168.3 + 11 ng/mL) (P < 0.01). The level of IGF‐I in the senior center older men was higher than that in the fitness center older men (P = 0.05). The physical activity of the fitness center older men (128.5 + 15 Kcal/kg/wk, avg + SE) was statistically similar to that of the young men (101.3 + 19 Kcal/kg/wk). The physical activity levels of both of these groups were significantly higher than that of the senior center older men (33.6 + 3 Kcal/kg/wk) (P < 0.010). Within none of the three groups was there a significant correlation between IGF‐I and physical activity. When the two groups of older men were combined, there was, in fact, an inverse correlation of IGF‐I and physical activity (P = 0.001).

Conclusion: The data do not support the hypothesis that lack of physical activity is responsible for the decline in serum IGF‐I with advancing age. J Am Geriatr Soc 42:71–76, 1994
Aging and Marrow Neutrophil Reserves
Authors: Chatta Gurkamal S. , Price Thomas H. , Stratton John R. , Dale David C.
Published: April 2015

Objectives: Measurement of blood neutrophil (PMN) counts after the administration of hydrocortisone, granulocyte colony‐stimulating factor (G‐CSF) and epinephrine.

Design: Prospective study, with subjects serving as their own controls before and after administration of hydrocortisone, G‐CSF, and epinephrine.

Setting: The G‐CSF and hydrocortisone studies were conducted at the Clinical Research Center, University of Washington, and the epinephrine study was conducted at the Seattle VA Medical Center.

Participants: Healthy volunteers of both sexes (ages 20 to 30 years and 70 to 80 years) were recruited from the community. The subjects had no acute or chronic medical problems and were on no prescription medications.

Main Outcome Measures: Change in the blood PMN count after administration of hydrocortisone (25 and 200 mg intravenously), G‐CSF (30 and 300 μg subcutaneously), or epinephrine (10, 25, and 50 ng/kg/min intravenously).

Results: Baseline PMN counts were similar for all comparison groups. The peak PMN response (maximum count‐baseline count) to hydrocortisone was significantly less in the older subjects (P < 0.01) at both doses. The peak PMN responses were 4588 + 418/mm3 (25 mg) and 6906 + 1121/mm3 (200 mg) in the young and 1886 + 399/mm3 (25 mg) and 2387 + 372/mm3 (200 mg) in the elderly subjects. The peak PMN response following G‐CSF was not different (P > 0.05) in the two groups at both the dosages: 6696 + 736/mm3 (30 μg) and 9801 + 893/mm3 (300 μg) in the young and 6340 + 833/mm3 (30 μg) and 9733 + 956/mm3 (300 μg) in the elderly. There was no age‐related change in the response to epinephrine.

Conclusions: Aging has no effect on baseline PMN counts, bone marrow PMN reserves as measured with G‐CSF, and blood PMN pools as measured with epinephrine. However the ability to mobilize these PMNs from the marrow into blood, as measured by the hydrocortisone response, is significantly reduced in the elderly. J Am Geriatr Soc 42:77–81, 1994
Increased Walking Variability in Elderly Persons with Congestive Heart Failure
Authors: Hausdorff Jeffrey M. , Forman Daniel E. , Ladin Zvi , Goldberger Ary L. , Rigney David R. , Wei Jeanne Y.
Published: April 2015

OBJECTIVES: To determine the effects of congestive heart failure on a person's ability to walk at a steady pace while ambulating at a self‐determined rate.

SETTING: Beth Israel Hospital, Boston, a primary and tertiary teaching hospital, and a social activity center for elderly adults living in the community.

PARTICIPANTS: Eleven elderly subjects (aged 70–93 years) with well compensated congestive heart failure (NY Heart Association class I or II), seven elderly subjects (aged 70–79 years) without congestive heart failure, and 10 healthy young adult subjects (aged 20–30 years).

MEASUREMENTS: Subjects walked for 8 minutes on level ground at their own selected walking rate. Footswitches were used to measure the time between steps. Step rate (steps/minute) and step rate variability were calculated for the entire walking period, for 30 seconds during the first minute of the walk, for 30 seconds during the last minute of the walk, and for the 30‐second period when each subject's step rate variability was minimal. Group means and 5% and 95% confidence intervals were computed.

MAIN RESULTS: All measures of walking variability were significantly increased in the elderly subjects with congestive heart failure, intermediate in the elderly controls, and lowest in the young subjects. There was no overlap between the three groups using the minimal 30‐second variability (elderly CHF vs elderly controls: P < 0.001, elderly controls vs young: P < 0.001), and no overlap between elderly subjects with and without congestive heart failure when using the overall variability. For all four measures, there was no overlap in any of the confidence intervals, and all group means were significantly different (P < 0.05).

CONCLUSIONS: Step rate variability is increased in elderly subjects with well compensated congestive heart failure compared with elderly subjects without congestive heart failure and healthy young adults.
Indices of Dehydration Among Frail Nursing Home Patients: Highly Variable but Stable over Time
Authors: Weinberg Andrew D. , Pals Jean K. , McGlinchey‐Berroth Regina , Minaker Kenneth L.
Published: April 2015

OBJECTIVE: To determine changes in standard laboratory measures of dehydration among residents of a nursing home care unit (NHCU) over a 6‐month period.

DESIGN: A prospective cohort analytic study.

SETTING: A 130‐bed NHCU in a Department of Veterans Affairs Hospital.

PATIENTS: Fifteen infirm but stable male residents (mean age 77 years; range (R) 62–93) on one ward of the NHCU.

MAIN OUTCOME MEASURES: We studied prospectively for 6 months the serum osmolality (osm), serum sodium (Na), blood urea nitrogen/creatinine (BUN/Cr) ratios and weight (wt) for 15 patients of the NHCU. None of the patients was acutely ill during the study period or exhibited clinical signs of dehydration.

RESULTS: Mean serum osm at baseline: 291.6 mOsm/kg (R 278 to 300); 3 months: 291.5 mOsm/kg (R 276 to 301); 6 months: 291.3 mOsm/kg (R 283–300) were all similar. Forty percent (6/15) of patients had at least one high normal/elevated reading (≥ 295 mOsm/kg) during the study. Three patients (20%) had readings of ≥ 300 mOsm/kg, but none of these patients had either concurrent increased serum Na (≥ 146 mmole/L) or BUN/Cr ratios (≥ 25). Mean serum Na at baseline: 143.0 mmole/L (R 139–148); 3 months: 142.1 mmole/L (R 138–149); 6 months: 142.9 mmole/L (R 137–150) were all similar. Sixty percent (9/15) of the patients maintained normal (nl) serum Na levels throughout the study. The relationship between the change in serum Na and serum osm levels from baseline to 6 months was not significant (r = 0.242). BUN/Cr ratios ranged from 12–34 over the study period with 3 of 15 patients (20%) demonstrating elevated ratios consistently throughout the study without clinical evidence of dehydration. Only two patients had both high nl/elevated serum osm and elevated serum Na, although both had nl BUN/Cr ratios. Neither of these patients was thought by staff to be clinically dehydrated. Analysis of variance (ANOVA) indicated none of the laboratory measures changed significantly over time (serum osm: F(2,28) < 1; Na: F(2,28) < 1; BUN/Cr: F(2,228) < 1). There was no significant change in weight between the baseline and six month readings.

CONCLUSIONS: These data suggest that in the presence of clinical stability, long‐term care residents may have a serum osm in the high normal/elevated range without overt clinical evidence of dehydration, an accompanying elevated Na, or BUN/Cr ratio. This may indicate a different central osm setting for these residents as the serum osm appeared to be stable for each resident over time. These data also suggest that measures of serum osm, Na, and BUN/Cr in the long‐term care setting may accurately predict future laboratory values in an individual patient if baseline values are drawn when the patient is not acutely ill.
Physician Assessment of Patient Competence
Authors: Markson Lawrence J. , Kern Donald C. , Annas George J. , Glantz Leonard H.
Published: April 2015

OBJECTIVE: To determine if physicians know and can apply the legal standard for determining competence; to determine if physician assessment of competence varies by physician age or specialty.

DESIGN: Mail survey with specific questions about a patient scenario and general questions about the law.

PARTICIPANTS: 2100 randomly selected Massachusetts internists, surgeons, and psychiatrists.

MEASUREMENTS: In Part I, the survey presented a scenario adapted from a court case that involved an elderly woman's refusing lifesaving surgery. The scenario was divided into three sections: the medical history, the patient's rationale, and a psychiatrist's opinion that the patient was incompetent. Respondents were not told that an appellate court later decided the psychiatrist applied the wrong standard of competence and the patient was indeed competent. Respondents were asked whether the patient was competent, whom they would consult, and how they would respond. Part II posed a series of theoretical questions about competence. Group differences were tested by chi‐square.

MAIN RESULTS: Surveys were returned by 823 (41%) of the sample. In Part I, before the psychiatrist's opinion, 58% thought the patient was competent, 92% would consult a psychiatrist to help assess competence, and only 17% would to go to court. After the psychiatrist's opinion, only 30% thought she was competent and 55% would go to court. In Part II, 89% knew the correct standard for competence; however, most incorrectly responded that conditions such as dementia and psychosis establish incompetence. Psychiatrists performed significantly better on theoretical, but frequently worse on scenario, questions.

CONCLUSIONS: Physicians in general, and psychiatrists in particular, know the standard for competence but may apply it incorrectly. This suggests that the common clinical practice of relying on expert medical opinion may introduce bias and produce inaccurate results that undermine patient autonomy.
Dexterity Testing as a Predictor of Oral Care Ability
Authors: Felder Robert , James Kenneth , Brown Claudia , Lemon Sherry , Reveal Marge
Published: April 2015

OBJECTIVE: To examine a spectrum of elderly people to determine if hand function/dexterity measures can predict oral care ability.

DESIGN: A series of dental, hand function, and dexterity measures were assessed by blinded examiners. Plaque scores were used as the criterion standard to assess plaque removal ability.

PATIENTS: A convenience sample of 52, predominately male, elderly patients were recruited from the patient population of the Portland Veteran Affairs Medical Center and a community nursing home. Entry into the study required that the patient be able to give consent, be age 65 or older, have a minimum of six contiguous teeth or a minimum of 12 teeth total, be medically stable, have grossly adequate vision, and be able to hear and understand spoken instructions.

OUTCOME MEASURES: The primary outcome measure was plaque score, as defined by the Turesky modification of the Quigley‐Hein index. This was related to four dexterity tests (Jebsen‐Taylor Hand Function test, Nine‐hole Peg test, Box and Block test, Toothbrushing Ability test), a grip strength measure, and a cognitive measure (Allen Cognitive Level Test).

RESULTS: Oral hygiene was significantly impaired among institutionalized elderly compared with outpatient elderly (P < 0.001), as was dexterity (P < 0.001). All dexterity tests correlated significantly with plaque score (Spearman rho: 0.49–0.77; P < 0.000). Forward stepwise regression analysis identified the Toothbrushing Ability Test (P < 0.0001) and the time spent brushing (P = 0.007) as the most significant predictors of plaque score.

CONCLUSIONS: Results suggest oral hygiene ability is decreased among long term care residents, that dexterity tests can help identify patients unable to perform adequate oral self‐care, and that these tests could be used to estimate brushing ability among elderly compromised patients.