bluuebunny/crossref_metadata_2025 huggingface dataset:
Osteoarthritis in Older Adults
Authors: Ling Shari Miura , Bathon Joan M.
Published: April 2015

OBJECTIVE: This review highlights the clinical and pathophysiologic features of osteoarthritis (OA) of the peripheral joints and discusses the current and future management options for this common but potentially disabling disease. This article also addresses the contribution of osteoarthritis to falls and functional impairment in older people.

DESIGN: A critical assessment of current data regarding the pathogenesis of osteoarthritis, current and future therapies, and the potential role of OA in falls and functional impairment in older people.

CONCLUSIONS: Osteoarthritis is the most prevalent articular disease in older adults. Disease markers that will detect early disease and allow early intervention with pharmacologic agents that modify, if not halt, disease progression are much needed, but they are presently unavailable. Current management should include safe and adequate pain relief using systemic and local therapies and should also include medical and rehabilitative interventions to prevent, or at least compensate for, functional deficits. Although OA can result in impaired mobility and lower extremity function, its contribution as a cause of recurrent falls or impaired self‐care, relative to other comorbid conditions, remains ill‐defined. Further analysis of the determinants of disability, loss of mobility and falls in older patients with OA is needed.
Serum Estrogen Levels, Cognitive Performance, and Risk of Cognitive Decline in Older Community Women
Authors: Yaffe Kristine , Grady Deborah , Pressman Alice , Cummings Steve
Published: April 2015

OBJECTIVE: To determine the association between serum estrogen levels, cognitive performance, and risk of cognitive decline in older women.

DESIGN: Prospective cohort study with an average follow‐up of 5 years.

SETTING: Clinical centers in Baltimore, MD, Minneapolis, MN, Portland, OR, and the Monongahela Valley in Pennsylvania.

PARTICIPANTS: 532 women aged 65 years or older who were the controls from two nested case‐control studies in the ongoing Study of Osteoporotic Fractures.

OUTCOME MEASURES: Three cognitive tests – a modified Mini‐Mental Status Exam, Digit Symbol, and Trails B – were administered at study initiation and were then repeated approximately 5 years later. Estrone and estradiol levels were determined by radioimmunoassay at two laboratories from baseline stored serum.

RESULTS: The characteristics of the women in the four serum estrogen quartiles did not differ except that body weight and change in weight since age 50 increased directly with higher quartile of serum estrogen (P <.001, for both estrone and estradiol). Initial cognitive performance on all three tests did not differ consistently by quartile of estradiol or by the estradiol to estrone ratio. Women in the higher estrone quartiles had 15% lower (worse) scores on Digit Symbol compared with the lower quartiles (P =.004) but there was no difference by quartile on the modified MMSE or on Trails B. Cognitive function test scores declined over the 5 years of follow‐up. There was no difference in amount of change by quartile of estradiol, but women in the higher estrone quartiles had greater reduction of scores on Trails B compared with those in the lower quartiles (P =.012), even after adjusting for age, education, depression, stroke history, weight, and change in weight since age 50. The age‐adjusted odds of cognitive decline (defined as tenth percentile of women with the largest decline in cognitive performance) did not vary across quartile of estrone or estradiol.

CONCLUSIONS: Endogenous estrogens are not associated consistently with cognitive performance or risk of cognitive decline on a selected battery of cognitive tests in older community‐dwelling women. Worse performance on two cognitive tests among women with higher estrone levels was surprising and warrants further investigation.
Oxidative Stress and Advancing Age: Results in Healthy Centenarians
Authors: Paolisso Giuseppe , Tagliamonte Maria Rosaria , Rizzo Maria Rosaria , Manzella Daniela , Gambardella Antonio , Varricchio Michele
Published: April 2015

OBJECTIVE: Our study aims at investigating the degree of oxidative stress in centenarians

DESIGN: Indices of oxidative stress (reaction products of malondialdehyde with thiobarbituric acid (TBARS) and lipid hydroperoxides (LPO)), and plasma concentrations of antioxidant defenses (plasma vitamin E and C concentrations and reduced/oxidized glutathione ratio (GSH/GSSG)) were determined.

SUBJECTS: Eighty‐two subjects volunteered for the study. They were divided into three groups: (1) adults (< 50 years of age, n = 30); (2) aged subjects (70–99 years, n = 30); (3) centenarians (age ≥ 100 years, n = 22).

MEASUREMENTS: TBARS and LPO, plasma vitamin E and C concentrations, and plasma GSH/GSSG ratio were determined. Insulin action was assessed by euglycemic hyperinsulinemic glucose clamp.

MAIN RESULTS: TBARS (0.44±0.07 vs 0.31 ±.05 nmol malondialdehyde/mL plasma, P =.020) and LPO (0.36 ± 0.05 vs 0.31 ±.04 μmol/L, P =.050) were lower in centenarians than in aged subjects. In contrast, plasma GSH/GSSG ratio (0.82 ± 0.09 vs 1.17 ±.06, P =.010), vitamin C (72.3 ± 4.6 vs 59.4 ± 3.8 μmol/L P =.010), and vitamin E (29.1 ± 2.2 vs 24.4 ± 2.3 μmol/L P =.050) concentrations were more elevated in centenarians than in aged subjects. Differences in daily vegetable intake, in fasting plasma glucose and free fatty acid (FFA) concentrations, and in insulin action are significant determinants of degree of oxidative stress. A specific genetic background in centenarians might also provide a possible explanation.

CONCLUSIONS: The degree of oxidative stress is lower in healthy centenarians than in aged subjects.
Elder Abuse in the Community: Prevalence and Consequences
Authors: Comijs Hannie C. , Pot Anne Margriet , Smit Johannes H. , Bouter Lex M. , Jonker Cees
Published: April 2015

OBJECTIVES: (1) To assess the prevalence and the consequences of chronic verbal aggression, physical aggression, financial mistreatment, and neglect in a community‐based sample; (2) to investigate the circumstances that led to the abuse and the ways in which the victims handled the problem.

DESIGN: Prevalence was assessed in a population‐based sample of 1797 older people living independently in Amsterdam, the Netherlands. In a follow‐up study 1 year later, the victims were questioned again about the background and consequences of the abuse.

RESULTS: The 1‐year prevalence of elder abuse was 5.6%. The prevalence of the various types of elder abuse was: verbal aggression 3.2%, physical aggression 1.2%, financial mistreatment 1.4%, and neglect 0.2%. Most victims reported emotional reactions immediately after the abuse. Seven of 36 victims experienced physical or financial damage as a consequence of the abuse. More than 70% of the victims were able to stop the abuse, either by themselves or with the help of others.

CONCLUSION: The rate of occurrence and the consequences of elder abuse in the Netherlands was established. Elder abuse is more widely spread if not only close relatives or people with whom the older person lives are considered as possible perpetrators but other familiar and trusted people are considered as well. Intervention should be focused on the roughly 40% of victims who were not able to stop the abuse.
The Use of Mammography by Women Aged 75 and Older: Factors Related to Health, Functioning, and Age
Authors: Blustein Jan , Weiss Linda J.
Published: April 2015

BACKGROUND AND OBJECTIVES: Mammographic screening for breast cancer is of uncertain clinical benefit for women 75 years of age and older. Some have argued against instituting routine screening in this age group, noting that disability and shorter life expectancy may diminish the desirability and cost‐effectiveness of screening. We sought to determine the extent to which health, functioning, and age influence mammography use in this cohort.

DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of a representative sample of women in the US aged 75 and older (n = 2352) who participated in the Medicare Current Beneficiary Survey.

MEASURES: Information about general health, level of functioning, medical history, age, and various sociodemographic characteristics elicited in the survey was linked with subjects' Medicare bills for 1991 and 1992 to ascertain patterns of mammography use.

RESULTS: Overall, 26.7% of the women had mammograms during the 2‐year period. Advanced age was associated with a decreased likelihood of receiving a mammogram. This did not reflect simply the decline in health and functioning that may accompany aging; those aged 85 and older were less likely to receive mammograms than those in the 75 to 79 age group, controlling for general health, medical history, functional status, and sociodemographic factors (adjusted OR =.41; 95% CI = 0.27 to 0.64). ADL limitations were also associated independently with decreased mammography use. For example, controlling for age, women with any limitations in Activities of Daily Living were 0.71 times as likely to have mammograms as women without ADL limitations (95% CI = 0.59 to 0.85). However, several comorbid conditions, including hypertension, diabetes mellitus, and a history of myocardial infarction were not significantly related to mammography use.

CONCLUSIONS: Within the cohort of women aged 75 and older, more advanced age and impaired functional status both substantially reduce the likelihood of mammography use. The extent to which this reflects patients' informed decisions, physicians' judgments, or other factors remains to be explored. J Am Geriatr Soc 46:941–946, 1998.
Hypoglycemia in Hospitalized Nondiabetic Older Patients
Authors: Shilo Shmuel , Berezovsky Svetlana , Friedlander Yechiel , Sonnenblick Moshe
Published: April 2015

OBJECTIVES: To analyze the clinical characteristics, associated risk factors, and outcome of hypoglycemia in nondiabetic hospitalized older patients.

DESIGN: A retrospective case control study.

PARTICIPANTS: Sixty patients, aged 65 years and older, in the acute medical and geriatric wards who developed hypoglycemia. A control group was composed of 83 older patients, sex and age matched, in orthopedic and surgery wards who were undergoing corrective surgery for hip fracture or hernioplasty.

MEASUREMENTS: For all patients, data for the following variables were abstracted from the charts: age, sex, degree of hypoglycemia, clinical presentation of hypoglycemia, number and duration of hypoglycemia episodes, nutritional state, and blood chemistry analysis. Risk factors were defined as nutritional state, heart failure, renal or liver disease, malignancy, and infection or sepsis.

RESULTS: Mean blood glucose in hypoglycemic cases was 38.9 ± 7 mg/dL. Symptoms and signs of hypoglycemia were noted in only 38.4% (23/60) of patients. All identified risk factors except cachexia were found significantly more frequently in the hypoglycemic patients than in the control group. Mean total number of risk factors was greater in the hypoglycemic group than in the control group, 2.97 ± 1.1 versus 1.64 ±.8, respectively (P <.001). In a multivariant logistic model, low plasma albumin level, liver disease, malignancy, and congestive heart failure were significant predictors of hypoglycemia. In‐hospital mortality rate was higher among the hypoglycemic patients, 48% versus 18.1% (P <.001), and was independent of the degree of hypoglycemia or the number of hypoglycemic episodes. Mortality was correlated significantly with the number of risk factors (3.4 ± 1.1 vs 2.5 ± 1.1; P =.006). Hypoglycemia remained a significant predictor of mortality (OR = 3.67; 95% CI, 1.2–11.2) even after the adjustment for other risk factors.

CONCLUSIONS: Hypoglycemic episodes occur even among nondiabetic hospitalized older patients. Symptoms and signs of hypoglycemia were noted in only two‐fifths of the patients. Albumin less than 3.0 g%, liver disease, renal insufficiency, malignancy, congestive heart failure, and sepsis were statistically significant predictors of developing hypoglycemia. The overall mortality rate was significantly higher among the hypoglycemic patients and was independent of hypoglycemia levels. Mean total number of risk factors was significantly higher among those who died compared with hypoglycemic patients who survived. Based on the present study, the estimated odds of mortality in an older patient with hypoglycemia were 3.67 times higher than in those without hypoglycemia. J Am Geriatr Soc 46:978–982, 1998.
Outcomes of Anesthesia and Surgery in People 100 Years of Age and Older
Authors: Warner Mark A. , Saletel Rachel A. , Schroeder Darrell R. , Warner David O. , Offord Kenneth P. , Gray Darryl T.
Published: April 2015

OBJECTIVE: To assess the outcomes of anesthesia and surgery for men and women 100 years of age and older.

DESIGN: Retrospective cohort study in the 20‐year time period from 1975 to 1994, with follow‐up through 1995.

SETTING: Mayo‐affiliated hospitals and Olmsted Community Hospital, Rochester, Minnesota.

PARTICIPANTS: All men and women 100 years of age and older who underwent surgery at a participating hospital.

MEASUREMENTS: Forty‐eight‐hour and 30‐day perioperative morbidity and mortality; long‐term survival.

RESULTS: Thirty‐one men and women aged 100 to 107 years underwent 42 procedures. One major complication (3%) within 48 hours was observed. The 48‐hour, 30‐day, and 1‐year mortality rates were 0%, 16.1%, and 35.5%, respectively. When compared with survival rates for age‐, gender‐, and calendar year of birth‐matched peers from the general population, the survival rate for centenarians who underwent surgery and anesthesia was comparable to the rate expected.

CONCLUSION: These data suggest that people 100 years of age and older who have operable diseases or injuries should not be denied surgical interventions because of perceived risks associated with their advanced age. J Am Geriatr Soc 46:988–993, 1998.
Anterior Cervical Osteophytes as a Cause of Pharyngeal Stage Dysphagia
Authors: Granville Lisa J. , Musson Nan , Altman Roy , Silverman Michael
Published: April 2015

OBJECTIVE: To describe the association of anterior cervical osteophytes impairing epiglottic movement as an etiology of pharyngeal stage dysphagia.

DESIGN: A retrospective chart review.

SETTING: An academic affiliated Veterans Affairs Medical Center.

PATIENTS: Veterans 60 years of age or older referred to speech pathology for dysphagia evaluation.

RESULTS: Of 376 veterans evaluated consecutively since 1990, 40 patients had dysphagia determined to be secondary to cervical bony protuberances. The evaluation and management of three cases with functional consequences at level C3–5 with no dysphagia etiology present are described.

CONCLUSION: Cervical osteophytes need to be considered in the differential diagnosis of dysphagia in older people. J Am Geriatr Soc 46:1003–1007, 1998.
The Association of Urinary Incontinence with Poor Self‐Rated Health
Authors: Johnson Theodore M. , Kincade Jean E. , Bernard Shulamit L. , Busby‐Whitehead Jan , Hertz‐Picciotto Irva , DeFriese Gordon H.
Published: April 2015

OBJECTIVES: To assess whether urinary incontinence (UI) and its severity are associated with poor self‐rated health in a national sample of community‐living older adults and whether this relationship persists after controlling for confounding attributable to functional status, comorbidity, and demographic factors.

DESIGN: A cross‐sectional analysis using multivariate logistic regression.

SETTING: Subjects were from the 1990–1991 National Survey of Self‐Care and Aging (N = 3485), a random sampling in geographic clusters of community‐dwelling Medicare beneficiaries 65 years of age or older in the contiguous United States.

MEASURES: The responses to an interviewer‐administered questionnaire regarding urinary incontinence, Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living (IADL), Mobility Activities of Daily Living (MADL), age, gender, place of residence, race, education, need for proxy response to the survey, and number of medical conditions.

RESULTS: Unadjusted analysis showed the presence of urinary incontinence to be associated with poor self‐rated health (OR 2.7, 2.1–3.3). With gender, number of comorbid conditions, race, IADL impairment, and interaction terms of incontinence/race and incontinence/IADL in the final model, UI was associated with poor self‐rated health in certain subgroups. White subjects with no IADL impairment and mild‐moderate incontinence had an OR of 2.0 (95% CI 1.5–2.9) and those with severe incontinence had an OR of 4.5 (95% CI 2.4–8.4) of rating their health as poor, whereas those with no IADL impairment and no incontinence were the referent group. For those with a lot of difficulty performing one or more IADL activity, the association of UI and poor self‐rated health was weak. For non‐white subjects, there was no association, or a very weak association, of UI and poor self‐rated health.

CONCLUSION: In this national sample, urinary incontinence was independently and positively associated with poor self‐rated health after adjustment for age, comorbidity, and frailty for most community‐dwelling older adults. This association between UI and poor self‐rated health was weaker and statistically insignificant when IADL impairment was present or in non‐white subjects. Further research is indicated to better understand the impact of urinary incontinence in specific cultural settings.
Causes and Prognosis of Acute Renal Failure in the Very Old
Authors: Pascual Julio , Liaño Fernando ,   Madrid Acute Renal Failure Study Group
Published: April 2015

OBJECTIVES: There is a tendency to treat older people with Acute Renal Failure (ARF) less aggressively because of the presumed less acceptable end results. This has not been proved, and their prognosis may be similar to that found in the younger population. There are no studies on the incidence, causes, and evolution of ARF in patients 80 years of age and older.

DESIGN: A multicenter, prospective, longitudinal study.

SETTING: The 13 hospitals with nephrology units that serve the 4.2 million people in Madrid, Spain.

MEASUREMENTS: A number of demographic, clinical, and therapeutic variables were studied in each case.

RESULTS: One hundred three episodes of ARF occurred in patients 80 years of age and older (Group 1), 256 in patients aged 65 to 79 years (Group 2), and 389 in people younger than age 65 (Group 3). Acute tubular necrosis was diagnosed in 39% of cases in Group 1, in 48% in Group 2, and in 55% in Group 3 (P = .004, 1 vs 3); prerenal ARF was diagnosed in 30%, 28%, and 21% (P = .054, 1 vs 3) and obstructive ARF in 20%, 11%, and 7% (P < .001, 1 vs 3) of cases, respectively. Serum creatinine at admission, peak values, values at discharge or death, duration of both admission and ARF episode, and mortality were similar in all groups. In stratified analysis, relative risk for mortality in patients aged more than 80 years was 1.09 [95% CI 0.86, 1.36 (P = .562)], and in those aged 65 to 79 it was 0.99 [95% CI 0.83, 1.18 (P = .954)] compared with patients aged less than 65 years. Risk of death was also similar when only acute tubular necrosis cases were considered. Sustained hypotension was associated with higher mortality (44% of nonsurviving older persons vs 9% of survivors, P < .001).

CONCLUSION: Age is not a particularly poor prognostic sign, and outcome seems to be within acceptable limits for very old patients with ARF. Acute dialysis should not be withheld from patients solely because they are more than 80 years of age.
Alzheimer's Disease Under Managed Care: Implications from Medicare Utilization and Expenditure Patterns
Authors: Weiner Michael , Powe Neil R. , Weller Wendy E. , Shaffer Thomas J. , Anderson Gerard F.
Published: April 2015

BACKGROUND: Little information is available about the costs, utilization patterns, and the delivery system used by Medicare beneficiaries with chronic illnesses. This information will become increasingly important as more Medicare beneficiaries with chronic illness enroll in managed care plans and delivery systems must be developed to meet their needs.

OBJECTIVES: To analyze health care expenditures and utilization patterns for Medicare beneficiaries with dementia of the Alzheimer type (DAT) and compare them with those of all Medicare beneficiaries.

DESIGN: A cross‐sectional study.

SETTING: Practices providing services to Medicare beneficiaries in the U.S.

SUBJECTS: Aged Medicare beneficiaries with DAT in fiscal year (FY) 1992.

MEASUREMENTS: Medical expenditures and utilization patterns.

RESULTS: In FY 1992, per capita Medicare expenditures for 9323 patients with DAT were $6208, or 1.9 times the per capita expenditure for all 1,221,615 beneficiaries in our sample. Inpatient care accounted for 62.7% of expenditures. Internal medicine was the specialty identified with the largest proportion of expenditures, but no single specialty accounted for the majority of care. Payments increased with comorbid conditions such as heart failure, chronic pulmonary diseases, and cerebrovascular disease.

CONCLUSION: Current Medicare capitation payments to managed care plans may not meet the higher expected annual costs of care for beneficiaries with DAT. In turn, physicians (or physician groups) who accept capitation for Medicare beneficiaries with DAT should also consider how capitation rates are established by managed care plans and should learn ways to reduce financial risk.
Developing Rehabilitative Behavioral Interventions for Long‐Term Care: Technology Transfer, Acceptance, and Maintenance Issues
Authors: Schnelle John F. , Cruise Patrice A. , Rahman Annie , Ouslander Joseph G.
Published: April 2015

Rehabilitative behavioral interventions that are documented in clinical trials to improve nursing home resident outcomes and are recommended by practice guidelines are often not adapted for daily use in nursing homes and other long‐term care (LTC) facilities. Failure to evaluate issues other than clinical efficacy when developing interventions contributes to this gap between efficacy and effectiveness in practice. A potential solution is a research model that supplements traditional clinical intervention research with methodology designed specifically to evaluate the ability of LTC facilities to implement the interventions. This paper discusses several critical issues of intervention and implementation that should be addressed, including targeting interventions, advocacy, cost‐effectiveness, training, and quality control. We also describe how clinical trials could be designed and staged to increase the probability that effective interventions will be implemented in the day‐to‐day care of frail older patients in LTC facilities. J Am Geriatr Soc 46:771–777, 1998.
Emerging Antidementia Drugs: A Preliminary Ethical View
Authors: Post Stephen G. , Whitehouse Peter J.
Published: April 2015

What ethical concerns regarding the application of new antidementia compounds are pertinent to the best interests of patients with Alzheimer's disease and their caregivers? Based on collected preliminary anecdotal accounts, these concerns are important and should be considered carefully by clinicians, researchers, and families.
Preventing Disability and Managing Chronic Illness in Frail Older Adults: A Randomized Trial of a Community‐Based Partnership with Primary Care
Authors: Leveille Suzanne G. , Wagner Edward H. , Davis Connie , Grothaus Lou , Wallace Jeffrey , LoGerfo Marianne , Kent Daniel
Published: April 2015

BACKGROUND: Effective new strategies that complement primary care are needed to reduce disability risks and improve self‐management of chronic illness in frail older people living in the community.

OBJECTIVE: To evaluate the impact of a 1‐year, senior center‐based chronic illness self‐management and disability prevention program on health, functioning, and healthcare utilization in frail older adults.

DESIGN: A randomized controlled trial.

SETTING: A large senior center located in a northeast Seattle suburb. The trial was conducted in collaboration with primary care providers of two large managed care organizations.

PARTICIPANTS: A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practices.

INTERVENTION: A targeted, multi‐component disability prevention and disease self‐management program led by a geriatric nurse practitioner (GNP).

MEASUREMENTS: Self‐reported Physical function, physical performance tests, health care utilization, and health behaviors.

RESULTS: Each of 101 intervention participants met with the GNP from 1 to 8 times (median = 3) during the study year. The intervention group showed less decline in function, as measured by disability days and lower scores on the Health Assessment Questionnaire. Other measures of function, including the SF‐36 and a battery of physical performance tests, did not change with the intervention. The number of hospitalized participants increased by 69% among the controls and decreased by 38% in the intervention group (P = .083). The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls (total days = 33 vs 116, P = .049). The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications.

CONCLUSIONS: This project provides evidence that a community‐based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults. Linking organized medical care with complementary community‐based interventions may be a promising direction for research and practice.
The Effect of Vitamin B12 Deficiency on Older Veterans and Its Relationship to Health
Authors: Bernard Marie A. , Nakonezny Paul A. , Kashner T. Michael
Published: April 2015

OBJECTIVE: To examine the effect of vitamin B12 deficiency on older veterans and its relationship to general health and cognitive impairment.

DESIGN: Cross‐sectional study.

SETTING: Oklahoma City Veterans Affairs Medical Center.

PARTICIPANTS: Data for this research were obtained from 303 ambulatory, older veterans who used the outpatient laboratories of the Oklahoma City Department of Veterans Affairs Medical Center. Subjects were included in the study if they were 65 years of age and older and if they had no known diagnosis associated with B12 deficiency. The sample in this study consisted of 301 men and 2 women aged 65 to 89 years.

MEASUREMENTS: This study used two separate measurements of vitamin B12 deficiency: (1) a strict definition of B12 deficiency (serum B12 level < laboratory norm) and (2) a broader definition of B12 deficiency (serum B12 level < laboratory norm or laboratory norm < B12 < 300 pg/mL and methyl malonic acid (MMA) or homocysteine (HC) elevated by more than two standard deviations). The laboratory norm is 200 pg/mL. The dependent variables were measures of cognitive impairment and general health. Cognitive impairment was measured using the Folstein Mini‐Mental State Examination (MMSE) and general health was measured using the RAND 36–Item Health Survey Version 1.0. The control variables for this study were the subjects' daily alcohol intake, daily intake of a vitamin/mineral supplement, annual income, and level of education.

RESULTS/CONCLUSIONS: Nineteen subjects (6%) were vitamin B12‐deficient as measured by the strict definition of B12 deficiency (serum B12 level < laboratory norm), and 49 subjects (16%) were vitamin B12‐deficient as measured by the broader definition of B12 deficiency (serum B12 level < laboratory norm or laboratory norm < B12 < 300 pg/mL and MMA or HC elevated by more than two standard deviations). Vitamin B12 level decreases as age increases. Of the nine general health outcomes measured by using the RAND 36‐Item Health Survey, only bodily pain is associated with vitamin B12 deficiency, and only then when B12 deficiency is measured as serum B12 level < laboratory norm, the strict definition of B12 deficiency. Vitamin B12‐deficient subjects experience more bodily pain than those with normal vitamin B12 levels. There is a significant difference between B12‐deficient subjects and B12 normal subjects on cognitive impairment, with B12 normal subjects indicating less cognitive impairment, only when B12 deficiency is measured as B12 level < laboratory norm, the strict definition of B12 deficiency. The broader measurement of vitamin B12 deficiency (i.e., serum B12 level < laboratory norm or laboratory norm < B12 < 300 pg/mL and MMA or HC elevated by more than two standard deviations) is not a significant correlate of cognitive impairment and general health.
Exercise to Improve Spinal Flexibility and Function for People with Parkinson's Disease: A Randomized, Controlled Trial
Authors: Schenkman Margaret , Cutson Toni M. , Kuchibhatla Maggie , Chandler Julie , Pieper Carl F. , Ray Laurie , Laub Kathryn C.
Published: April 2015

OBJECTIVES: The effectiveness of an exercise intervention for people in early and midstage Parkinson's disease (stages 2 and 3 of Hoehn and Yahr) in improving spinal flexibility and physical performance in a sample of community‐dwelling older people is described.

DESIGN AND SETTING: Fifty‐one men and women, aged 55–84 years, identified through advertisement, local support groups, and local neurologists were enrolled into a randomized, controlled trial. Subjects were assigned randomly to an intervention or a usual care arm (i.e., no specific exercise). Of the original 51 participants, 46 completed the randomized, controlled trial. Participants in the exercise arm (n = 23) received individual instruction three times per week for 10 weeks. Participants in the usual care arm (n = 23) were “wait listed” for intervention.

MEASUREMENTS: Changes over 10 weeks in spinal flexibility (i.e., functional axial rotation) and physical performance (i.e., functional reach, timed supine to stand) were the primary outcome measures.

RESULTS: MANOVA conducted for the three primary outcome variables demonstrated significant differences (P≤: s .05) between the two groups. Further analysis using ANOVA demonstrated significant differences between groups in functional axial rotation and functional reach for the intervention compared with the control group. There was no significant difference in supine to sit time.

CONCLUSION: Study results demonstrate that improvements in axial mobility and physical performance can be achieved with a 10‐week exercise program for people in the early and midstages of PD.
The Association of Non‐Insulin‐Dependent Diabetes Mellitus and Cognitive Function in an Older Cohort
Authors: Scott Ronald D. , Kritz‐Silverstein Donna , Barrett‐Connor Elizabeth , Wiederholt Wigbert C.
Published: April 2015

OBJECTIVE: In this study, we examined the association of non‐insulin‐dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) with cognitive function in a population‐based sample of older individuals.

RESEARCH DESIGN AND METHODS: Subjects were 1509 healthy, community‐dwelling men and women aged 55 years and older who were participants in the Rancho Bernardo Study and attended clinic visits in 1984–87 and in 1988–91. An oral glucose tolerance test was administered during the 1984–87 visits. Based on World Health Organization criteria, participants were classified into those with NIDDM, IGT, or normal glucose tolerance. During the 1988–91 clinic visits, 12 tests of cognitive function were administered.

RESULTS: Of the participants, 14.3% of the men and 9.9% of the women had NIDDM, and 21.0% of the men and 28.0% of the women had IGT. Multiple regression analysis was used to compare the cognitive function of individuals with NIDDM and IGT with individuals with normal glucose tolerance after adjustment for age, education, obesity, depression, blood pressure, and current estrogen use. In men, there were no statistically significant differences in any of the 12 cognitive function tests by glucose tolerance category. Compared with those with normal glucose tolerance, women with IGT had lower scores on almost every cognitive function test, whereas women with NIDDM had higher scores, but none of these differences were statistically significant after adjustment for multiple comparisons. Futhermore, observed differences by NIDDM or IGT status were small and accounted for <0.6% of the explained variance in cognitive function.

CONCLUSIONS: This study shows no strong or consistent association between IGT or mild diabetes with cognitive function in community‐dwelling older adults.
Clock Drawing Test in Very Mild Alzheimer's Disease
Authors: Esteban‐Santillan Concepcion , Praditsuwan Rungnirand , Veda Hideki , Geldmacher David S.
Published: April 2015

OBJECTIVES: The primary objective of this study was to determine the efficacy of the clock drawing test to predict the presence of very mild Alzheimer's disease (AD). A secondary objective was to identify elements of clock drawing that were most useful in differentiating cognitively intact older adults from those with mild Alzheimer's disease.

DESIGN: Cohort based comparison of retrospective data.

SETTING: Academic research center.

PARTICIPANTS: Clock drawings from 41 outpatient cases of mild AD with Mini‐Mental State Exam scores of 24 or higher and 39 age‐ and education‐matched older adults were scored.

MEASUREMENTS: Clock drawings were blindly and independently scored by two raters using the Clock Drawing Interpretation Scale and the scoring system reported by Rouleau et al. Predictive values for positive and negative tests were calculated using cut‐off scores for total score and component subscores from each of these two systems.

RESULTS: Two or more errors in the depiction of the clock hands on the Clock Drawing Interpretation Scale had a positive predictive value for AD of 100% and a negative predictive value of 51%. A score of 2 or less on the 4‐point hand‐placement component of the Rouleau et al. scoring system provided a positive predictive value for AD of 94% and was associated with a negative predictive value of 62%.

CONCLUSION: An individual who commits two errors or more in drawing the clock hands deserves further investigation for a possible dementia. Normal hand placement on the clock drawing test does not exclude AD. However, when prevalence rates of dementia in community‐dwelling older adults are considered, these results argue that normal clock hand placement indicates that dementia is unlikely.
Contribution of Individual Items to the Performance of the Norton Pressure Ulcer Prediction Scale
Authors: Perneger Thomas V. , Gaspoz Jean‐Michel , Raë Anne‐Claire , Borst François , Héliot Céliane
Published: April 2015

OBJECTIVES: To assess the specific contribution to overall scale performance of each of the five items that constitute the Norton pressure ulcer prediction scale.

DESIGN: A comparison of statistical models based on cross‐sectional surveys of hospitalized patients.

SETTING: An urban teaching hospital in Geneva, Switzerland.

PARTICIPANTS: 2373 hospitalized patients who were free of pressure ulcers on admission.

MEASUREMENTS: Norton scale items measuring activity, mobility, physical condition, mental condition, and incontinence on a 4‐point scale were examined as predictors of stage 1 or greater pressure ulcers.

RESULTS: A total of 245 new pressure ulcers occurred between admission and patient observation. After adjustment for other independent predictors in proportional hazards models, only the activity and mobility items remained associated significantly with the risk of pressure ulcer. A simplified 2‐item scale was more strongly associated with pressure ulcer risk than was the classic 5‐item Norton scale.

CONCLUSIONS: Our study suggests that the activity and mobility items of the Norton scale are sufficient to express the risk of pressure ulcers in hospitalized patients. Confirmation of this finding in prospective studies is warranted.
On the Number of Automated Timed Manual Performance Trials to Administer
Authors: Busby‐Whitehead Jan , Robinson Pamela S. , Matteson Elizabeth S. , Rosemond Cherie , PhD William L. Dunn
Published: April 2015

OBJECTIVE: To determine the number of trials needed to obtain satisfactory results when evaluating function in older subjects using the automated version of the Williams short (three‐door) Timed Manual Performance (TMP) test.

DESIGN: Administration of from one to five trials in succession on a given test date.

SETTING: A Continuing Care Retirement Community (CCRC), assisted living centers, nursing homes, and a community residence, all located in central North Carolina.

PARTICIPANTS: The subject population consisted of 182 older volunteers, aged 63 to 100 years. One hundred nineteen lived independently in a CCRC, 33 were assisted‐living residents, 29 lived in nursing homes, and one lived independently in the community. Each subject was administered at least three trials in succession on his or her first test date; 23 of the independently living CCRC residents were given three trials on a second test date. The community‐dwelling volunteer was administered from one to five trials on each of 26 test dates over an approximately 16‐month period.

MEASUREMENTS: The time it takes to perform five door opening and closing operations as measured by the three‐door Cognatemp® Automated Timed Manual Performance (ATMP) system.

MAIN RESULTS: Average ATMP time for the subjects living independently decreased approximately 10% between the first two trials but negligibly between trials two and three. The more dependent groups continued to improve between trials two and three. The community‐dwelling subject tended to improve in the first three or four trials and to decline by the fifth trial.

CONCLUSIONS: It is recommended that two trials be administered and the best time used; if neither trial results in a time less than 10 seconds, one or two more trials should be administered. It is generally not necessary nor advantageous to administer more than four trials.
A Prospective Study of the Use of Liquid Oral Dietary Supplements in Nursing Homes1
Authors: Kayser‐Jones Jeanie , Schell Ellen S. , Porter Carol , Barbaccia Joseph C. , Steinbach Catherine , Bird William F. , Redford Maryann , Pengilly Kathryn
Published: April 2015

OBJECTIVE: To investigate the use of liquid oral dietary supplements among nursing home residents who were eating poorly and losing weight.

DESIGN: A prospective, descriptive, anthropological study.

SETTING: Two proprietary nursing homes with 105 and 138 beds.

PARTICIPANTS: Purposive sampling was used to select 40 residents from among the 100 residents who were not eating well. Dietary data were collected on this sub‐sample of 40 residents.

MEASUREMENTS: Participant observation, in‐depth interviews, event analysis, bedside dysphagia screenings, oral health examinations, body weight, body mass index (BMI), and chart review were used to collect data. Dietary data were collected over a 3‐day period, and data were gathered on how supplements were ordered, served, and consumed.

RESULTS: Supplements had been ordered for 29 of the subsample of 40 residents. Only nine of 29 residents were served the correct number and type of supplements as ordered by their physicians, and only two residents consumed the full amount of supplement as ordered. The overall mean percentage of supplement consumed compared with that ordered was 55.1%. Although supplements were ordered primarily to prevent weight loss and to facilitate weight gain, nearly half (n = 14) of the residents continued to lose weight. Supplements were ordered without investigating the underlying factors contributing to weight loss, such as inadequate staffing and lack of supervision at mealtime, undiagnosed dysphagia, and poor oral health. Without evaluation of these factors, it is unknown which residents might benefit from oral supplements.

CONCLUSION: Findings indicate that supplements were used nonspecifically as an intervention for weight loss in nursing home residents without regard to dose, diagnosis and management of underlying problem(s), amount of supplement consumed, and outcome. Further research is needed to establish when supplements should be ordered, how to ensure that they will be taken, and whether they are effective.
Reproductive and Hormonal Risk Factors for Urinary Incontinence in Later Life: A Review of the Clinical and Epidemiologic Literature
Authors: Thorn David H. , Brown Jeanette S.
Published: April 2015

OBJECTIVES: To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life.

DESIGN: An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence.

RESULTS: Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross‐sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short‐term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies.

CONCLUSIONS: This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.
Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip‐Fracture
Authors: Feldt Karen S. , Ryden Muriel B. , Miles Steven
Published: April 2015

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

DESIGN: Prospective comparative survey design.

PARTICIPANTS: A convenience sample of 88 hip fracture patients (53 cognitively impaired, 35 cognitively intact) from three Midwestern urban hospital orthopedic units was interviewed between days 2 and 5 postoperatively. Subjects whose Folstein Mini‐Mental State Exam (MMSE) score was less than or equal to 23 were categorized as impaired.

RESULTS: Pain report and intensity did not differ significantly between the two groups. One‐third of the subjects in both groups rated pain as severe or worse. Cognitively impaired subjects scored significantly higher on the Checklist of Nonverbal Pain Indicators observed with movement (CNPI‐m) than did cognitively intact subjects. Cognitively impaired subjects received significantly less opioid analgesics than cognitively intact subjects in the first and second 48 hours postoperatively. Both groups received less than 25% of the mean prescribed amount of opioid analgesics. Age, MMSE, and CNPI‐m score accounted for 27% of the variance in the amount of opioid analgesic administered in the first 48 hours postoperatively.

CONCLUSIONS: Pain is treated poorly in older postoperative patients. Cognitive impairment and age strongly influence the amount of analgesic nurses administer to older patients after surgical repair of hip fracture. Provision for patient comfort is a fundamental ethical obligation of healthcare providers. Clinicians need to pursue this goal more aggressively, especially for cognitively impaired, postoperative older adults.
A Prospective Study of the Efficacy of the Physician Order Form for Life‐Sustaining Treatment
Authors: Tolle Susan W. , Tilden Virginia P. , Nelson Christine A. , Dunn Patrick M.
Published: April 2015

OBJECTIVES: The Physician Orders for Life‐Sustaining Treatment (POLST), a comprehensive, one‐page order form, was developed to convey preferences for life‐sustaining treatments during transfer from one care site to another. This study examined the extent to which the POLST form ensured that nursing home residents' wishes were honored for Do Not Resuscitate (DNR) and requests for transfer only if comfort measures fail.

DESIGN: The study used chart record data to follow prospectively a sample of nursing home residents with the POLST.

SETTING: Eight geographically diverse, long‐term, adult‐care facilities in Oregon in which the POLST was in use.

PARTICIPANTS: Nursing home residents (n = 180), who had a POLST recording DNR designation and who indicated a desire for transfer only if comfort measures failed, were followed for 1 year.

MEASUREMENTS: For all subjects: treatment and disposition after significant health status changes; orders for narcotics and for provision or limitation of aggressive interventions. For hospitalized subjects: diagnosis, medical interventions, and DNR orders. For those who died: cause and location of death, life‐sustaining treatments attempted, and comfort measures provided.

RESULTS: No study subject received CPR, ICU care, or ventilator support, and only 2% were hospitalized to extend life. Of the 38 subjects who died during the study year, 63% had an order for narcotics, and only two (5%) died in an acute care hospital. A total of 24 subjects (13%) were hospitalized during the year. Hospitalized subjects' mean length of stay was 4.9 days, and the mean rate of hospitalizations for all subjects was 174 per 1000 resident years. In 85% of all hospitalizations, patients were transferred because the nursing home could not control suffering. In 15% of hospitalizations (n = 4), the transfer was to extend life, overriding POLST orders.

CONCLUSIONS: POLST orders regarding CPR in nursing home residents in this study were universally respected. Study subjects received remarkably high levels of comfort care and low rates of transfer for aggressive life‐extending treatments.