bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence of and Predictors for Chronic Disability in Activities of Daily Living Among Older People in Taiwan
Authors: Wu Shwu Chong , Leu Szu‐Yun , Li Chung‐Yi
Published: April 2015

OBJECTIVES: To estimate the incidence of chronic activities of daily living (ADL) disability and to analyze the sociodemographic, health status, adverse lifestyle, and leisure‐time physical activity predictors for chronic ADL disability.

DESIGN: We recruited a cohort of community‐dwelling older people in Taipei, Taiwan, who were not ADL disabled in August 1993, and we followed them until August 1996.

SETTINGS AND PARTICIPANTS: The study subjects were 1321 community‐dwelling people aged 65 years or older who were ADL intact at the initial interview in August 1993. The study sample was a subset of a probability sample (n = 1583) randomly selected from household registrations in the four districts of the Taipei metropolitan area.

MEASUREMENTS: Baseline information regarding various factors potentially associated with the development of chronic ADL disability was assessed and collected at the beginning of the study. Study participants were assessed annually for ADL function by a structured home interview using a six‐item scale. Participants who were unable to perform independently at least one of the six items—eating, bathing, dressing, toileting, transfers, and walking inside the house—for more than 3 months were considered chronically ADL disabled. Cox proportional hazard regression models were utilized to examine the independent effect of the potential predictors on risk of chronic ADL disability.

RESULTS: During the 3‐year study period, 145 (11.0%) participants developed chronic ADL disability, 58 (4.4%) participants were lost to follow‐up, and 83 (6.3%) participants died. Multiple hazard regression analysis showed that individuals aged 70 to 79 years or older than age 80 had increased risk of ADL disability (relative risk: 2.05 (95% confidence interval (CI), 1.35‐3.11) and 3.89 (95%CI, 2.33‐6.50), respectively) compared with those participants younger than age 70. Risk of chronic ADL disability was inversely associated with routine exercise (RR = 0.52; 95% CI, 0.39‐0.68).

CONCLUSIONS: Age is the most significant predictor of chronic ADL disability. Lack of routine exercise is also a significant predictor of ADL disability in older adults. J Am Geriatr Soc 47:1082–1086,1999.
Circadian Heart Rate Rhythms in Japanese Centenarians
Authors: Shimizu Kenichiro , Hirose Nobuyoshi , Yonemoto Takayuki , Wakida Yasushi
Published: April 2015

OBJECTIVE: To investigate age‐associated changes in the circadian rhythm of the heart rate.

DESIGN: The circadian rhythm was extracted from diurnal heart rate (HR) variations, and patterns of HR rhythm were compared in centenarians and controls.

SETTING: Centenarians living in the metropolitan area of Tokyo and in Aichi prefecture in 1992.

PARTICIPANTS: Fifty centenarians underwent 24‐hour ambulatory electrocardiogram (Holter) monitoring. The control group, comprised of 100 clinically healthy subjects who underwent similar Holter monitoring, was subdivided, by age, into two groups: the younger controls (age range 23 to 54 years, mean age 41) and the older controls (age range 55 to 82 years, mean age 69).

MEASUREMENTS: Harmonic analysis was used to approximate the 24‐hour RR interval (the interval between two neighboring R waves on the electrocardiogram) data obtained by Holter monitoring to a summation of three cosine waves with 24‐hour, 12‐hour, and 8‐hour periods. The power of the period was adjusted for the goodness of curve‐fit. The power of each period and the circadian acrophase (the timing of the peak in a 24‐hour rhythm) were compared among the centenarians, older controls, and younger controls. HR rhythms were classified by k‐means cluster analysis based on the power of the period. The prevalence of each pattern was compared among the three age groups. In the centenarians, the relationship between clinical parameters (activities of daily living, cognitive function, nutritional status, and present illness) and patterns of HR rhythm was investigated.

RESULTS: The power of the 24‐hour period in the centenarians was significantly smaller than that in the older (P < .05) and younger (P < .001) controls. The power of the 8‐hour period in the centenarians was significantly larger than that in the younger controls (P < .05). Advances or delays in the circadian acrophase were frequently observed in the centenarians compared with the younger controls. The power of each period did not differ between centenarians with (n = 11) and without (n = 39) overt diseases capable of altering HR rhythms. Five patterns of HR rhythm were identified: 24‐hour period dominant (n = 84), 24‐hour+12‐hour period (n = 18), 12‐hour period dominant (n = 11), 8‐hour period dominant (n = 7), and low goodness of curve‐fit (n = 30). The 8‐hour period dominant pattern and the low goodness of curve‐fit pattern were observed commonly in the centenarians, whereas the 24‐hour period dominant pattern and the 24‐hour + 12‐hour period pattern were observed frequently in the younger controls. Patterns of HR rhythm were not related to clinical parameters in the centenarians.

CONCLUSIONS: The circadian rhythm of HR changed with aging: there was reduction in the power of the 24‐hour period, augmentation in the power of the 8‐hour period, and a shift in the circadian acrophase. J Am Geriatr Soc 47:1094–1099,1999.
Seroprevalence of Viral Hepatitis in an Older Nursing Home Population
Authors: Chien Norman T. , Dundoo Gayatbri , Horani Mohamad H. , Osmack Patricia , Morley John H. , Di Bisceglie Adrian M.
Published: April 2015

OBJECTIVES: To assess the prevalence of current or previous infection with viral hepatitis agents in an older nursing home population.

DESIGN: A prospective cohort study.

SETTING: Three nursing homes in the greater St. Louis area affiliated with Saint Louis University.

SUBJECTS: Older residents admitted to these facilities.

MEASUREMENTS: Residents were interviewed and examined for evidence of hepatitis or liver disease. Serum samples were tested for hepatitis B surface antigen (HBsAg), antibody to hepatitis B core and surface antigens (anti‐HBc and anti‐HBs), antibody to hepatitis A virus (anti‐HAV), antibody to hepatitis C virus (anti‐HCV), and hepatitis G virus RNA (HGV RNA).

RESULTS: Of 329 residents queried, 199 gave consent and were able to participate. The seroprevalence of hepatitis was: HBsAg 0%, anti‐HBc 24.1%, anti‐HBs 19.5%, anti‐HAV 79.9%, anti‐HCV 4.5%, and HGV‐RNA 10.6%. Frequency of HAV infection increased significantly with age whereas HBV infection correlated with ethnic status and former occupation as a manual worker. A history of blood transfusion was associated with a higher rate of anti‐HCV. End stage renal disease, present in 17 patients, was associated with anti‐HBc, anti‐HCV, and HGV RNA positivity but not with anti‐HBs or anti‐HAV positivity

CONCLUSIONS: The seroprevalence of anti‐HCV was surprisingly high in this population residing in skilled nursing facilities, and we recommend that all new patients admitted to this type of institution be screened for anti‐HCV. The prevalence of HGV RNA was higher than in the general US blood donor population, but the significance of this finding remains uncertain. J Am Geriatr Soc 47:1110–1113,1999.
“Warm‐Up” Phenomenon Detected by Electrocardiographic Ambulatory Monitoring in Adult and Older Patients
Authors: Napoli Claudio , Liguori Antonio , Cacciatore Francesco , Rengo Franco , Ambrosio Giuseppe , Abete Pasquale
Published: April 2015

OBJECTIVE: Inducing tolerance to myocardial ischemia by repeated brief episodes of ischemia has been called “ischemic preconditioning.” “Warm‐up” phenomenon refers to patients with coronary heart disease improving performance after a first exertion and may represent a clinical counterpart to ischemic preconditioning. The goal of this study was to assess whether the severity of myocardial ischemia would be attenuated by two repeated walking‐induced ischemic episodes in adult and older patients.

SUBJECTS: Thirty‐eight adults (51 ± 5 years) and 39 older patients (76 ± 4 years) with stable angina and angiographic evidence of coronary stenosis.

MEASUREMENTS: Holter monitoring was performed in adult and older patients walking on two consecutive occasions, with a 5‐minute rest between walks, a distance known to have previously caused myocardial ischemia.

RESULTS:Computer‐assisted analysis recorded by ambulatory Holter monitoring revealed that the mean maximal ST‐segment depression (P < .001) and ischemia duration decreased (P < .001), whereas the ischemic threshold increased (P < .001), from the first to the second walk in the adult but not in the older group.

CONCLUSIONS: Myocardial ischemia is attenuated and ischemic threshold is increased between two brief ischemic episodes in adult but not in older patients. These results indicate that the “warm‐up” phenomenon, involved in increasing myocardial ischemic tolerance, is absent in the aging heart. J Am Geriatr Soc 47:1114–1117,1999.
The Predictive Value of Combined Hypoalbuminemia and Hypocholesterolemia in High Functioning Community‐Dwelling Older Persons: MacArthur Studies of Successful Aging
Authors: Reuben David B. , Ix Joachim H. , Greendale Gail A. , Seeman Teresa E.
Published: April 2015

OBJECTIVES: To examine the effect of simultaneous hypoalbuminemia and hypocholesterolemia levels on 3‐ and 7‐year rates of mortality and decline in functional status.

METHODS: In this cohort study, 937 community‐based persons aged 70 to 79 years in 1988, who had high baseline physical and cognitive functioning, were classified into four groups: Group 1 (low albumin, low cholesterol), Group 2 (low albumin, normal cholesterol), Group 3 (normal albumin, low cholesterol) and Group 4 (normal albumin, normal cholesterol) using baseline blood values. Crude and multiply adjusted rates of (1) mortality (2) decline in Rosow‐Breslau (RB) functional status, and (3) mortality or decline in RB functional status in 1991 and 1995 were calculated.

RESULTS: Group 1 subjects had multiply adjusted relative risks (ARR) of 3.62 and 3.53 for 3‐and 7‐year mortality compared with Group 4. Group 1 subjects had ARRs of 3.82, 3.02, and 2.67 of 3‐year mortality or decline in RB activity scale when compared with Groups 4, 2, and 3, respectively.

CONCLUSIONS: Concomitant low serum cholesterol and albumin levels may identify high functioning older persons who are at increased risk of subsequent mortality and functional decline.
Atrial Natriuretic Peptide and the Development of Congestive Heart Failure in the Oldest Old: A Seven‐Year Prospective Study
Authors: Knight Eric L. , Fish Loretta C. , Kiely Dan K. , Marcantonio Edward R. , Davis Kenneth M. , Minaker Kenneth L
Published: April 2015

BACKGROUND: Atrial natriuretic peptide (ANP) levels are elevated in symptomatic heart failure and correlate with invasively measured left heart pressures.

OBJECTIVE: To examine the association between plasma ANP level and the subsequent development of congestive heart failure (CHF) in older subjects with no history of CHF.

DESIGN: A 7‐year, prospective, blinded, cohort study.

SETTING: A life care facility in Boston, Massachusetts.

PARTICIPANTS: Two hundred fifty‐six frail older subjects (mean age 88 ± 7) with no history of CHF at study entry.

MAIN OUTCOME MEASURE: Clinical episodes of CHF with confirmatory chest roentgenogram findings. Cox proportional hazard analyses were performed to examine the relationship between ANP levels and the development of CHF while controlling for 19 clinical, physical, and laboratory parameters. A Kaplan‐Meier estimator (log‐rank test) was used to determine if the development of CHF differed by tertile of ANP.

RESULTS: During the follow‐up period, 32% of the cohort developed CHF. The mean ANP level in the CHF group was 95 pmol/L ±11 pmol/L versus 60 pmol/L ± 5 pmol/L in the no CHF group (two tailed t test P = .005). On multivariate analysis, a high ANP level was found to be associated significantly (P =. 01) with the development of CHF.

CONCLUSIONS: There is a statistically significant association between ANP level and the subsequent development of CHF in frail older individuals with no history of CHF.;
Diabetes and Dementia in Long‐Term Care
Authors: Tariot Pierre N. , Ogden M. Allison , Cox Christopher , Williams T. Franklin
Published: April 2015

OBJECTIVES: To examine the presence or absence of dementia, and the prevalence rates for different dementias, in patients with and without adult onset diabetes (AODM).

DESIGN: Chart survey.

SETTING: A public long‐term care facility in Rochester, New York, chosen to provide an enriched sample with respect to the diseases and demographic variables of interest.

PARTICIPANTS: All long‐term care residents in the facility aged 50 years or older (n = 476), mean age 74.8 years. Thirty‐six (7.6%) had probable Alzheimer's disease (AD), 49 (10.3%) had possible AD, 38 (8.0%) had clinically diagnosed vascular dementia, 84 (17.6%) had unspecified dementias, and 269 (56.5%) were not demented.

MEASUREMENTS: Demographic data, dementia and diabetes determined on the basis of extraction of chart data, and hypertension, myocardial infarction, congestive heart failure, and hypercholesterolemia determined on the basis of chart diagnoses.

RESULTS: There were 99 residents with AODM in the sample, a prevalence rate of about 21%. The rates of both dementia and AODM were as expected for this age group and setting. Patients with probable or possible AD had the lowest rates of AODM (0 and 6.1%, respectively), and patients with vascular dementia had the highest rates of AODM (47.4%). Age, sex, and race influenced both the risk of having a dementia and the type of dementia. When these variables were adjusted for in multiple logistic regression, however, AODM remained a robust predictive factor because of its significant negative association with AD. Patients with unspecified dementias and no dementia showed rates of AODM (about 20%) that were roughly comparable and intermediate between vascular dementia and AD.

CONCLUSIONS: In our study, AD diagnosed clinically and AODM did not co‐occur, whereas AODM was associated with vascular dementia diagnosed clinically. Conversely, in non‐Alzheimer, nonvascular dementias diagnosed clinically, the rates of AODM were equivalent to those in nondemented patients. These findings are in agreement with some, but not all, previous studies.
The General Medical Health Rating: A Bedside Global Rating of Medical Comorbidity in Patients with Dementia
Authors: Lyketsos Constantine G. , Galik Elizabeth , Steele Cynthia , Steinberg Martin , Rosenblatt Adam , Warren Andrew , Sheppard Jeannie‐Marie , Baker Alva , Brandt Jason
Published: April 2015

OBJECTIVE: Dementia is a serious public health problem. General medical comorbidity is common in dementia patients and critical to their care. However, little is known about medical comorbidity in these patients, and there are no straightforward bedside global rating scales for the seriousness of comorbid medical illness. This paper describes the development and measurement properties of the General Medical Health Rating (GHMR), a rapid global rating scale of medical comorbidity in dementia patients.

DESIGN: Interrater reliability, concurrent validity, and predictive validity of the GMHR are reported.

SETTING: An outpatient dementia clinic, assisted living, and nursing home.

PARTICIPANTS: A total of 819 consecutive dementia clinic outpatients and 180 consecutive admissions to Copper Ridge, a long‐term care residence for people with dementia, were included in the study.

RESULTS: GMHR was found to be highly reliable (weighted kappa =. 91). Across all stages and types of dementia, GMHR ratings were correlated with number of comorbid medical conditions, number of medications being taken for comorbid conditions, and with activity of daily living impairment, even after adjustment for severity of dementia. GMHR ratings were also a strong predictor of falls and of mortality in long‐term care residents after adjustment for age and severity of dementia.

CONCLUSION: GMHR is a reliable, valid, global bedside measure of severity of general medical comorbidity for patients with dementia that can be used for clinical and research purposes.
Clinical Profile of Delirium in Older Patients
Authors: Sandberg Olov , Gustafson Yngve , Brannstrom Benny , Bucht Gosta
Published: April 2015

OBJECTIVE: To examine the prevalence, psychiatric and behavior symptoms, differing symptom profiles, and diurnal variations of delirium in older patients.

DESIGN: A descriptive, point prevalence study with a cross‐sectional design,.

SETTING: One ordinary county hospital (n = 148), three nursing homes (n = 202), five old people's homes (n = 196), and home medical care patients (n = 171) in parts of a hospital catchment area in Mid‐Sweden.

PARTICIPANTS: A total of 717 patients 75 years of age and older were observed and assessed for the prevalence of delirium. Women accounted for 66.4% of the studied population, and the mean age for both sexes was 83.7 years.

MEASUREMENTS: All patients were examined using the OBS (Organic Brain Syndrome) scale, and delirium was diagnosed according to DSM‐III‐R.

RESULTS: Delirium was diagnosed in 315 of 717 (43.9%) patients, and 135 of 315 (42.9%) of the delirious patients had dementia. Thirty‐seven percent of the patients with delirium were delirious in the afternoon, evening, or at night, and 47% of the delirious patients had morning delirium. The delirious patients presented a wide variety of psychiatric symptoms. More than half the patients xhibiting anxiety, psychomotor slowing, depressed mood, and irritability. Nearly 26% were classified as having hypoactive, 22% as having hyperactive, and 42% as having mixed delirium, whereas 11% had neither hypo‐ nor hyperactive delirium. Seventy‐seven percent were classified as having delirium with pronounced emotional and 43% with pronounced psychotic symptoms

CONCLUSIONS: This study shows that patients with delirium have very different clinical profiles. This might indicate a need for different treatment strategies for patients with different types of delirium. J Am Geriatr Soc 47:1300–1306, 1999.
Preventing the Spread of Vancomycin‐Resistant Enterococci in a Long‐Term Care Facility
Authors: Silverblatt Fredric J. , Tibert Cynthia , Mikolich Dennis , Blazek‐D'Arezzo Julia , Alves Josephine , Tack Marc , Agatiello Paul
Published: April 2015

OBJECTIVES: To test the hypothesis that infection control practices can prevent the spread of vancomycin‐resistant enterococci (VRE) to residents of a long‐term care facility (LCF) from an affiliated acute care facility with a high endemic rate of colonization.

DESIGN: Point prevalence study of the rate of rectal colonization.

SETTING: A state‐supported veterans nursing home and an acute care veterans hospital.

PARTICIPANTS: Residents in a state veterans home.

INTERVENTIONS: Identification of patients with rectal colonization by VRE before transfer to the state veterans home, contact isolation for colonized veterans, use of oral bacitracin to eliminate colonization.

MEASUREMENTS: Rectal swab and culture for VRE, review of clinical records and recording of presumptive risk factors for VRE colonization. The risk factors were age, gender, length of stay at nursing home, treatment with vancomycin or oral antibiotics, prior hospitalization at the acute care facility during the prior year, use of indwelling urethral catheters, presence of diarrhea, and fecal or urinary incontinence.

RESULTS: Sixty‐nine of 200 residents were cultured in the first study (1996) and 130 of 230 residents were cultured in the second study (1998). Residents who consented to culture differed from those who did not only with regards to gender (2 vs 7, P = .012). In neither study were any residents found to be colonized with VRE who had not already been identified as positive on admission.

CONCLUSIONS: Adherence to infection control practices by the patient care staff of the LTCF was associated with the absence of transmission of VRE colonization among its residents. The presence of rectal colonization with VRE in an acute care patient should not be a barrier to acceptance in a nursing home.
A Serious Outbreak of Parainfluenza Type 3 On a Nursing Unit
Authors: Faulks J. Todd , Pharm R. , Drinka Paul J. , Shult Peter
Published: April 2015

OBJECTIVE: To report a serious outbreak of respiratory illness in a nursing home, with isolation of parainfluenza type 3 in four cases.

DESIGN: Viral respiratory cultures from a sample of symptomatic residents, and retrospective chart review.

SETTING: A 50‐bed nursing unit/floor in a skilled nursing facility.

PARTICIPANTS: All residents of the nursing unit.

MEASUREMENTS: Respiratory viral cultures and clinical chart review.

RESULTS: Twenty‐five of 49 residents developed new respiratory symptoms between September 2 and September 25, 1999. Ten cases (40%) had a tympanic temperature of 100°F or greater. Eighteen (72%) had a chest X‐ray with 11 (44%) new infiltrates. Sixteen (64%) were treated with antibiotics. Three cases were hospitalized and four died (16%) within 1 to 9 days after onset of symptoms. Four of 10 viral cultures yielded parainfluenza type 3.

CONCLUSIONS: Parainfluenza type 3 may cause outbreaks complicated by pneumonia and fatal outcome. Clinicians should consider uniform secretion precautions to contain all viral URIs in nursing homes.
Mammography Use, Breast Cancer Stage at Diagnosis, and Survival Among Older Women
Authors: McCarthy Ellen P. , Burns Risa B. , Freund Karen M. , Ash Arlene S. , Shwartz Michael , Marwill Sandra L. , Moskowitz Mark A.
Published: April 2015

BACKGROUND: Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammography's value is less well demonstrated in older women.

OBJECTIVE: To investigate the relationship between prior mammography use, cancer stage at diagnosis, and breast cancer mortality among older women with breast cancer.

DESIGN: Retrospective cohort study using the Linked Medicare‐Tumor Registry Database.

SETTING: Population‐based data from three geographic areas included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program.

PARTICIPANTS: Women aged 67 and older diagnosed with a first primary breast cancer, from 1987 to 1993, residing in Connecticut, metropolitan Atlanta, Georgia, or Seattle‐Puget Sound, Washington.

MEASUREMENTS: Medicare claims were reviewed and women were classified according to their mammography use during the 2 years before diagnosis: nonusers (no prior mammograms), regular users (at least two mammograms at least 10 months apart), or peri‐diagnosis users (only mammogram(s) within 3 months before diagnosis). Mammography utilization was linked with SEER data to determine stage at diagnosis and cause of death. Our main outcome variables were (1) stage at diagnosis, classified as early (in situ/Stage I) or late (Stage II or greater), and (2) breast cancer mortality, measured from diagnosis until death from breast cancer or end of the follow‐up period (December 31, 1994).

RESULTS: Older women who were nonusers of mammography were diagnosed with breast cancer at Stage II or greater more often than regular users (adjusted odds ratio (OR), 3.12; 95% confidence interval (CI), 2.74–3.58). This association was present within each age group studied. Nonusers of mammography were at significantly greater risk of dying from their breast cancer than regular users for all women (adjusted hazard ratio (HR), 3.38; 95% CI, 2.65–4.32) and for women within each age group. Even assuming a lead time of 1.25 years, nonusers of mammography continued to be at increased risk of dying from breast cancer. Our findings remained significant for all women and for the two youngest age groups (67–74 years, 75–85 years), although the benefit was no longer statistically significant for the oldest women (85 years and older).

CONCLUSIONS: Older women who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. These data support the use of regular mammography in older women and suggest that mammography can reduce breast cancer mortality in older women, even for women age 85 and older.
GERIATRICS IN MANAGED CARE
Authors: Brummel‐Smith Kenneth , Phillips V. L. , Paul Wendy , Becker Edmund R. , Osterweil Dan , Ouslander Joseph G.
Published: April 2015

OBJECTIVE: To describe the healthcare utilization of a long‐term care population receiving primary and specialty care in a closed system and to compare Medicare fee‐for‐service (FFS) reimbursement with the amount that would have been paid under capitation for these services.

SETTING: A life care community in California composed of two facilities, both having residential care and nursing facility (NF) beds.

PARTICIPANTS: Residents (n = 700) living in the community between September 1995 and February 1996.

METHODS: Data on Medicare Part A and Part B reimbursements were gathered from billing records for hospitalizations, based on diagnostic related group payments, primary and specialty care visits, various procedures, diagnostic tests, and therapeutic services. These data were compared with what the facility, in collaboration with the providers and an affiliated hospital, would have received under Medicare capitated rates at that time.

RESULTS: Annually, residents averaged 16.3 primary care visits, 7.7 specialist visits, and 3453 hospital days per thousand. Nursing facility residents received significantly more primary care than did those in residential care. Total Medicare Part A and B payments per resident per month averaged $558. The monthly capitation rate in effect at the time for this population was substantially higher at $1085, generating an annual “risk pool” of $9.1 million.

Care provided in the two facilities varied greatly. Hospitalization rates, clinic‐based primary care and specialist visits, and therapy sessions were greater in facility one. Overall expenditures were lower for residents at facility two, where the majority of care was provided by trained geriatricians in collaboration with physician extenders and without sophisticated clinical pathways and utilization controls.

CONCLUSIONS: Our data support other studies that suggest that teams of geriatricians and physician extenders can reduce hospitalization rates and overall expenditures. Capitated rates for the frail, geriatric population warrant careful study. These rates must balance fiscal responsibility with the need for adequate, risk‐adjusted payments that create incentivesfor providers to produce high quality as well as cost‐effective care.
Midazolam Sedation for Upper Gastrointestinal Endoscopy in Older Persons: A Randomized, Double‐Blind, Placebo‐Controlled Study
Authors: Christe C. , Janssens J.P. , Armenian B. , Herrmann F. , Vogt N.
Published: April 2015

OBJECTIVES: To investigate the benefits and risks of using midazolam for sedation during upper gastrointestinal endoscopic procedures in older persons.

DESIGN: Randomized, double‐blind, placebo‐controlled study.

SETTING: A 304‐bed geriatric university hospital.

PATIENTS: Sixty‐five geriatric inpatients (mean age 84 ± 7) undergoing gastroscopy.

INTERVENTION: Sedation with either midazolam (30 μg/kg IV) or saline (placebo). All patients received supplemental oxygen during the procedure (2 L/minute).

MEASUREMENTS AND RESULTS: Patients' recall of their tolerance to the exam (categorical scale) and pain score were significantly in favor of midazolam at 2 and 24 hours. Multivariate analysis at 2 hours showed that midazolam increased the probability of good tolerance (odds ratio (OR) = 19.3; 95% confidence interval (CI) 2.2–170.4, P = .008). Circumstantial amnesia occurred at 24 hours in 84% (midazolam) versus 27% (placebo) (P < .001). With midazolam, mean sedation time was 83 ± 13 minutes and mean arterial pressure (MAP) was about 10 mm Hg lower without clinically significant hypotension. Hypoxemia (SaO2 < 92%) was more frequent in the midazolam group after endoscopy (44% vs. 18%, P = .033), but no major desaturation was observed. Cognitive function (Mini‐Mental State Exam, MMSE) was similar before and 2 and 24 hours after the exam in both groups. Acute confusion was observed in two patients (1 midazolam, 1 placebo). In multivariate analysis, midazolam was associated with a higher risk of hypoxemia after endoscopy (OR = 3.5; 95% CI 1.1–10.8, P = .029) but not of confusion.

CONCLUSIONS: Under adequate surveillance, the benefits in terms of tolerance to the procedure of low‐dose midazolam for upper gastrointestinal endoscopic sedation outweigh the risks in older people.
Undetected Dementia in Community‐Dwelling Older People: The Canadian Study of Health and Aging
Authors: Sternberg Shelley A. , Wolfson Christina , Baumgarten Mona
Published: April 2015

OBJECTIVE: To estimate the frequency and correlates of undetected dementia in community‐dwelling older people.

DESIGN: Secondary analysis of data from the Canadian Study of Health and Aging (CSHA) prevalence survey of dementia.

SETTING: All 10 provinces of Canada excluding Indian reserves and military units.

PARTICIPANTS: A total of 252 community‐dwelling older adults diagnosed with dementia in the CSHA survey.

MAIN OUTCOME MEASURE: Undetected dementia, defined as occurring in persons who meet standard diagnostic criteria for dementia but who report never having seen a doctor for memory problems.

RESULTS: Of the 252 subjects, 64% had undetected dementia. Subjects with mild functional impairment were significantly more likely to have undetected dementia (odds ratio = 2.4, 95% confidence interval 1.2, 5.0). Older subjects and those with mild cognitive impairment showed a trend toward undetected dementia, although the results did not achieve statistical significance. Educational level, number of comorbid conditions, and degree of social support were not significantly associated with undetected dementia.

CONCLUSIONS: A large number of older persons are living in the community with undetected dementia. These older people may be at significant risk for delirium, motor vehicle accidents, medication errors, and financial difficulties. As preventive strategies are developed and new cognitive enhancing therapies emerge, we need to reexamine our current guidelines about screening for cognitive impairment in older adults.
Glycemic Control in Older Subjects with Type 2 Diabetes Mellitus in the Fremantle Diabetes Study
Authors: Bruce D. G. , Davis W. A. , Davis T. M. E.
Published: April 2015

OBJECTIVES: We investigated whether there were differences in glycemic control in older compared with younger subjects with type 2 diabetes mellitus enrolled in the Fremantle Diabetes Study, a prospective study of diabetes care, control, and complications in an urban setting.

DESIGN: Cross‐sectional observational study.

SETTING: University teaching hospital clinical research center.

PARTICIPANTS: A total of 1205 patients with type 2 diabetes mellitus, 404 (33.3%) of whom were aged over 70 years and 83 (6.9%) aged over 80 years.

MEASUREMENTS: Fasting plasma glucose, HbA1c, body mass index, and waist/hip ratio.

RESULTS: In multiple linear regression analysis, age was inversely associated with glycemic control whereas duration of diabetes and treatment with either oral hypoglycemic agents or insulin were positively associated with glycemic control. For most age groups there was a significant worsening of glycemic control with duration of diabetes. Octogenarians differed significantly from younger age groups in that those with longer diabetes duration did not demonstrate the increase in hyperglycemia seen in other age groups. As a result, significantly greater proportions of these oldest diabetic subjects had satisfactory glycosylated hemoglobin levels compared with younger subjects.

CONCLUSIONS: Octogenarians do not demonstrate the usual progressive deterioration of glycemic control with diabetes duration seen in type 2 diabetes mellitus. The reasons for this difference are unknown but are likely to have clinical significance with regard to therapy and the development of diabetic complications.
The Impact of Metrifonate Therapy on Caregivers of Patients with Alzheimer's Disease: Results from the MALT Clinical Trial
Authors: Shikiar Richard , Shakespeare Annabelle , Sagnier Pierre‐Philippe , Wilkinson David , McKeith Ian , Dartigues Jean‐François , MD Bruno Dubois
Published: April 2015

OBJECTIVE: To assess the impact on burden reported by caregivers of patients with mild to moderate Alzheimer's disease (AD) who were treated with metrifonate during a randomized double blind clinical trial.

DESIGN: Randomized clinical trial, with a 2‐week screening period and a 26‐week double blind, placebo controlled, treatment phase. Caregivers were assessed at baseline, at 12 weeks, and at end of trial.

SETTING: Caregivers were interviewed at clinics as part of the assessment of the patients.

PARTICIPANTS: Six hundred and three caregivers of AD patients who were enrolled in the MALT trial; 591 (98%) provided data suitable for analysis at baseline, and 546 (91%) provided data allowing for inclusion in the analysis of change scores.

MEASUREMENTS: The Caregiver Burden Assessment consisted of the Screen for Caregiver Burden, including both subjective (SCB‐subj) and objective (SCB‐obj) scores; the cognitive subscale of Poulshock and Deimling (PD); an abridged version of the Relatives Stress Scale (aRSS); assessments of time spent in providing care, including the Caregiver Activity Time Scale (CATS); and demographic and background variables on both the patient and caregiver.

RESULTS: Treatment of mild to moderate AD patients with metrifonate for a duration of 26 weeks significantly reduced the psychological burden of care to the caregivers, as measured by the SCB‐subj, the PD, and the aRSS. There were no statistically significant differences on the measures assessing the time spent in caregiving, except for the caregiver's subjective impression of the change in time spent providing care during the trial. When comparing individual dose groups, most of the measures of burden showed the largest benefits in burden for the 60/80 mg group, followed by the 40/50 mg group, and then the placebo group. However, there was no statistically significant dose effect.

CONCLUSIONS: This study provides the first evidence from a randomized clinical trial of any acetylcholinesterase inhibitor used in the treatment of AD demonstrating a positive impact on the patient's caregiver as well as benefits to the patient. These results were shown consistently across several measurement scales and were observed after six months of treatment. These findings reinforce the clinical significance of research that has shown that metrifonate has beneficial impacts on the cognitive, behavioral, and functional abilities of AD patients. Because caregiver burden is a leading factor in the decision for institutional care placement, the ability to favorably impact that burden through pharmacological treatment of the patient is important. J Am Geriatr Soc 48: 268–274, 2000.
Can the Control of Bodily Orientation Be Significantly Improved in a Group of Older Adults with a History of Falls?
Authors: Rose Debra J. , Clark Sean
Published: April 2015

OBJECTIVE: To determine the short‐term effectiveness of a biofeedback‐based, computerized intervention that applied the principles of the ecological theory of perception and control of bodily orientation to the rehabilitation of older adults with a history of falling.

PARTICIPANTS: Forty‐five older adults (X = 78.5 years) with a history of falls were assigned to either a control (n = 21) or intervention group (n = 24).

DESIGN: A 2 × 2 (Group × Time) mixed factorial design with repeated measures on the second factor.

MEASUREMENT: Impairments in multiple dimensions of balance (i.e., dynamic postural control and sensory organization) were measured before and after an 8‐week balance intervention using the 100% Limits of Stability Test® and Sensory Organization Test®. More functional limitations in balance and/or mobility were measured using two clinical tests: Berg Balance Scale and Timed Up and Go test.

MAIN RESULTS: Repeated measures multivariate analyses and follow‐up testing indicated significant improvements in the dynamic balance and sensory integration capabilities in the case of the intervention group only (P < .03). Significant improvements were also observed in the two clinical measures of balance and mobility evaluated before and after the intervention for the intervention group only.

CONCLUSIONS: Theory‐driven rehabilitation programs that focus on manipulating individual, task, and environmental constraints concurrently can significantly improve the control of bodily orientation of older adults with a previous history of falls in both static and dynamic action environments. Moreover, the significant improvements in functional performance observed for the intervention group suggest that interventions emphasizing task‐specific practice are not the only means by which an older adult's ability to perform daily activities requiring postural control can be improved. J Am Geriatr Soc 48: 275–282, 2000.
A Randomized Trial of Weighted Vest Use in Ambulatory Older Adults: Strength, Performance, and Quality of Life Outcomes
Authors: Greendale Gail A. , Salem George J. , Young Jean T. , Damesyn Mark , Marion Michael , Wang Man‐Ying , Reuben David B.
Published: April 2015

BACKGROUND: Lower extremity weakness is a major risk factor for falls and hip fractures. Aging muscle is capable of responding to strengthening techniques. Strategies for providing accessible, inexpensive, safe, and effective strengthening programs for older adults are needed.

OBJECTIVE: To evaluate whether use of a weighted vest improved strength, physical performance, markers of bone turnover, or health‐related quality of life.

DESIGN: A 27‐week randomized, controlled, unmasked clinical trial. The primary outcome was peak isokinetic knee extensor strength at follow‐up, adjusted for baseline strength.

SETTING: Home‐based program.

PARTICIPANTS: A total of 62 women and men, mean age 74 years.

INTERVENTIONS: Subjects were randomized to: no vest (n = 21), 3% body weight (BW) vest (n = 19), or 5% BW vest (n = 22). The vest is a nylon garment with pockets that are loaded with adjustable weights. The vest was prescribed for 2 hours daily, 4 days per week. No specific physical activities were mandated.

MEASUREMENTS: All measures were made at baseline and 27 weeks. These included: knee strength and endurance by isokinetic dynamometer; timed physical performance tests; serum osteocalcin and urinary N‐telopeptides; and health‐related quality of life scales.

RESULTS: Follow‐up values of muscular strength and endurance, physical performance, bone turnover markers, and health‐related quality of life did not differ by treatment assignment. The final study visit was attended by 19 (90%), 15 (80%), and 20 (91%) of the control, 3%, and 5% groups, respectively. Three permanent discontinuations of vest use occurred.

CONCLUSIONS: Weighted vest use did not result in improvement in multiple domains of strength and function and did not affect bone turnover markers. We conclude that the training stimulus afforded by the vest (at the dosage tested) was below the required amount to produce strength gains or bone stimulation. J Am Geriatr Soc 48: 305–311, 2000.
Knowledge, Attitudes, and Practices of Geriatricians Regarding Patients with Dementia Who Are Potentially Dangerous Automobile Drivers: A National Survey
Authors: Cable Greg , Reisner Michelle , Gerges Salwa , Thirumavalavan Vallur
Published: April 2015

OBJECTIVES: To determine geriatrician knowledge regarding how to prevent a patient with dementia who is a potentially dangerous driver from driving and to determine their willingness to recommend license revocation against the wishes of both the patient and the patient's family. Included is a comparison of responses from geriatricians in California, where related legislation has existed for a decade, with responses from geriatricians from all other US states combined.

DESIGN: Survey sample.

SETTING: Geriatric practices.

PARTICIPANTS: Probability sample of 467 geriatricians.

MAIN OUTCOME MEASURES: Survey responses.

RESULTS: More than 28% of all geriatricians (95% CI, 24.3%–32.7%) do not know how to report patients with dementia who are potentially dangerous drivers. A 22% difference (95% CI, 13.9%–30.8%) exists between California geriatricians and those in all other US states. More than 75% (95% CI, 71.5%–79.5%) of all geriatricians agreed that physicians are responsible for reporting patients. More than 86% (95% CI, 83.2%–89.6%) of all geriatricians would contact state authorities despite the objections of the patient, and 72.9% (95% CI, 68.7%–77.1%) would contact authorities despite the objections of the patient's family.

CONCLUSIONS: Although most geriatricians will act to protect the public from patients with dementia who are potentially dangerous drivers, many do not know how to report these drivers. Legislation can improve a physician's ability to report patients with dementia who are potentially dangerous drivers. J Am Geriatr Soc 48: 14–17, 2000.
Aging‐Related Decline of Gonadal Function in Healthy Men: Correlation with Body Composition and Lipoproteins
Authors: Denti Licia , Pasolini Giuseppe , Sanfelici Laura , Benedetti Raffaella , Cecchetti Alessandra , Ceda Gian Paolo , Ablondi Fabrizio , Valenti Giorgio
Published: April 2015

OBJECTIVE: To assess if androgen decline in physiological aging contributes to the concomitant changes in body composition and lipoprotein levels.

DESIGN: Cross‐sectional, observational study.

SETTING: A university‐based outpatient center.

SUBJECTS: The study comprised 206 healthy volunteers (aged 18–95 years).

MEASUREMENTS: Blood samples were drawn after an overnight fast for the assay of hormones (free testosterone (FT), estradiol (E2), and sex hormone‐binding globulin (SHBG)) and lipids (total cholesterol, triglycerides, high‐density lipoprotein cholesterol, and lipoprotein Lp(a)). At the same time, body composition was assessed by both anthropometry (fat mass percentage (FM%) estimated from four measures of skinfold thickness using the Durnin and Womersley equation and the Siri equation) and by bioimpedance analysis (FM% estimated using the Segal or Deurenberg equations, respectively, for subjects younger or older than 62 years).

RESULTS: A significant age‐related decline was found for FT and E2 concentrations, whereas SHBG levels were related positively with age. No significant association was apparent between hormonal changes and the concomitant modifications of body composition and lipoproteins. Only SHBG showed a significant inverse association between FM% and the waist‐to‐hip ratio, independent of age. The comparison between older hypogonadal (with FT levels below the lower limit of the normality range assessed in younger subjects) and eugonadal men did not show any significant differences in body composition or lipid profile.

CONCLUSIONS: This study suggests that, in men, androgen decline caused by normal aging does not significantly affect some targets of testosterone action, such as body composition and lipid metabolism. Therefore, androgen supplementation in hypogonadal older men cannot be expected to influence nutritional status and body composition to the same extent that it does other main targets of testosterone action, such as sexual activity and muscle strength. However, we cannot exclude that selected subsets of older patients with low testosterone levels, especially if affected by catabolic disease, could benefit from the effects of androgen administration on nutritional status. J Am Geriatr Soc 48: 51–58, 2000.
Are We Improving the Quality of Nursing Home Care: The Case of Pressure Ulcers
Authors: Berlowitz Dan R. , Bezerra Herminio Q. , Brandeis Gary H. , Kader Boris , Anderson Jennifer J.
Published: April 2015

BACKGROUND: There are widespread concerns regarding the quality of nursing home care and whether care is improving. We evaluated a large provider of nursing home care to determine whether risk‐adjusted rates of pressure ulcer development have changed.

METHODS: We used the Minimum Data Set to study National HealthCare Corporation nursing homes from 1991 through 1995. Rates of pressure ulcer development were calculated for successive 6‐month periods by determining the proportion of residents initially ulcer‐free having a stage 2 or larger pressure ulcer on subsequent assessments. Rates were risk‐adjusted for patient characteristics. The proportion of new ulcers that were deep (stages 3 or 4) were also calculated.

RESULTS: We examined risk‐adjusted rates of pressure ulcer development based on 144,379 observations of 30,510 residents at 107 nursing homes. The number of observations per 6‐month period ranged from 11,041 to 15,805. Between 1991 and 1995, there was a significant (P < .05) rate decline of more than 25%. Additionally, the proportion of new ulcers that were stages 3 or 4 declined from 30 to 22% (P < .01).

CONCLUSIONS: Nursing homes showed significant improvement in the quality of pressure ulcer preventive care from 1991 to 1995. J Am Geriatr Soc 48: 59–62, 2000.
Elderly Persons' Last Six Months Of Life: Findings from the Hospitalized Elderly Longitudinal Project
Authors: Somogyi‐Zalud Emese , Zhong Zhenshao , Lynn Joanne , Hamel Mary Beth
Published: April 2015

BACKGROUND: Few studies describe the end of life in very old people.

OBJECTIVES: To characterize the last 6 months of life and dying in patients 80 years and older by describing demographic characteristics, functional state and quality of life, symptoms, preferences, use of life‐sustaining treatments, satisfaction with care, and family burden.

DESIGN: A retrospective analysis for patients enrolled in a prospective cohort study.

SETTING: Four teaching hospitals who participated in the Hospitalized Elderly Longitudinal Project (HELP).

SUBJECTS: 417 patients who died within 1 year of their enrollment hospitalization.

MEASUREMENTS: Chart reviews and interview data with patients and surrogates at several points in time. We constructed four observational time windows backward in time beginning with the patients' death.

RESULTS: Before hospitalization, two out of three patients reported fair quality of life, and patients averaged 2.4 impairments in activities of daily living. Seventy percent preferred comfort care on the third day of hospitalization. During the last month of life, three of five patients interviewed in the hospital and four of five interviewed out of the hospital preferred not to be resuscitated. At the time of death, four of five patients had a do not resuscitate (DNR) order and two of five had an order to withhold a ventilator. During the last month of life, one out of four patients reported severe pain.

CONCLUSIONS: Patients reported increasing functional impairments and limited quality of life. The majority preferred comfort care. The number of patients in severe pain was substantial. Before death, the majority had measures in place to limit aggressive care.