bluuebunny/crossref_metadata_2025 huggingface dataset:
Memory Complaints of Elderly People in a Population Survey: Variation According to Dementia Stage and Depression
Authors: Grut Michaela , Jorm Anthony F. , Fratiglioni Laura , Forsell Yvonne , Viitanen Matti , Winblad Bengt
Published: April 2015

Objective: To study the relationship between subjective memory complaints, cognitive functioning, and clinical diagnosis of dementia.

Design: Cross‐sectional, total‐population survey.

Measurements: A two‐phase study was done. All 2368 were screened by Mini‐Mental State Examination (MMSE). Then the 314 who screened positive and a sample of 354 who screened negative were examined clinically (by examining the subject and interviewing an informant) for DMS‐III‐R criteria for dementia, Clinical Dementia Rating (CDR) scale for severity of dementia and the presence of memory complaints or depressed mood.

Setting: An area in Stockholm, Sweden.

Participants: All inhabitants of the area (2368) born in 1912 or before, living at home or in institutions.

Results: A greater percentage of informants reported marked memory impairment than did the subjects themselves. Neither the informants' nor the subject' reports differed according to the type of dementia, but they differed clearly according to the stage of dementia. Informants reported memory impairment more frequently as dementia severity increased, while the subjects' complaints of marked memory impairment were most common in mild‐moderate dementia. Furthermore, non‐demented subjects with marked complaints performed more poorly on the MMSE. Subjects with depressed mood were also more likely to complain about their memory, both in the demented and non‐demented groups.

Conclusion: Our data show the validity of the informants' reports about the subjects' memory deficits. Moreover, the study confirmed the clinical impression that the patient's own complaints should not be ignored, as subjects in the mild stage of dementia often have some insight into their own memory deficit. However, depressed individuals may underestimate their own memory, and individuals with moderate‐severe dementia may overestimate theirs.
Verbal Learning and/or Memory Improves with Glycemic Control in Older Subjects with Non‐Insulin‐Dependent Diabetes Mellitus
Authors: Gradman Theodore J. , Laws Ami , Thompson Larry W. , Reaven Gerald M.
Published: April 2015

Objective: To determine whether cognitive function improves with improved glycemic control in older subjects with non‐insulin‐dependent diabetes (NIDDM). We hypothesized that with improved glycemic control: 1) learning and memory, 2) attention, and 3) complex perceptual‐motor function would improve, but that 4) simple perceptual‐motor function would not.

Design: Non‐randomized control trial.

Setting: Aging Study Unit, Department of Veterans Affairs Medical Center.

Subjects: Thirty subjects with NIDDM; 17 on oral hypoglycemic agents; 13 untreated at study entry. Thirteen normal controls.

Intervention: Subjects on oral hypoglycemic agents were taken off medications. After 1 month, they and previously untreated subjects began treatment with glipizide. Dose was titrated up weekly until fasting plasma glucose was less than 7.8 mmol/L or maximal dose (40 mg/day). Controls received no medication.

Measurements: Fasting plasma glucose (FPG), glycated hemoglobin, and measures of cognitive function in four general categories: 1) learning and memory, 2) ability to sustain attention, 3) complex perceptual‐motor function, and 4) simple perceptual‐motor function. All were evaluated in subjects with NIDDM at baseline (T1), after 1‐month washout (T2), and after 2 (T3) and 4 months (T4) of optimal glycemic control or maximal dose. Controls were evaluated at the same intervals.

Results: FPG and glycated hemoglobin rose in previously treated subjects from T1 to T2 (9.4 ± SEM 0.4 to 14.7 ± 0.7 mmol/L and 10.9 ± 0.7% to 12.2 ± 0.6%, respectively) but were unchanged in previously untreated subjects (11.3 ± 0.6 to 11.8 ± 0.9 mmol/L and 10.9 ± 0.7% to 11.7 ± 0.7%). With glipizide treatment, there was a decrease in FPG level at T3 (9.4 ± 0.5 mmol/L in previously treated, 6.9 ± 0.4 mmol/L in previously untreated), which persisted at T4. Glycated hemoglobin fell similarly. FPG and glycated hemoglobin were unchanged in controls. As hypothesized, learning and memory improved over time with treatment in both groups of subjects but was unchanged in controls (P < 0.05). Detailed analysis indicated that the improvement occurred primarily in the learning of verbal material. Contrary to hypothesis, attention and complex perceptual‐motor function did not show improvement. As expected, simple perceptual‐motor function did not show any improvement with treatment.

Conclusions: The results are consistent with previous findings that poor glycemic control in older subjects with NIDDM is associated with decreased cognitive functioning, and suggest that verbal learning and memory may improve with improved glycemic control.
Comparison of Clinical Indicators in Two Nursing Homes
Authors: Rudman Daniel , Mattson Dale E. , Alverno Luca , Richardson Timothy J. , Rudman Inge W.
Published: April 2015

Objective: Pressure ulcer prevalences in 30 VA nursing homes in 1986 ranged from 0% to 15%. The institutions with lowest (“A”) and highest (“B”) prevalence were selected for further examination.

Design: Analysis of nursing home files for five study periods, each lasting 6 months.

Setting: A and B were 60‐bed rural and 280‐bed urban facilities, respectively.

Measurements: Eleven outcome indicators were calculated for each study period: prevalences and incidences of pressure ulcer, aggressive behavior and disruptive behavior, 6‐month declines in each of the four activities of daily living (ADLs), and prevalence of underweight.

Results: Populations in A and B were similar with regard to age, sex, length of stay, degree of dependency, and level of nursing care. All indicators for the first study period were more favorable in A than in B. In addition, underweight (body mass index <22 kg/M2) was significantly less prevalent in A than in B. The differences between the two institutions in the indicators were persistent over the five study periods from 1988 to 1991.

Conclusions: The populations of A and B were similar in the available measures of severity of illness. Nevertheless, the residents in nursing home A were significantly less likely to experience adverse outcomes than were the residents in nursing home B. The virtual absence of pressure ulcers, physical aggression, and verbal disruption in nursing home A, despite the presence of many immobile and demented residents, suggested that these complications can mostly be prevented.
Effect of Aging on Body Fat
Authors: Silver Andrew Jay , Guillen Clarita P. , Kahl Mary Jo , Morley John E.
Published: April 2015

Objective: To examine the effects of aging on body fat.

Design: Cross‐sectional comparison by age and gender.

Setting: Community health fairs, medical school, and a Department of Veterans Affairs Nursing Home Care Unit.

Participants: Five hundred and fourteen individuals between the ages of 29–96 attending three different community health fairs; 62 first year medical students; and 121 male residents of a nursing home.

Intervention: None

Measurements: All underwent measurements of weight, height, and percentage body fat using the RJL Spectrum Bodycomp II Bioelectrical Impedance machine.

Results: Percentage body fat increased slightly between ages 20 to 39 years and 40 to 84 years. There were no significant differences noted in percentage body fat among the age groups 40–64, 65–74 and 75–84 in either males or females. There were also no significant differences noted in percentage body fat between any age groups when age‐matched for body mass index. Patients over the age of 85 had significantly lower percentage body fat compared with all other age groups. Finally, nursing home patients were more likely to have a lower percentage body fat compared with the ambulatory population.

Conclusions: The percentage body fat does not appear to increase significantly after the age of 40 years. In addition, the major reason for the increase in body fat in older persons appears to be weight gain rather than a true age‐related increase in percentage body fat. Previous studies suggesting a marked increase in percentage body fat with advancing age have failed to correct for the presence of an increased body mass index that commonly occurs at middle age.
How the Manner of Presentation of Data Influences Older Patients in Determining Their Treatment Preferences
Authors: Mazur Dennis J. , Merz Jon F.
Published: April 2015

Objective: To assess how the manner of presentation of graphic data to older patients influences their treatment preferences.

Design: Cross‐sectional structured interviews with patients.

Setting: A university‐based Department of Veterans Affairs Medical Center.

Patients: One hundred sixty‐six consecutive patients (mean age = 64.8 years, range of ages 29–82) seen in a Department of Veterans Affairs general medicine clinic.

Measurements: Five pairs of 5‐year survival curves were presented to patients. Each pair was composed of two survival curves for alternative unidentified treatments for an unidentified medical condition. Curve A (LT = better long‐term, worse short‐term survival) was fixed throughout all curve pairs. Curve B (ST = better short‐term, worse long‐term survival) changed in each curve pair, showing incrementally better chances of short‐term survival across the five curve pairs. Patients were randomly assigned to view the curve pairs in forward (increasing short‐term survival) or backward (decreasing short‐term survival) order.

Results: Order is a significant predictor of patients' initial preferences for the short‐term survival curve (P = 0.0004) as well as their willingness to shift preferences during presentation of the five curve pairs. Patients ≥65 were more likely to initially choose the ST curve in forward order presentation than patients <65. More educated patients generally were less likely to prefer the ST curve under both elicitation orders.

Conclusions: The data indicate that the method of eliciting patients' preferences strongly influenced their expressed preferences, and that these preferences may have predictable relationships with demographic characteristics such as age.
Hospital Outcomes Project for the Elderly (HOPE): Rationale and Design for a Prospective Pooled Analysis
Authors: Margitić Susan E. , Inouye Sharon K. , Thomas Julia L. , Cassel Christine K. , Regenstreif Donna I. , Kowal Jerome ,   HOPE Group
Published: April 2015

Objective: To describe a collaborative investigation that is based on a series of six clinical studies aimed at reducing functional decline in the acutely‐ill hospitalized elderly.

Design: A prospective, multicenter pooled analysis project involving collection of a common set of data from a group of related but distinct intervention trials with similar objectives.

Setting: Five university‐affiliated hospitals and one community hospital.

Participants: Elderly patients (age minimums from 65 to 75 years) admitted for a range of acute illnesses.

Interventions: Site‐specific interventions include exercise and physical therapy; developing and implementing methods to improve detection and evaluation of delirious patients; a multidisciplinary geriatric care unit; a multidisciplinary intervention implemented in‐hospital that includes some postdischarge care; and a nursing‐centered geriatric care program.

Main outcome measure: Functional status.

Conclusion: The prospective, multicenter design of the Hospital Outcomes Project for the Elderly (HOPE) provides an innovative approach for analysis of hospital outcomes in the elderly. Although differences in study populations and interventions exist, qualitative comparisons across sites will enhance generalizability and will provide a great opportunity to examine consistency among the sites. The HOPE pooled analysis project will impart greater statistical power to detect the primary and secondary outcomes compared with previous single‐center trials that have assessed interventions related to functional decline in the hospitalized elderly.
The Seattle FICSIT/Movelt Study: The Effect of Exercise on Gait and Balance in Older Adults
Authors: Buchner David M. , Cress M. Elaine , Wagner Edward H. , de Lateur Barbara J. , Price Robert , Abrass Itamar B.
Published: April 2015

While exercise is generally recommended for older adults, the specific role of exercise in preventing falls and frail health is unclear. The Seattle FICSIT/Movelt study is a population‐based, randomized, controlled trial comparing the effects of three 6‐month exercise interventions (endurance training, strength training, or combined endurance and strength training), and three 3‐month endurance training interventions (stationary cycle, walking, or aerobic movement). Primary study outcomes are aerobic capacity, strength, gait, balance, and physical functional status. The study enrolls adults age 68–85 who have leg weakness and impaired gait. It differs from most previous community‐based exercise studies in several respects: recruitment of subjects from a defined population; eligibility criteria based upon physiologic and functional status deficits; random assignment to exercise groups; assessment of both physiologic and functional status outcomes; follow‐up beyond the completion of supervised exercise; and a large sample size (TotalN= 180).
Effects of Physical Therapy on Functional Status of Nursing Home Residents
Authors: Mulrow Cynthia D. , Gerety Meghan B. , Kanten Deanna , DeNino Louis A. , Cornell John E.
Published: April 2015

Nursing home residents typically have decreased functional and physical status and high health care utilization and costs. This randomized trial evaluates whether physical therapy is beneficial for frail debilitated long‐stay residents of nursing homes. Subjects are recruited from a cohort of academic and community nursing home residents who have resided in the nursing home for greater than 3 months and are over age 60 and dependent in at least two activities of daily living. Subjects randomized to the intervention group receive one‐on‐one physical therapy sessions three times weekly for 4 months, while control group subjects receive structured social visits three times weekly to control for potential Hawthorne effects. Physical therapy sessions generally last 30 minutes and consist of functional activity and general conditioning exercises; these exercises are individually tailored to the subject's level of physical and functional disability. Prime outcome variables are physical function assessed by an observer‐administered, performance‐based instrument and self‐perceived health status assessed by the Sickness Impact Profile. Health care utilization and associated costs are calculated for the following areas: the nursing home, hospitalizations, outpatient visits and procedures, medications, and the intervention. A cost‐effectiveness ratio dividing incremental health care utilization and physical therapy intervention costs by the observed improvement in physical function is calculated. It is expected that results of this study can be used to help determine whether long‐stay nursing home residents should be eligible for physical therapy.
The Atlanta FICSIT Study: Two Exercise Interventions to Reduce Frailty in Elders
Authors: Wolf Steven L. , Kutner Nancy G. , Green Robert C. , McNeely Elizabeth
Published: April 2015

This study examines the effect of two different exercise approaches on balance and frailty measures among more than 200 community‐dwelling individuals greater than 70 years of age. Exercises are provided for 15 weekly sessions on an individual basis for participants randomly assigned to a Balance Training group. Training consists of center‐of‐mass feedback displayed on a motor under static conditions, or, in later sessions, as the floor surface is moved, with eyes open or closed. This high technology interface provides instantaneous information about displacement of body weight in space so that balance can be enhanced. An alternative procedure is comparatively simple and requires little expense or space. Tai Chi Quan was originally developed as a martial arts form but has been used for centuries in China as an exercise among elderly citizens. Participants randomly assigned to this intervention meet twice weekly for 15 weeks to learn a condensation of 108 Tai Chi forms into 10 that emphasize movement components often restricted or absent with aging. A third group serves as a control for exercise interventions by meeting weekly for 15 sessions to discuss topics of interest such as memory loss, drug management, and nutrition. All subjects are screened prior to assignment, and a host of physical, behavioral, and functional measures are assessed before and after the intervention as well as 4 months later. Measurements unique to the Atlanta site include: balance with eyes closed, programmed force‐distribution changes when stance is perturbed, cardiovascular assessments, WAIS, Affects Balance Scale, and a survey of home environment.
Prevalence and Significance of Electroencephalographic Abnormalities in Patients with Suspected Organic Mental Syndromes
Authors: Leuchter Andrew F. , Daly Kathleen A. , Rosenberg‐Thompson Susan , Abrams Michelle
Published: April 2015

Objective: To determine the prevalence of electroencephalogram (EEG) abnormalities at different levels of cognitive impairment and to assess the possible diagnostic usefulness of the test.

Design: Combined prospective assessment of subjects receiving EEGs and retrospective chart review of symptoms and medications.

Setting: Academic geriatric psychiatry service.

Patients: 350 adults age 50 and above; 312 were patients being evaluated for possible organic mental syndrome and 38 were normal controls.

Measurements: All subjects had EEGs and Mini‐Mental State Examinations (MMSE) performed at the time of the EEG. EEGs were rated for the presence and type of abnormality, and subjects were stratified according to the severity of impairment. Charts were reviewed by a person blinded to EEG results to determine clinical diagnosis and medications received.

Main Results: Abnormal EEGs were significantly more common among all patients (67%) in the study than among controls (11%), and the prevalence of abnormality increased with increasing impairment. Many demented patients with equivocal impairment (42%), and most with mild‐to‐moderate impairment (65%) had abnormal EEGs. An abnormal EEG was not indicative of dementia even when clear cognitive impairment was present, since patients with depression frequently also had abnormal EEG results.

Conclusions: These findings suggest that the EEG is a moderately sensitive but non‐specific indicator of brain dysfunction in the elderly. The significance of abnormalities among patients with equivocal impairment should be more fully assessed by longitudinal follow‐up to determine if greater cognitive impairment develops.
Do Family Caregivers Recognize Malnutrition in the Frail Elderly?
Authors: Albert Steven M.
Published: April 2015

Objective: To determine if family caregivers are aware of the severely underweight elder's risk of malnutrition and accordingly increase nutritional care efforts.

Design: Case‐control study.

Participants: Familial caregivers to community‐dwelling elders.

Measurements: Risk of malnutrition as defined by body mass index ≤ 5th percentile of the national average for elders aged 65–90.

Results: Compared with caregivers of elders without risk for malnutrition, caregivers to undernourished elders are significantly more likely to give elders protein supplements, to make foods accessible to elders, and to encourage and pressure the elder to eat.

Conclusions: Caregivers recognize gross signs of malnutrition in elders, increase nutritional care in response, and deserve some measure of support for their claims of health expertise.
Effects of Age, Gender and Education on Selected Neuropsychological Tests in an Elderly Community Cohort
Authors: Wiederholt W. C. , Cahn Deborah , Butters Nelson M. , Salmon David P. , Kritz‐Silverstein Donna , Barrett‐Connor Elizabeth
Published: April 2015

Objective: To establish population‐based data, with special emphasis on the effects of age, gender, and education, for eight, widely used neuropsychological tests in a community‐dwelling cohort of normal and cognitively impaired older adults.

Design: A population‐based observational study.

Setting: Examinations were performed in a research clinic by specially trained staff during a 1988–1992 evaluation for osteoporosis.

Participants: 1,692 community‐dwelling subjects, aged 55 to 94 years, who were members of the Rancho Bernardo Heart and Chronic Disease Study initiated in 1972. The mean age for men was 73.9 years (SD 9.3) and for women, 73.5 (SD 9.1).

Outcome measures: Eight neuropsychological tests were used to measure cognitive functions. Analysis of variance and post hoc contrasts were performed to determine the effects of age, gender, education, and their interactions on performance on these tests.

Results: Performance on all tests decreased progressively, without leveling off, from the youngest, age 55, to the oldest, age 94. Women performed better on verbal tasks and men on tests of visuospatial, visuoconceptual, and mental control functions. Performances of men on several tests declined more rapidly with advancing age than those of women. Both men and women with some college education performed better on most tests than men and women with high school educations, and the rate of decline with age was sometimes slower in the college‐educated group. Only the savings score from the Visual Reproduction Test, which is a measure of rate of forgetting, and the scores of short‐term recall derived from the Selective Reminding Test (Buschke‐Fuld) were unaffected by educational attainment.

Conclusions: In a community‐dwelling cohort, including normal and cognitively impaired elderly men and women, advancing age is accompanied by decline in cognitive functions as measured by neuropsychological tests. This decline is slower in women and in college‐educated subjects. Two cognitive indices were unaffected by education, and these may be especially useful in cross‐cultural studies.
Functional Decline in Alzheimer's Disease: A Longitudinal Study
Authors: Green Cynthia R. , Mohs Richard C. , Schmeidler James , Aryan Moshen , Davis Kenneth L.
Published: April 2015

Objective: To assess the reliability of activities of daily living (ADL) measures and determine the rate and pattern of longitudinal ADL change in patients with Alzheimer's disease (AD).

Design: Longitudinal study with evaluations every 6 months.

Setting: Alzheimer's Disease Research Center Clinics at Mount Sinai Medical Center, New York, and the Veterans Affairs Medical Center, Bronx, New York.

Patients: 104 patients meeting NINCDS‐ADRDA criteria for probable AD were followed an average of 31 months.

Measurements: Physical Self‐Maintenance Scale (PSMS) and Instrumental Activities of Daily Living Scale (IADLS) of Lawton and Brody and the Blessed Test of Information, Memory, and Concentration.

Results: For men there was inconsistency over time in the decision about whether or not some IADLS items such as “Laundry” were appropriate for a given patient. Test‐retest and inter‐rater reliabilities were high for all PSMS items and for IADLS items that were judged to be appropriate. IADLS scores changed an average of 2.06 (±3.27) points annually, and change scores were smaller for patients with severe dementia. PSMS scores changed an average of 2.44 (±3.87) points annually with virtually all change occurring in severely demented patients. There was a marked ceiling effect for the IADLS and a curvilinear relationship of PSMS annual change with PSMS baseline.

Conclusions: Both PSMS and IADLS measures can be reliable in AD patients, but better IADLS items for males need to be developed. IADLS scores are sensitive to change in mild and moderately demented AD patients, while PSMS scores are sensitive to change in more severely demented patients.
The Importance of Dietary Protein in Healing Pressure Ulcers
Authors: Breslow Rosalind A. , Hallfrisch Judith , Guy David G. , Crawley Barbara , Goldberg Andrew P.
Published: April 2015

Objective: To determine the effect of dietary protein on healing of pressure ulcers in malnourished patients.

Design: Nutritional intervention trial with the non‐randomized assignment of patients by pressure ulcer stage and bed type.

Setting: Long‐term care facility.

Patients: Twenty‐eight malnourished patients (age = 72 ± 18 years, mean ± SD) with a total of 33 truncal pressure ulcers. Nine patients had stage II ulcers, eight had stage III ulcers, and 16 had stage IV ulcers.

Methods: Patients received liquid nutritional formulas as tubefeedings or meal supplements containing either 24% protein (61 g protein/L; n = 15) or 14% protein (37 g protein/L; n = 13) for 8 weeks.

Results: There was a significant decrease in total truncal pressure ulcer surface area of the 15 patients in the 24% protein group (‐4.2 ±7.1 cm2, P < 0.02), but not in the 13 patients in the 14% protein group (‐2.1 ±11.5 cm2, P = NS). The change in total ulcer area correlated with both dietary protein intake per kg body weight (rs = −0.50, P < 0.01) and caloric intake per kg body weight (rs = −0.41, P < 0.03). The decrease in stage IV ulcer area in eight patients in the 24% protein group (‐7.6 ± 5.8 cm2, P < 0.02) was significantly greater (P < 0.05) than in eight patients in the 14% protein group (‐3.2 ± 16.4, P = NS). In these 16 patients, the decrease in ulcer size also correlated with dietary protein intake per kg body weight (rs = −0.63, P < 0.01).

Conclusion: High protein diets may improve the healing of pressure ulcers in malnourished nursing home patients.
L‐Deprenyl in the Treatment of Mild Dementia of the Alzheimer Type: Preliminary Results
Authors: Burke William J. , Ranno Anthony E. , Roccaforte William H. , Wengel Steven P. , Bayer Barbara L. , Willcockson Nancy K.
Published: April 2015

Objective: To examine the short‐term cognitive and behavioral effects of L‐deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 2‐month period.

Design: A 15‐month randomized, double‐blind, placebo‐controlled trial using a parallel‐group design. This report deals with the first 2 months of the trial.

Participants: 39 subjects with mild DAT (CDR 1) selected using NINCDS‐ADRDA criteria.

Measures: A battery of neuropsychological tests and clinical rating scales.

Results: The placebo and L‐deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. There was no evidence of a L‐deprenyl effect on any clinical or neuropsychological measures after 2 months.

Conclusion: L‐deprenyl did not have a measurable impact on behavior or cognitive function over a 2‐month period in this group of subjects with mild DAT.
The Role of Prognostic Scores in Targeting Stroke Rehabilitation in Elderly Patients
Authors: Kalra L. , Crome P.
Published: April 2015

Objective: To determine the validity of clinically derived prognostic scores in targeting stroke rehabilitation in elderly patients.

Design, Setting and Participants: One‐year prospective cohort study in 96 hospitalized stroke patients over 75 years of age from a well defined geographical area.

Measurements: Edinburgh prognostic score (incorporating measures of motor deficit, proprioception, and power), Orpington prognostic score (Edinburgh score modified to include a measure of cognition), and Barthel ADL scores were measured at 1, 2, and 4 weeks after stroke. These scores were correlated with outcome and patients' Barthel ADL score at discharge or at 16 weeks if still in hospital.

Results: Edinburgh prognostic score measured at 2 weeks correlated significantly with Barthel ADL score at discharge or at 16 weeks (r2 = 0.57, P < 0.001), and Orpington prognostic scores showed greater correlation (r2 = 0.89 vs 0.57), especially in patients with dementia (r2 = 0.81 vs 0.39). Barthel ADL scores at 2 weeks showed a weak correlation with Barthel ADL scores at discharge or 16 weeks (r2 = 0.58). Patients with Orpington Score <3.2 were discharged within 3 weeks of stroke, whereas those scoring <5.2 required long‐term care. Most patients (90%) with Orpington Score of 3–5 were eventually discharged home although this was not always apparent on initial clinical assessment at the time of admission.

Conclusions: The Orpington score when assessed at 2‐weeks post‐stroke is a useful prognostic indicator with special suitability for the elderly and may help to select patients most likely to benefit from stroke unit rehabilitation.
The Menopause: Health Implications and Clinical Management
Authors: Greendale Gail A. , Judd Howard L.
Published: April 2015

Objective: To review the anatomy, physiology, clinical symptoms, long‐term health effects, and treatment of the menopause and climacteric syndrome, with a special emphasis on features, such as incontinence, particularly relevant to geriatric medicine.

Data sources: English‐language publications on menopause and the climacteric.

Study selection: Articles and books containing recent information pertinent to the topics covered. Studies in human subjects were given priority, but primate studies that amplify physiologic concepts are included.

Data synthesis: Due to increased longevity, the average US woman will spend one‐third of her life as a postmenopausal individual. Anatomic and physiologic changes associated with the peri‐ and postmenopausal state include hot flushes, genitourinary atrophy, and bone loss. Possible correlates of the menopausal transition and postmenopause include affective changes and unfavorable alterations in lipoproteins and other cardiac risk factors. Clinical correlates of these changes can include incontinence, sexual dysfunction, increased risk of fracture, dysphoric mood, and increased risk of cardiovascular disease. Formal indications for estrogen therapy are hot flushes, genital atrophy, and osteoporosis prevention; other common clinical uses are reviewed. Non‐contraceptive estrogens can be administered orally, transdermally, vaginally, or by injection. Each route and preparation has some unique features with respect to actions and side effects. Progestins, in adequate doses, protect against the unwanted side effect of endometrial hyperplasia; alternatives to progestin use are presented. Non‐hormonal alternatives for some peri‐ and postmenopausal symptoms are described.

Conclusions: A discussion of the menopause and the benefits and risks of hormone therapy should be part of the routine health care of older women. Since the use of hormone therapy is elective, health care providers must elicit the goals, needs, and preferences of each patient, supply her with relevant information, and serve as a facilitator of her individual decision.
Functional Status Care Categories and National Health Policy
Authors: Thomasma David C.
Published: April 2015

Our society clearly needs to set limits on health care. The United States health care delivery system is the fourth largest economy in the world, yet its inflation continues to grow at twice the normal rate of other products and services. The inefficiencies are built in in such a way that while intensive care beds are plentiful, and very expensive, 37 million Americans cannot gain access to health care because they are either uninsured or underinsured. It is estimated that this figure will approach 39 million by the end of the decade.1 Since many of these individuals are young, the problem, it is said, has no real practical consequences because the young are relatively healthy. Yet evidence exists that the uninsured and underinsured receive poorer care than covered individuals.2 This and other inequities in the system have led many thinkers like Leonard Heck to ask how just we must be in society.3 The answer to this question would presumably help us determine the lengths we must go in correcting the inequities.

Even if the peace‐dividend emerges from the new political events around the world, and we are able to spend more of our money on health care, our resources are not a bottomless pit. If need alone drives the system, just performing open‐heart surgery on everyone who needs it would cost more than the annual budget itself. Virtually everyone agrees, then, that escalating health care costs are a moral problem because justice is involved, a political problem because public interest is involved, and that limits must be set that are moral and public.4
Who Cares for Missouri's Medicaid Nursing Home Residents? Characteristics of Attending Physicians
Authors: Lawhorne Larry W. , Walker Georgia , Zweig Steven C. , Snyder Judy
Published: April 2015

Objective: To describe the characteristics of physicians attending Medicaid recipients in Missouri's certified nursing homes (NH).

Design: Retrospective survey of multiple data sources.

Setting: Missouri's certified nursing homes.

Participants: 1,339 physicians attending 22,452 Medicaid recipients.

Measurements: Physician characteristics were determined by reviewing a roster of medical directors of NHs compiled by the Missouri Department of Social Services' Division of Aging and physician directories compiled by the Missouri State Board of Registration for the Healing Arts, the AMA, the AOA, the ABFP, and the ABIM. Physician clinical activity was determined by examining NH inspection of care reports compiled by the Missouri Department of Social Services' Division of Aging.

Results: Each physician attended a mean of 16.8 and a median of six Medicaid recipients in the nursing home. The skewed distribution is reflected by 426 (31.8%) of the physicians attending only one or two residents, and 28 (2.1%) of the physicians attending 100 or more residents. Twenty‐seven percent of the state's licensed osteopaths (DOs, 362) attended nursing home patients, compared with 11% of allopathic physicians (MDs, 977). Significantly more DOs than MDs attended more than the median number of patients (57% vs 45%, P < 0.001). Half were attended by the 605 (45%) physicians without board certification. Of those who were board certified, family physicians were more likely to include Medicaid nursing home patients in their practices than internists (43% vs 18%, P < 0.001). Physicians licensed for 11 to 20 years and rural physicians had the heaviest patient loads.

Conclusions: Many doctors are caring for very few nursing home residents while a few doctors may be caring for too many patients. In addition, half the Medicaid recipients residing in Missouri's nursing homes in 1988 were attended by physicians without board certification, and almost one‐third were attended by physicians who may be retiring between 2000 and 2010.
Epidemic Keratoconjunctivitis in a Chronic Care Facility: Risk Factors and Measures for Control
Authors: Buffington Joanna , Chapman Louisa E. , Stobierski Mary Grace , Hierholzer John C. , Gary Howard E. , Guskey Louis E. , Breitenbach Ray A. , Hall William N. , Schonberger Lawrence B.
Published: April 2015

Objective: To study patterns of transmission of epidemic keratoconjunctivitis (EKC) in a chronic care facility and to assess control measures and prevent future outbreaks in this setting.

Design: A retrospective cohort study.

Setting: A 120–bed, four‐unit, skilled nursing facility.

Patients: Residents and employees of the above facility.

Interventions: Increased frequency of cleaning; use of bleach disinfectant; universal precautions in handling eye secretions from residents with conjunctivitis; cohorting residents by unit; suspension of new admissions; closure of common gathering areas.

Measurements: Resident demographics; possible risk factors for infection among residents (including mobility, underlying illness, medications, involvement in social activity, level of confusion) and among employees (including co‐morbid illnesses and eye conditions, exposures to persons with conjunctivitis, visits to eye care specialists, use of contact lenses or glasses); testing of conjunctival specimens from symptomatic persons for viral and bacterial agents.

Results: Of 95 residents on three chronic care units, 47 (attack rate 49%) had onset of eye symptoms consistent with EKC between September 14 and December 7, 1990. Thirty‐eight (81%) of these had onset following the onset of symptoms in a resident with dementia who, despite habitual eye‐rubbing and wandering into other residents' rooms, was not isolated or restricted in any way. Attack rates were higher (though not statistically significant) among more mobile residents (60% for ambulatory residents) and among those considered by staff to be confused (56%). Rapid antigen detection and culture confirmed adenovirus type 37 as the etiologic agent.

Conclusions: Transmission of infection with adenovirus type 37 was successfully interrupted following strict infection control, suspension of new admissions, cohorting of residents by unit, and change to a disinfectant that inactivates adenovirus. Recognition of conjunctivitis as an appropriate reason for restricting movement of an infected resident may have prevented extensive viral transmission in this outbreak.
Fever of Unknown Origin in Elderly Patients
Authors: Knockaert Daniel C. , Vanneste Laurent J. , Bobbaers Herman J.
Published: April 2015

Objective: To describe the spectrum of diseases that may give rise to fever of unknown origin in elderly patients and to delineate the diagnostic approach in these patients.

Design: Subgroup analysis of a prospectively collected case series followed more than 2 years.

Setting: General Internal Medicine Service based at University hospital, Leuven, Belgium.

Patients: Forty‐seven consecutive patients, older than 65 years, meeting the classic criteria of fever of unknown origin.

Measurements: The final diagnosis established and the clinical value of diagnostic procedures.

Results: Infections, tumors and multisystem diseases (encompassing rheumatic diseases, connective tissue disorders, vasculitis including temporal arteritis, polymyalgia rheumatica, and sarcoidosis) were found in 12 (25%), six (12%) and 15 patients (31%), respectively. Drug‐related fever was the cause in three patients (6%), miscellaneous conditions were found in five patients (10%), and six patients (12%) remained undiagnosed. Microbiologic investigations were diagnostic in eight cases (16%), serologic tests yielded one diagnosis, immunologic investigations had a diagnostic value in four cases, standard X‐rays yielded a diagnostic contribution in 10 cases, ultrasonography and computed tomography were diagnostic in 11 cases, Gallium scintigraphy had a diagnostic contribution in 17 cases, and biopsies yielded the final diagnosis in 18 cases.

Conclusions: Multisystem diseases emerged as the most frequent cause of fever of unknown origin in the elderly, and temporal arteritis was the most frequent specific diagnosis. Infections, particularly tuberculosis, remain an important group. The percentage of tumors was higher in our elderly patients than in the younger ones but still clearly lower than in other recent series of FUO in adults. The number of undiagnosed cases was significantly lower in elderly patients than in younger individuals (P ≤ 0.01). The investigation of elderly patients with FUO should encompass routine temporal artery biopsy and extensive search for tuberculosis if the classic tests such as blood count, chemistry, urinalysis, cultures, chest X‐rays, and abdominal ultrasonography do not yield any clue. Gallium scintigraphy should be considered as the next step and not as a last‐resort procedure.
Joint Impairment and Ambulation in the Elderly
Authors: Gibbs James , Hughes Susan , Dunlop Dorothy , Edelman Perry , Singer Ruth , Chang Rowland
Published: April 2015

Objective: To test the impact of joint impairment on ambulation in the elderly, using a multivariate model.

Design: Cross‐sectional observational study (baseline data from an ongoing longitudinal study).

Subjects: Five hundred thirty‐two persons over age 60, including continuing care retirement community (CCRC) (n = 222), homebound (n = 63), and ambulatory (n = 247) respondents. Mean age at assessment = 76.6 (SD = 6.6).

Measurement: Independent variables included sociodemo‐graphics, physician measures of lower joint impairment, an index of cormorbidities derived from physical examination or chart abstract, self‐assessed arthritis pain, depression, and anxiety. The dependent variable, ambulation, was measured as walk‐rate, based on the time required to walk 50 feet.

Main Results: For the total sample, 61% of the subjects were impaired in more than one lower joint group, with almost 50% of the homebound impaired in more than three joint groups. Demographics (particularly age and education) explained much of the variance in walk‐rate. After controlling for demographics and membership in the groups purposely sampled (CCRC, homebound, ambulatory), lower joint impairment accounted for an additional 7% of the variance in walk‐rate. Total amount of variance explained by the model was 56% (Adjusted R2 = .56). A 3‐point change in lower joint impairment score, equivalent to the maximum impairment score for a single joint group, is associated with a 4‐second change in the mean time required to walk 50 feet. The knee and lower spine joints contributed most to the impact of the lower joint impairment measure.

Conclusions: Among the elderly, age and education are strong predictors of performance on a walk‐rate test. Independent of demographics and non‐musculoskeletal conditions, joint impairment is associated with diminished walking ability in this population.
Malnutrition in Institutionalized Elderly: How and Why?
Authors: Keller Heather H.
Published: April 2015

Objective: To determine the prevalence of undernutrition and overnutrition in long‐term care elderly patients and the functional, behavioral, environmental, nutritional, and medical variables associated with this prevalence.

Design: Cross‐sectional, observational.

Setting: Long‐term care hospital in Canada.

Subjects: Two hundred elderly patients (n = 166 male), average age 78.5 years.

Measurements: Assessment of nutritional status and presence of specific behavioral, medical, environmental, and functional characteristics known to impact on nutritional status. Nutritional status was determined by weight, % weight loss, BMI, skinfolds, arm circumference, area measurements, and % body fat. Multiple regression analyses were performed to identify the factors associated specifically with undernutrition and overnutrition in this population.

Results: Severe undernutrition was present in 18% (n = 36) and severe overnutrition in 10% (n = 20). Mild/moderate undernutrition was present in 27.5% (n = 55) and mild/moderate overnutrition in 18% (n = 36). Overnutrition was positively associated with primary diagnosis and number of medications and negatively associated with poor appetite, number of feeding impairments, protein intake, and mental state. Undernutrition was positively associated with dysphagia, slow eating, low protein intake, poor appetite, presence of a feeding tube, and age and negatively associated with primary diagnosis.

Conclusions: Undernutrition exists at a level that is high (45.5%) but not unusual for this type of institutional setting. Behavioral, environmental, and disease‐related factors greatly influence nutritional status. Undernutrition appears to be affected by nutritional factors more than overnutrition. Efforts should be directed toward influencing some of these factors to decrease undernutrition in the institutionalized elderly.
L‐Deprenyl in the Treatment of Mild Dementia of the Alzheimer Type: Results of a 15–Month Trial
Authors: Burke William J. , Roccaforte William H. , Wengel Steven P. , Bayer Barbara L. , Ranno Anthony E. , Willcockson Nancy K.
Published: April 2015

Objective: To examine the cognitive and behavioral effects of L‐deprenyl in persons with mild dementia of the Alzheimer type (DAT) over a 15‐month period.

Design: A 15‐month randomized, double‐blind, placebo‐controlled trial using a parallel‐group design.

Participants: 39 subjects with mild DAT (CDR 1) selected using NINCDS‐ADRDA criteria.

Outcome Measures: A battery of neuropsychological tests and clinical rating scales.

Results: The placebo and L‐deprenyl subjects were similar at baseline on the clinical and neuropsychological tests. The total score on the Brief Psychiatric Rating Scale (BPRS) was significantly less after 15 months in subjects taking L‐deprenyl. The only individual item of the BPRS which differed between groups was disorientation. There was no evidence of a L‐deprenyl effect on any other clinical or neuropsychological measure after 2, 8, or 15 months.

Conclusion: L‐deprenyl did appear to have a slight effect on a single measure of psychopathology, the BPRS. It did not have a measurable impact on any other measure of behavior or cognitive function over a 15‐month period in this group of subjects with mild DAT and did not appear to slow the progression of the disease.
Non‐Hodgkin's Lymphoma in the Older Person: A Review
Authors: Ballester Oscar F. , Moscinski Lynn , Spiers Alexander , Balducci Lodovico
Published: April 2015

Objective: To study the epidemiology of non‐Hodgkin's Lymphoma (NHL) in the older person and to explore treatment strategies for older persons with NHL.

Design: Review of the English literature.

Measurements: Incidence of NHL in patients of different ages; prevalence of NHL of different grades and stages in persons of different ages; and response to treatment, disease free survival, and survival, for patients of different ages.

Results: The incidence of NHL in the aged has increased approximately 80% since 1970, and approximately one‐half of the 40,000 annual new cases occur in persons aged 60 and older in the USA. The 2–4 phenoxy pesticides may be partly responsible for this increment. The treatment of low grade lymphoma is mostly palliative and well tolerated by the aged. Age may have an adverse effect on the prognosis of intermediate grade lymphomas, and the prevalence of poor prognostic factors and comorbidity increases with age. Among persons aged 65–75, the complete response rate (CRR) of intermediate grade NHL to chemotherapy is approximately 50%, and approximately one‐third of complete responders remain alive and free of disease 5 years from diagnosis. Among those aged 75 and older, the CRR to chemotherapy is approximately 40%, and the median duration of response is 16 months. Strategies aimed to ameliorate treatment‐related toxicity include lower doses of chemotherapy, choice of drugs better tolerated by older individuals, and prevention of chemotherapy‐induced toxicity.

Conclusions: NHL are an increasingly common problem for older persons. Approximately 80% of older patients with low grade lymphomas and 40%–50% of those with intermediate grade lymphomas may benefit from chemotherapy. Individualized treatment, based on life expectancy and comorbidity, is the key to effective management.