bluuebunny/crossref_metadata_2025 huggingface dataset:
The Use of Targeting Criteria in Hospitalized HMO Patients: Results from the Demonstration Phase of the Hospitalized Older Persons Evaluation (HOPE) Study
Authors: Reuben David B. , Wolde‐Tsadik Girma , Pardamean Bens , Hammond Betty , Borok Gerald M. , Rubenstein Laurence Z. , Beck John C.
Published: April 2015

Objective

To determine the yield of standardized targeting criteria for identifying hospitalized HMO patients who are at high risk for mortality and nursing home placement and, therefore, may be appropriate for comprehensive geriatric assessment.

Design

Prospective cohort study.

Setting

Four HMO (Southern California Kaiser‐Permanente) hospitals.

Subjects

3,697 patients 65 years of age or older admitted to any inpatient service from July 1 through September 30, 1990.

Main Outcome Measures

Screening measures for standardized targeting criteria, administered 24–48 hours after admission.

Results

Overall, 35.1% of patients screened met at least one inclusionary criterion, which is considerably higher than other published reports. The most commonly met criteria were incontinence, impairment in performing activities of daily living, malnutrition, and immobility. The percentage of patients meeting at least one criterion and meeting each criterion varied considerably among hospitals. The vast majority of patients (83%) who were judged appropriate for assessment met at least three criteria.

Conclusions

The yield of standardized criteria differs when applied to patients in different health care systems and to patients at different hospitals within a health care system, which may reflect differences in the populations being served and the practice styles of physicians and the delivery system. Because no single criterion identified more than approximately half of patients who were judged appropriate for assessment, it is likely that a battery of criteria will be necessary to identify these patients.
Anemia and Hemoglobin Levels in Older Persons: Relationship with Age, Gender, and Health Status
Authors: Salive Marcel E. , Cornoni‐Huntley Joan , Guralnik Jack M. , Phillips Caroline L. , Wallace Robert B. , Ostfeld Adrian M. , Cohen Harvey J.
Published: April 2015

Objective

To determine the relationship of hemoglobin levels and anemia with age and health status in older adults.

Design

Survey.

Setting

Community.

Participants and Methods

Hematologic tests were obtained from 3,946 adults aged ≥71 years in three communities (East Boston, MA; Iowa and Washington counties, IA; and New Haven, CT).

Results

Hemoglobin level was inversely associated with age, although this was more pronounced in men than in women. The proportion anemic was equal for men and women aged 71–74 years (8.6%) and increased differentially with age, reaching 41% and 21% for men and women aged ≥90 years, respectively. Hemoglobin and anemia were independently associated with age, race, body‐mass index, smoking, cancer, hospitalization, renal insufficiency, and hypoalbuminemia. The adjusted relative odds of anemia for a 5‐year increase in age was 1.5 (95% confidence interval [CI] 1.3–1.8) for men and 1.2 (95% CI 1.1–1.4) for women.

Conclusions

Age is significantly associated with both hemoglobin levels and anemia, with a stronger effect in men compared with women, even after simultaneously adjusting for demographic characteristics and health status. The decline of hemoglobin and concomitant increased anemia with age is not necessarily a result of “normal aging” so the detection of anemia in an older person should prompt appropriate clinical attention.
Multidimensional Risk Assessment versus Age as Criterion for Retirement of Airline Pilots
Authors: Stuck Andreas E. , van Gorp Wilfred G. , Josephson Karen R. , Morgenstern Hal , Beck John C.
Published: April 2015

Objective

To determine whether airline pilots over the age of 60 pose a hazard to aviation safety and whether risk assessment could replace age‐based retirement.

Data Sources

A computer‐assisted literature search (MEDLINE), expert consultation, and government reports.

Study Selection

Original studies on flight performance and pilot age; sudden incapacitation, neuropsychological testing, and/or medication use in pilots; and/or non‐invasive testing for predicting sudden death or stroke in asymptomatic subjects.

Data Extraction

Pertinent results and methods data were abstracted from the 49 included studies.

Data Synthesis

No study on aircraft accidents or pilot performance has shown an increased accident risk for over‐60‐year‐old pilots. Normal age‐related cognitive changes probably have minimal impact on aviation safety up to age 70, given above average health, education, and experience in airline pilots. Cognitive tests have not been validated for predicting flight performance safety, but they can detect early stages of cognitive disease. Cardiovascular incapacitation risk increases with age, but risk factor profiles and non‐invasive tests could identify pilots with non‐acceptable risk.

Conclusions

An improved medical certification test could identify those pathologic conditions that might occur more frequently in older subjects. If pilots also underwent adequate performance testing, a gradual increase of the retirement age to approximately age 70 would seem justified. In the future, a longitudinal database should be established to validate medical tests for their ability to predict a pilot's accident risk. Using individual pilots as their own controls might be more sensitive than using population‐based norm values. Progress in this field would advance medical assessment for other groups such as air traffic controllers or automobile drivers.
BOOK REVIEWS
Authors: Katz Paul R. , Weksler Marc
Published: April 2015

Molecular Biology of Aging. Edited by Finch CE and Johnson TE, eds. New York, Wiley‐Liss, 1990: 430 pages. $110.00.
BOOK REVIEWS
Authors: Pannill Fitzhugh C.
Published: April 2015

Managing Urinary Incontinence. By Schnelle JF. New York, Springer Publishing Co., 1991: 138 pages. $26.95.
BOOK REVIEWS
Authors: Patt Richard B.
Published: April 2015

The Management of Pain, 2nd Ed. Edited by Bonica JJ. Philadelphia, Lea and Febiger, 1990: 2120 pages. Hardcover, $220.00.
Prevalence and Predictors of Regularly Scheduled Prescription Medications of Newly Admitted Nursing Home Residents
Authors: Renner Elizabeth A. , Engle Veronica F. , Graney Marshall J.
Published: April 2015

Objective

The purpose of this study was to identify the prevalence and predictors of commonly prescribed regularly scheduled medications.

Design

Data were collected on the first day following nursing home admission in this non‐experimental study.

Setting

A stratified, proportional probability sample of eight nursing homes in a large Mid‐South city participated in this study.

Participants

A consecutive sample of 574 new and readmitted nursing home residents who did not refuse participation.

Interventions

None.

Main Outcome Measure(s)

Data were collected on regularly scheduled prescription medications and resident and nursing home characteristics.

Results

Residents without a diagnosis of dementia were more likely to receive cardiovascular medications (Odds Ratio = 2.34; 95% CI = 1.56–3.49), and white residents were more likely to receive cardiovascular medications (Odds Ratio = 1.74; 95% CI = 1.19–2.53) or central nervous system medications (Odds Ratio = 1.72; 95% CI = 1.18–2.51). Older residents were less likely to receive central nervous system medications (Odds Ratio = 0.97 per year; 95% CI = 0.96–0.99), and females were more likely to receive cardiovascular medications (Odds Ratio = 1.89; 95% CI = 1.30–2.75).

Conclusions

Resident characteristics were the most important predictors for cardiovascular and central nervous system medication prescriptions of new and readmitted nursing home residents.
Somatic Complaints and the CES‐D
Authors: Foelker George A. , Shewchuk Richard M.
Published: April 2015

Objective

To evaluate the Center for Epidemiology Surveys‐Depression (CES‐D) scale for inordinate false positives, due to measurement of non‐depression‐related somatic complaints.

Design

Cross‐sectional correlation of analysis of random multi‐cluster samples.

Setting

Thirteen counties considered representative of the community‐dwelling elderly population of Alabama.

Participants

One‐thousand‐sixty persons aged 55 and older.

Intervention

None.

Main Outcome Measures

Study evaluated the relationship of somatic symptomatology, as measured by the Multi‐Level Assessment Instrument's Physical Health Domain Index (PHDI) composite score and its three component indices, with the CES‐D and its four component scales, particularly the Somatic scale.

Results

The CES‐D total score and the Somatic scale were not related to: age increases in the sample; PHDI composite score or the three index scores; or to subgroups of high and low PHDI composite scores. Among those screened as depressed, the PHDI and the three indices were not related to the CES‐D total score or three of the four subscales. The CES‐D Somatic scale was positively related to those depressed persons with the highest number of total PHDI somatic complaints. However, among the depressed group there were more persons scoring greater than 1.5 standard deviations above the mean on the CES‐D Depressive Affect scale (n = 81) than on the Somatic scale (n = 65).

Conclusions

The CES‐D and its Somatic scale were relatively unbiased by the respondent's somatic complaints. The CES‐D can continue to be considered valid under these circumstances.
BOOK REVIEWS
Authors: Hershey Linda A.
Published: April 2015

Clinics in Geriatric Medicine: Cerebrovascular Disorders in the 1990s. By Biller J. Philadelphia, WB Saunders Company, 1991, 243 pages. $69.00 quarterly, $88.00 institutions.
Role of the Opioid System in the Hypodipsia Associated with Aging
Authors: Silver Andrew Jay , Morley John E.
Published: April 2015

Objective

To compare the effects of the opioid antagonist, naloxone, on fluid ingestion in young and older males, in order to estimate the role of the opioid system in hypodipsia of older men.

Design

Single‐blinded, randomized, cross‐over, placebo‐controlled study.

Setting

Outpatient Department of Veterans Affairs.

Study Participants

Sixteen young subjects (aged 23 to 39) and eight older subjects (aged 69 to 75). All subjects were healthy, community‐dwelling, non‐smoking men, on no medications.

Intervention

Subjects were randomized to receive either placebo or naloxone on day one. Whichever substance the subject did not receive was given on day two with days one and two separated by at least a 2‐week washout period.

Main Outcome Measures

Fluid intake after overnight food and fluid deprivation, with placebo or naloxone injected in the morning.

Results

After overnight fluid deprivation, older individuals consumed 29% less fluid in 2 hours compared with younger individuals (ns). After overnight fluid deprivation and injection with naloxone 100 μg/kg, fluid intake was diminished by 42% (P < 0.05) in young subjects compared with placebo, but only by 7% (ns) in older subjects. Subjective ratings did not differ significantly between young and old subjects.

Conclusions

These preliminary data suggest that the opioid system plays a role in the drinking response in young subjects while failing to alter fluid intake in older subjects. Hypodipsia in older individuals may be due to a deficit in the opioid drinking drive.
Pessaries in the Geriatric Patient
Authors: Zeitlin Michael P. , Lebherz Thomas B.
Published: April 2015

Pessaries have been used for centuries in the management of uterine prolapse. Although surgical repair has been popularized by surgeons and gynecologists for younger women with pelvic relaxation, pessaries remain a useful palliative strategy for patients who refuse surgery or represent higher operative risks. Despite the fact that pessaries are commonly used today, there is scant geriatric literature to describe their use among elderly patients. This article will review the indications and management of pessaries among elderly women with the goal of preventing complications and promoting investigation for their clinical application.
Association between Stimulated Plasma C‐peptide and Age: The Wadena City Health Study
Authors: French L. Ronald , Goetz Frederick C. , Martinez Anita M. , Boen James R. , Bushhouse Sally A. , Sprafka J. Michael
Published: April 2015

Objective

To assess age‐related changes in stimulated plasma C‐peptide in a population‐based sample of adults.

Design

Cross‐sectional study.

Setting

Wadena, Minnesota, a city of 4,699 residents (1980 census) in west central Minnesota, approximately 150 miles from Minneapolis/St. Paul.

Study Subjects

344 non‐diabetic subjects (NDDG standards) from a stratified random sample of the total adult population of Wadena, MN. The six‐study strata were men and women from three age groups: young, 20–39 years of age; middle‐aged, 40–59; and older, >60 years of age.

Measurements

During a liquid meal of Ensure‐Plus (Ensure‐Plus® challenge test; EPCT; Ross Laboratories), blood samples were taken for glucose, free fatty acids, creatinine, and C‐peptide. Plasma C‐peptide taken 90 minutes after the EPCT was used as a surrogate measure for insulin. Clinical tests included one‐time samples for hemoglobin, glycosylated hemoglobin, plasma cholesterol, triglycerides, and lipoproteins. Physical measurements included height, weight, and blood pressure. Urine was assayed for C‐peptide and creatinine. Assays of urine and plasma C‐peptide used antibody M1221 (from Novo; Copenhagen, Denmark).

Main Results

No differences were observed for the relationship between age and C‐peptide within each of the three age groups for men and the three age groups for women. However, the levels of plasma C‐peptide for older men or women were statistically significantly higher than levels for the young age groups of the same sex; fasting plasma glucose also was higher for older groups of both sexes, and postmeal glucose was significantly higher for older women. There were decreases with age in urine C‐peptide clearance for women and men; the decline for women was statistically significant. In multiple regression models for men alone and women alone, that controlled for age, post‐meal plasma glucose best explained plasma C‐peptide levels. For young men, plasma glucose alone provided the best prediction of plasma C‐peptide levels; body mass index (BMI) and plasma glucose provided the best prediction for young women. For older men and both middle‐aged and older women, a combination of urine C‐peptide clearance and plasma glucose best predicted plasma C‐peptide levels; for middle‐aged men, BMI also contributed to the prediction.

Conclusions

Secretion of insulin in response to an orally administered mixed meal is undiminished with age in non‐diabetic adults.
Prospective versus Retrospective Methods of Identifying Patients with Delirium
Authors: Johnson J. C. , Kerse N. M. , Gottlieb G. , Wanich C. , Sullivan E. , Chen K.
Published: April 2015

Objective

To determine if DSM‐III criteria or clinical or discharge diagnoses, reviewed retrospectively, are as accurate an indicator of the presence of delirium as prospective evaluation by a psychiatrist.

Design

Selection of delirious patients prospectively by a psychiatrist, followed by retrospective record review of the same patients.

Setting

A referral‐basesd university hospital.

Patients

From a sample of 235 consecutive medical patients over age 70, 47 delirious patients were identified prospectively by a research psychiatrist using DSM‐III criteria. The medical record of these delirious patients was reviewed after discharge for evidence of delirium.

Results

Four patients were assigned ICD‐9 codes suggestive of delirium (sensitivity 0.09). Review of physicians' diagnoses correctly identified 8 of 47 (sensitivity 0.17) patients as being delirious or acutely confused. The specific diagnostic criteria necessary to meet a DSM‐III diagnosis of delirium could be ascertained from 10 of 47 records (sensitivity 0.21).

Conclusion

The retrospective medical record review is very imprecise in establishing the diagnosis of delirium. As research in this field moves from descriptive epidemiology to studies of pathogenesis and treatment, prospective designs will be needed.
Hypertension: Cardiovascular Implications in a Cohort of Old Old
Authors: Guzik Howard J. , Ooi Wee Lock , Frishman William H. , Greenberg Steven , Aronson Miriam K.
Published: April 2015

Objective

To examine the prevalence and cardiovascular implications of hypertension in advanced age.

Design

Prospective non‐interventional study of a fixed cohort of very elderly subjects.

Participants and Setting

The subjects were 488 community‐dwelling volunteers. Mean age at entry was 79 years (range 75–85). All subjects were ambulatory, non‐demented, and free of terminal illness at baseline. Participants were evaluated at the gerontology department of an urban medical school.

Main Outcome Measures

Cardiovascular morbid and mortal events that were followed included fatal and non‐fatal myocardial infarction, fatal and non‐fatal stroke, and death. Prevalence of unrecognized myocardial infarction defined by electrocardiographic changes was also assessed.

Results

When hypertension was defined by history, current use of medications, or measured elevations in blood pressure, 78% of the subjects could be considered hypertensive. Univariate analysis showed an increased incidence of strokes in subjects with measured hypertension (P = 0.04). Subjects with elevated blood pressure (untreated) were more likely to develop clinically unrecognized myocardial infarction (P = 0.017). Multivariate survival analysis showed hypertension to be a modest predictor of overall cardiovascular disease (P = 0.067) but not of all‐cause mortality. Left ventricular hypertrophy was a predictor of cardiovascular disease (P = 0.013) and all‐cause mortality (P = 0.008). Age remained a significant risk factor for these endpoints, even in the very old. Isolated systolic hypertension was analyzed separately and in univariate analysis was a risk factor for stroke but not other cardiovascular morbidity.

Conclusions

Hypertension at advanced age remains a modestly important risk factor in the development of cardiovascular disease.
An Interdisciplinary Approach to the Assessment and Behavioral Treatment of Urinary Incontinence in Geriatric Outpatients
Authors: McDowell B. Joan , Burgio Kathryn L. , Dombrowski Marianne , Locher Julie L. , Rodriguez Eric
Published: April 2015

Objective

To test the effectiveness of an interdisciplinary assessment and behavioral treatment of persistent urinary incontinence in geriatric outpatients.

Design

Prospective case series in which frequency of incontinence was measured before and after intervention.

Setting

We established an interdisciplinary continence program within an existing academic center, the Benedum Geriatric Center.

Patients

Convenience sample of 70 non‐demented outpatients aged 56 to 90 years. Behavioral treatment was provided to 29 patients including many with multiple medical problems (Mean = 6.0 problems).

Intervention

Behavioral treatment consisted of biofeedback, pelvic floor muscle exercise, scheduled voiding, and other strategies for preventing accidental urine loss.

Outcome measure

Outcome of treatment was measured by comparing bladder diaries completed in the 2 weeks immediately following treatment to those completed in the pre‐treatment phase.

Results

Following an average 5.6 treatment sessions, the mean weekly frequency of accidents was reduced from 16.9 to 2.5 (P < 0.01). Individual reductions ranged from 30.8% to 100% with an average of 81.6% improvement. Ten patients achieved continence. Patients with mixed incontinence had greater improvement than those with urge incontinence alone (P < 0.05), and patients who reported previous evaluation or treatment had a poorer outcome than those coming for their first evaluation (P = 0.05). Degree of improvement was not significantly related to age, duration of symptoms, baseline frequency of accidents, number of treatment sessions, number of other medical diagnoses, or urodynamic findings.

Conclusion

We conclude that older adults who are able and willing to participate in behavioral treatment can benefit significantly despite other health problems or disabilities.
BOOK REVIEWS
Authors: Chang June I.
Published: April 2015

Respite for Caregivers of Alzheimer's Patients: Research and Practice. By Lawton MP, Brody EM, and Saperstein AR. New York, Springer Publishing Company, 1991. 164 pages. $24.95.
BOOK REVIEWS
Authors: Feather John
Published: April 2015

International Handbook on Old‐Age Insurance. Edited by Tracy MB and Pampel FC. Connecticut, Greenwood Press, 1991. 272 pages. $75.00.
Bedside Assessment of Executive Cognitive Impairment: The Executive Interview
Authors: Royall Donald R. , Mahurin Roderick K. , Gray Kevin F.
Published: April 2015

Objective: This study is a pilot validation of the Executive Interview (EXIT), a novel instrument designed to assess executive cognitive function (ECF) at the bedside.

Objective: Inter‐rater reliability testing and validation using inter‐group comparisons across levels of care and measures of cognition and behavior.

Participants: Forty elderly subjects randomly selected across four levels of care.

Setting: Settings ranged from independent living apartments to designated Alzheimer's Special Care units in a single 537‐bed retirement community.

Measurements: The EXIT: a 10‐minute, 25‐item interview scored from 0–50 (higher scores = greater executive dyscontrol) was administered by a physician. Subjects were also administered the Mini‐Mental State Exam (MMSE) and traditional tests of “frontal” executive function by a neuropsychologist, and the Nursing Home Behavior Problem Scale (NHBPS) by Licensed Vocational Nurses.

Results: Interrater reliability was high (r= .90). EXIT scores correlated well with other measures of ECF. The interview discriminated among residents at each level of care. In contrast, the MMSE did not discriminate apartment‐dwelling from residential care residents, or residential care from nursing home residents. The EXIT was highly correlated with disruptive behaviors as measured by the NHBPS (r= .79).

Conclusions: These preliminary findings suggest that the EXIT is a valid and reliable instrument for the assessment of executive impairment at the bedside. It correlates well with level of care and problem behavior. It discriminates residents at earlier stages of cognitive impairment than the MMSE.J Am Geriatr Soc 40:1221–1226, 1992
Historical Perspective: The Neurotrophic Theory of Skin Ulceration
Authors: Levine Jeffrey M.
Published: April 2015

Though nearly forgotten, the neurotrophic theory was very much a part of mainstream medical thinking during the mid‐nineteenth century. This theory stated that all bodily organs are maintained by special nutritional factors secreted by the central nervous system. Development of skin ulceration in the face of neurologic injury became a model for the theory, and controversy involved two great neurologists of the time, Jean Martin Charcot and Edouard Brown‐Séquard. As the neurotrophic theory fell into disfavor, interest in decubitus ulcers waned as well. Today, pressure sores remain a major epidemiologic problem for the growing population of frail elderly persons in both acute and long‐term care settings. Because of the increased mortality, morbidity, and cost associated with these lesions, attention needs to be refocused on research and education concerning the decubitus ulcer.
The Relationship between Electromyographically Documented Peripheral Neuropatny and Falls
Authors: Richardson James K. , Ching Christopher , Hurvitz Edward A.
Published: April 2015

Objective: To determine if the presence of an electromyographically demonstrated peripheral polyneuropathy involving the lower extremities is associated with falls.

Design: Case control study.

Setting: A University‐based referral center.

Patients: Twenty‐five patients with an axonal peripheral polyneuropathy affecting the lower extremities, demonstrated by electromyography more than 8 and less than 16 months before, and 25 age‐ and sex‐matched controls who had normal electromyographic studies of the lower extremities during the same time period, were identified from a computer record of all electromyography results during the year prior to the study, using diagnostic codes and demographic data. Twenty‐eight pairs were identified, 25 of whom completed the study.

Main Outcome Measures: Number of falls and resultant injuries during the year before the interview, and number of previously identified risk factors for falling, based on interview.

Results: Peripheral neuropathy was found to be significantly associated with falling (14/25, 56% vs 2/25, 8% ‐ odds ratio 23.0, 95% confidence interval 2.5, > 100) and repetitive falling (10/25, 40% vs 1/25, 4% ‐ odds ratio, 95% confidence interval 1.4, > 100). There was a trend toward increased injury requiring medical attention (5/25, 20% vs 0/25, 0%), but it did not reach statistical significance. Previously identified risk factors were not significantly more common in the peripheral neuropathy group.

Conclusion: An electromyographically identified peripheral neuropathy is strongly associated with and may be a risk factor for falls. J Am Geriatr Soc 40:1008–1012, 1992
Public‐Private Partnerships: The Connecticut Model for Financing Long‐Term Care
Authors: Mahoney Kevin J. , Wetle Terrie
Published: April 2015

Responses to the growing crisis in long‐term care financing have included efforts to negotiate partnerships between the private and public sectors for the purpose of developing innovative models for long‐term care insurance. One such set of models has been encouraged by support from the Robert Wood Johnson Foundation's “Long Term Care Insurance Program” grants. The Connecticut Partnership for Long Term Care uses a cooperative approach to encourage the development of private sector long‐term care insurance products that are integrated with Medicaid eligibility determinations. The Connecticut model is described, accompanied by a history of its development, and a comparison is made with other models currently under consideration by national policy analysts. J Am Geriatr Soc 40:1026–1030, 1992
Quinine Sulfate for Leg Cramps: Does It Work?
Authors: Sidorov Jaan
Published: April 2015

Objective

To study the efficacy of quinine in the prevention of nocturnal leg muscle cramps.

Design

Double‐blind, randomized, crossover trial with four periods of observation, each lasting 2 weeks.

Setting

General internal medicine outpatient clinic.

Participants

Ambulatory outpatients who experienced an estimated two or more typical nocturnal leg cramps per week.

Intervention

200 mg of quinine taken at bedtime.

Main Outcome Measures

Self‐reported ratings of leg cramp frequency, duration, and intensity.

Results

Sixteen patients completed the trial. During the 2 weeks patients used quinine, there was no statistically significant reduction in mean leg cramp number (quinine 3.5 vs placebo 4.2, P = 0.48), mean leg cramp duration (quinine 152 seconds vs placebo 163 seconds, P = 0.89), or patient ratings of severity using a 1 (low) to 10 (high) scale (quinine = 4.2 vs placebo = 4.0, P = 0.83).

Conclusion

No significant reduction in nocturnal leg cramp frequency, intensity, or duration could be found using nightly quinine in this study. Since quinine is not without the potential for side effects and drug interactions, clinicians need to carefully consider the likelihood of modest benefit associated with quinine against the potential for side effects and drug‐drug interactions.
The Relationship between Ankle‐Arm Index and Mortality in Older Men and Women
Authors: Vogt Molly T. , McKenna Matthew , Anderson Stewart J. , Wolfson Sidney K. , Kuller Lewis H.
Published: April 2015

Objective

To determine whether the ankle‐arm blood pressure index is a useful predictor of mortality in a large group of patients aged 50 or older.

Design

Cohort study over a 13‐year period.

Setting

Peripheral vascular laboratory in a hospital affiliated with an academic health center.

Participants

1,027 male and 903 female patients referred for arterial evaluation.

Outcome Measures

All‐cause and cause‐specific mortality.

Results

A decrease in ankle‐arm index was a strong independent predictor of all‐cause mortality [relative risk (RR) for men = 1.8(95% CI 1.5, 1.9); for women = 1.5, (1.2, 2.0)] and atherosclerotic heart disease mortality [RR for men = 2.0 (1.4, 2.9); for women = 2.1 (1.4, 3.1)]. The risk of mortality was inversely proportional to the ankle‐arm index. No relationship was found between the index and mortality due to stroke or cancer.

Conclusions

These results suggest that a decreased ankle‐arm index has important prognostic significance for mortality due to atherosclerotic heart disease in older men and women. Measurement of this index may be useful in identifying those at high risk who may benefit from aggressive therapeutic intervention.
Acute Exercise Facilitates Semantically Cued Memory in Nursing Home Residents
Authors: Stones M. J. , Dawe Doreen
Published: April 2015

Objective

To study the acute effects of non‐strenuous physical exercise on memory retrieval and visuo‐motor performance in old‐old nursing home residents.

Design

A randomized control trial.

Setting

A nursing home.

Participants

Ambulatory volunteers from the nursing home, with all 20 shown to be normal on mental status. Three were male and 17 female, with a means of 84.5 years for age and 9.3 years for education. They were divided at random into an exercise and a control group.

Intervention

A single 15‐minute standardized bout of non‐strenuous exercise administered independently to each participant in the exercise group. Control group participants watched a video of similar exercises for 15 minutes.

Measurements

Two measures requiring the retrieval of category instances with semantic or initial consonant cues. Retrieval time was 60 seconds for each of four categories per measure. Visuo‐motor performance was measured by Symbol Digit coding. Testing sessions were held before exercise, immediately post‐exercise and 30 minutes post‐exercise.

Results

The group‐by‐time interaction was significant only for semantically cued memory (P < 0.01), with higher retrieval at post‐testing only in the exercised group. The higher retrieval was mainly attributable to more new items retrieved by the exercise group at the immediate post‐test (P < 0.05).

Conclusions

This study provides preliminary support for the hypothesis that non‐strenuous physical exercise has positive acute effects on meaningfully cued memory.
BOOK REVIEWS
Authors: Katz Paul R. , Schaer Teresa
Published: April 2015

A Clinical Guide for The Care of Older Women Edited by Richard L. Byyny and Leon Speroff. Baltimore, Williams & Wilkins, 1990. 318 pages. $52.00.
Nursing Home Medical Directors: Ideals and Realities
Authors: Zimmer James G. , Watson Nancy M. , Levenson Steven A.
Published: April 2015

Objective

To evaluate what nursing home medical directors actually do, what they and other nursing home personnel believe would be desirable to do, and what problems and deficiencies are perceived.

Design

Mail survey with follow‐up telephone interview when necessary.

Setting

Forty‐five nursing facilities in upstate New York.

Participants

The medical directors, administrators, and directors of nursing of the 45 facilities.

Measurements

Inventory of what medical directors reported as to their actual activities and time spent, and of what they, the administrators, and the directors of nursing felt should be their responsibilities and activities under ideal circumstances.

Results

For part‐time medical directors, self‐reported time spent on medical directorship activities averaged 12 hours per month; of all directors, 45% spent 8 hours or less per month. Proportion of time spent on various specific activities varied widely. There was general agreement that substantially more time should be spent, in particular, on evaluating and addressing problems of adequacy and quality of care, communicating with attending physicians about problems, and assisting with inservice training programs.

Conclusions

To fill the role adequately, more time should be spent by many part‐time medical directors, which will require greater financial commitment by facilities and reimbursement systems. Efforts need to made to better coordinate the expectations of medical directors and facility staff.
Effects of Cognitive Impairment on the Reliability of Geriatric Assessments in Nursing Homes
Authors: Phillips Charles D. , Chu Catharine W. , Morris John N. , Hawes Catherine
Published: April 2015

Objective

To explore the relationship between an elderly subject's cognitive status and the reliability of multidimensional assessment data.

Design

Survey, with cognitive status as the independent variable and interrater reliability as dependent variable.

Setting

Medicare/Medicaid‐certified nursing homes.

Participants

147 residents age 65 or older.

Measurements

Dual assessments of elderly nursing home residents were performed by nurse assessors using the Health Care Financing Administration's new Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). Assessments were classified on the basis of residents' cognitive status, and levels of disagreement between assessors were analyzed.

Main Results

Overall assessment reliability, agreement concerning a resident's activities of daily living status, and the reliability of estimates of his or her communication skills and sensory abilities were significantly affected by a resident's cognitive status. The presence of cognitive impairment made these measurements less reliable—especially those related to communication skills, vision, and hearing.

Conclusions

Assessments of residents suffering from cognitive impairment were significantly less reliable than assessments of cognitively intact residents. However, these differences in reliability were not uniform across all assessment domains. When treating the cognitively impaired elderly, clinicians must exercise caution in their reliance on standardized measurements that may be less reliable for this population.
Effects of Testosterone Replacement Therapy in Old Hypogonadal Males: A Preliminary Study
Authors: Morley John E. , Perry H. Michael , Kaiser Fran E. , Kraenzle Dale , Jensen Judy , Houston Kathy , Mattammal Michael , Perry H. Mitchell
Published: April 2015

Objective

To examine the effects of testosterone administration to older hypogonadal males (bioavailable testosterone less than 70 ng/dL).

Design

Alternate‐case controlled trial.

Setting

St. Louis University.

Patients

Eight males (mean age 77.6 ± 2.3 years) who received testosterone and six males (mean age 76 ± 2.3 years) who served as controls. Selected from alumni of the SHEP trial and attendees at the St. Louis University Impotence Clinic.

Interventions

Testosterone enanthate (200 mg/mL) was administered intramuscularly to the treatment group every 2 weeks for 3 months.

Measurements

Serum testosterone, bioavailable testerone and estradiol, weight, % body fat, right hand muscle strength, balance, cholesterol, HDL‐cholesterol, hematocrit, BUN, creatinine, albumin, calcium, PTH, 25(OH) vitamin D, 1,25 (OH)2 vitamin D, osteocalcin, prostate‐specific antigen, and fructosamine.

Results

Males who received testosterone had a significant increase in testosterone and bioavailable testosterone concentration, hematocrit, right hand muscle strength and osteocalcin concentration. They had a decrease in cholesterol (without a change in HDL‐cholesterol) levels and decreased BUN/Creatinine ratios.

Conclusion

These preliminary findings support the need for long term studies of testosterone therapy in older hypogonadal males.
Percutaneous Transhepatic Cholecystostomy for Acute Complicated Calculous Cholecystitis in Elderly Patients
Authors: Steenbergen Werner Van , Rigauts Hans , Ponette Eric , Peetermans Willy , Pelemans Walter , Fevery Johan
Published: April 2015

Objective

To assess the immediate and long‐term outcomes of elderly patients with acute complicated cholecystitis treated by percutaneous cholecystostomy. To assess the results of bile cultures obtained in this group of patients.

Design

Case series.

Setting

Tertiary care center.

Patients

Thirty‐two patients, with a mean (±S.D.) age of 78 ± 8 years (range, 58–92 years), and who presented with acute cholecystitis complicated by empyema formation. Sixty‐six percent had associated disorders, which rendered them at high risk for surgical intervention.

Intervention

Percutaneous transhepatic catheter drainage of the gallbladder, with a mean drainage time of 20 days (range 0–84 days). In addition, endoscopic sphincterotomy with removal of common bile duct stones was performed in six patients and percutaneous aspiration of an associated liver abscess in four cases.

Results

Percutaneous cholecystostomy was followed by rapid regression of clinical symptoms and of radiologic abnormalities in all patients. Sixteen cases (50%) underwent elective cholecystectomy 1–12 weeks after cholecystostomy. One of them died of aspiration pneumonia, whereas 15 had no post‐operative problems and were discharged 9 days (mean) after surgery. Forty‐four percent (14/32) were considered inoperable: they remained completely free of biliary symptoms and died of unrelated illness (22%) after a mean follow‐up of 6 months (range, 1–22 months) or are still alive (22%) with a mean follow‐up of 15 months (range, 5–36 months). Bile cultures were positive in 75% of the patients. Escherichia coli, other aerobic Gram‐negative micro‐organisms, and anaerobic bacterial species accounted for 35% (16/46), 28% (13/46), and 20% (9/46) of the isolated bacteria, respectively. All aerobic Gram‐negative species tested in vitro were susceptible to gentamicin and to temocillin.

Conclusions

Percutaneous transhepatic cholecystostomy is a safe and effective procedure in the treatment of elderly high‐risk patients with acute cholecystitis complicated by empyema formation. It can be followed by elective cholecystectomy, if possible, or by expectant conservative management in patients who are inoperable because of systemic disease.
When Older Adults Face the Chair‐Rise Challenge: A Study of Chair Height Availability and Height‐Modified Chair‐Rise Performance in the Elderly
Authors: Weiner Debra K. , Long Rebecca , Hughes Michael A. , Chandler Julie , Studenski Stephanie
Published: April 2015

Objective: Define the range of community seating heights available for use by older adults; test whether raising chair height by small increments facilitates chair‐rise performance; and heighten physician and furniture industry awareness of discrepancies that may exist between actual and acceptable chair heights for older adults.

Design: Phase 1: Survey of commercially available chair heights. Phase 2: Cross‐sectional descriptive study of chair‐rise ability.

Setting: Phase 1: Local furniture stores, physician offices, hospital waiting areas, and nursing homes. Phase 2: Postural Control Lab.

Participants: Twenty‐two volunteers (nursing home residents and community dwellers). Exclusion criteria: inability to stand independently and inability to bear full weight on the lower extremities in the standing position.

Measurements: Chair rise success at six heights (17–22 inches), self‐reported difficulty (visual analogue scale), change in minimum hip angle and maximum shoulder angle during rise, using motion analysis.

Results: Phase 1: Community chair heights ranged from 12 to 18 inches, with a mean of 16.3 in physician offices, 16.6 in nursing homes, 16.4 in hospitals, 17.3 in “kitchens” and 15 in “living rooms.” Phase 2: As chair height increased from 17 to 22 inches, chair rise effort decreased, as shown by near doubling of percent successful rises, decline in mean self‐reported difficulty score, increase in mean minimum hip angle, and decrease in mean maximum shoulder angle.

Conclusions: Seating height may need to be more closely scrutinized in areas frequented by frail elders. Augmentation of seat height by small increments facilitates chair rise performance.
Transcranial Doppler Assessment of the Cerebral Circulation during Postprandial Hypotension in the Elderly
Authors: Krajewski Adam , Freeman Roy , Ruthazer Robin , Kelley Margaret , Lipsitz Lewis A.
Published: April 2015

Objective: The aim of the present study was to evaluate whether alterations in postprandial hemodynamics in the elderly were associated with changes in cerebral perfusion assessed by transcranial Doppler ultrasonography.

Design: Time series, ie, post‐intervention compared to pre‐intervention with no‐intervention controls.

Participants: Ten elderly institutionalized subjects (4 women, 6 men, mean age 84.9 years). Three subjects had a history of syncope.

Setting: A 725‐bed academic long‐term care facility.

Intervention: A 400‐kcal mixed meal.

Measurements: Heart rate, blood pressure, and blood flow velocity in the middle cerebral artery by transcranial Doppler recording, before the test meal and at 5‐minute intervals for 60 minutes afterwards.

Results: Systolic, diastolic, and mean arterial blood pressure declined significantly from baseline between 30 and 55 minutes after the meal (P < 0.05, ANOVA); however, maximum and mean blood flow velocity did not change. The pulsatility index (end diastolic to peak systolic amplitude divided by mean velocity) increased significantly (P < 0.05, ANOVA) between 30 and 55 minutes after the meal, suggesting increased arteriolar resistance. There were no significant changes in blood pressure, blood flow velocity, and pulsatility index during a control study conducted with four subjects under identical conditions but without a meal.

Conclusions: The results of this study suggest a small, unexpected increase in resistance of the intracranial circulation following a meal in elderly people with postprandial hypotension. Although the clinical significance of this finding is not known, the occurrence of postprandial arteriolar vasoconstriction may lead to cerebral ischemia during periods of marked blood pressure decline.
Correction of Massive Vaginal Prolapse in an Older Population: A Four‐Year Experience at a Rural Tertiary Care Center
Authors: Kaminski Paul F. , Sorosky Joel I. , Pees Richard C. , Podczaski Edward S.
Published: April 2015

Objective: To ascertain the success of complex reconstructive vaginal surgery in older women.

Design: Retrospective review of hospital and outpatient records.

Setting: Rural tertiary care referral center, Pennsylvania State University Hospital, Hershey, Pennsylvania

Patients: Twenty‐four patients referred for massive eversion of the vagina and/or complete procidentia.

Measurements: Symptoms and anatomic correction of patients' complaints.

Results: After surgery, 83 percent were asymptomatic without pelvic relaxation, 4 percent were asymptomatic with pelvic relaxation, 4 percent were symptomatic without pelvic relaxation, and 9 percent were symptomatic with relaxation.

Conclusions: Older women can undergo major vaginal reconstructive surgery with relief of symptoms and restoration of vaginal depth and axis.
A Comparison of Hand‐Held Isometric Strength Measurement with Isokinetic Muscle Strength Measurement in the Elderly
Authors: Reed Richard L. , Den Hartog Robert , Yochum Kathleen , Pearlmutter Lori , Ruttinger A. Clark , Mooradian Arshag D.
Published: April 2015

Objective: To compare hand‐held isometric muscle strength measurement to an isokinetic muscle strength measurement in a healthy elderly population.

Design: Cross‐sectional survey.

Setting: Retirement community in Southeastern Arizona.

Participants: Thirty‐two volunteers (16 men and 16 women) age 60 and over (mean age 70.3 years) who were free of musculoskeletal problems and did not have significant health problems.

Interventions: None.

Measurements: Isometric muscle strength was determined using a hand‐held isometric strength device (Penny and Giles) for elbow flexion and extension and knee flexion and extension. Isokinetic muscle strength (average peak torque and average work per repetition) was measured on the same individuals using a Lido® isokinetic dynamometer.

Results: Correlations between the strength measurement techniques were generally favorable with the lowest correlation being .72, (95 percent confidence interval .50–.86) and the highest being .85, (95 percent confidence interval .72–.93). However, there was substantial variability of hand‐held strength reading at some levels of isokinetic strength.

Conclusions: Hand‐held dynamometry for strength measurement correlates strongly with measurement of strength using isokinetic dynamometry. Despite these high correlations, there is remaining variability of hand‐held muscle strength readings when compared with isokinetic strength measurement at some levels of isokinetic muscle strength. Modification of the testing methodology or instrumentation used in this study is needed to improve the consistency of these measurements.
Alcoholism and Prescription Drug Abuse in the Elderly: St. Louis University Grand Rounds
Authors: Solomon Kenneth , Manepalli Jothika , Ireland Gordon A. , Mahon Gerald M.
Published: April 2015

This Grand Rounds will review the problem of alcoholism and prescription drug abuse in the elderly. Several case vignettes will be presented. The pharmacology of alcohol and potentially addictive prescription medications will be reviewed. The clinical presentation of and psychiatric symptoms associated with these disorders will be discussed. The process of addiction and issues regarding the clinical evaluation of the elderly addict will be discussed. The medical complications of these disorders will be reviewed, followed by a discussion of guidelines for the appropriate use of these drugs in the elderly. The grand rounds will conclude with a discussion of the treatment of patients with these disorders.
Hospital Resources Used To Treat the Injured Elderly at North Carolina Trauma Centers
Authors: Covington Deborah L. , Maxwell J. Gary , Clancy Thomas V.
Published: April 2015

Objective: The purpose of this paper is to compare the hospital resources used by elderly, adult, and pediatric patients treated in hospitals reporting to the North Carolina Trauma Registry (NCTR).

Design: We analyzed data on all patients entered into the NCTR from 1 January 1988 to 31 December 1990.

Setting: The NCTR is a statewide registry of all trauma patients admitted for at least 24 hours or dead on arrival at the eight Level I and II trauma center hospitals in North Carolina.

Patients: The total number of patients included in the study was 21,214; elderly adults included those age 65 and older (n = 2808), adults included those 15 to 64 years old (n = 15,776), and pediatric patients included those 0 to 14 years old (n = 2630).

Main Outcome Measures: We examined hospital resources using three measures: overall length of hospital stay in days, intensive care unit (ICU) length of stay in days for those admitted to the ICU, and total hospital charges billed during the hospitalization.

Results: Controlling for injury severity, we found that elderly adults had longer mean hospital and ICU lengths of stay and higher mean hospital charges than adults or children. Whereas only 22% of injuries to elderly adults were transportation‐related, transportation injuries generated 38% of their hospital charges. Sixty‐eight percent of their injuries were caused by falls, generating total hospital charges of $17.6 million, an average of 15 days in hospital stay and 9 days in ICU stay.

Conclusion: A 10% reduction in both transportation injuries and falls among the elderly could save $3.5 million in this population over 3 years.