Showing papers in "Age and Ageing in 1997"

Comfortable and maximum walking speed of adults aged 20—79 years: reference values and determinants

Abstract: Objectives: to establish reference values for both comfortable and maximum gait speed and to describe the reliability of the gait speed measures and the correlation of selected variables with them. Design: descriptive and cross-sectional. Methods: subjects were 230 healthy volunteers. Gait was timed over a 7.62 m expanse of floor. Actual and height normalized speed were determined. Lower extremity muscle strength was measured with a hand-held dynamometer. Results: mean comfortable gait speed ranged from 127.2 cm/s for women in their seventies to 146.2 cm/s for men in their forties. Mean maximum gait speed ranged from 174.9 cm/s for women in their seventies to 253-3 cm/s for men in their twenties. Both gait speed measures were reliable (coefficients > 0.903) and correlated significantly with age (r^ — 0.210), height (r^ 0.220) and the strengths of four measured lower extremity muscle actions (r = 0.190-0.500). The muscle action strengths most strongly correlated with gait speed were nondominant hip abduction (comfortable speed) and knee extension (maximum speed). Conclusions: these normative values should give clinicians a reference against which patient performance can be compared in a variety of settings. Gait speed can be expected to be reduced in individuals of greater age and of lesser height and lower extremity muscle strength.

Circumstances and consequences of falls in independent community-dwelling older adults

Abstract: BACKGROUND: knowledge of the circumstances and consequences of falls in older adults is important for understanding the aetiology of falls as well as for effective clinical assessment and design of fall prevention strategies. Such data, however, are relatively scarce, especially in community-dwelling elders. METHOD: accidental falls (including their circumstances and consequences) occurring in 96 male and female participants between 60 and 88 years of age were monitored prospectively for 1 year. After the monitoring period, participants were divided into three groups based on fall status: non-fallers (n = 46), one-time fallers (n = 27) and recurrent fallers (n = 23). Frequency distributions were created for selected circumstances and consequences of falls and the prevalence of these consequences were examined. RESULTS: 50 participants (52%) fell during the 1 year period, amassing 91 falls. Trips and slips were the most prevalent causes of falls, accounting for 59% of falls. Falls most often occurred during the afternoon and while subjects walked on level or uneven surfaces. Fallers most commonly attributed falls to hurrying too much. Fractures resulted from five of the 91 falls and eight other falls resulted in soft tissue injuries that required treatment by a physician. There were no differences between one-time and recurrent fallers in the circumstances and consequences of falls. However, several notable differences were found between men (n = 20) and women (n = 30) who fell. Falls by men most often resulted from slips whereas falls by women most often resulted from trips. Moreover, women and men differed in the time of the year in which falls occurred, with men falling most often during winter and women during summer. CONCLUSIONS: the results of this study provide insight into the circumstances and consequences of falls among independent community-dwelling older adults and suggest some possible ways of preventing falls. Preventive services, however, should not solely target recurrent fallers, nor should the type of services necessarily differ for one-time and recurrent fallers. Language: en

The Parkinson's Disease Questionnaire (PDQ-39): development and validation of a Parkinson's disease summary index score

Abstract: Objectives: to briefly outline the development and validation of the Parkinson's Disease Questionnaire (PDQ-39) and then to provide evidence for the use of the measure as either a profile of health status scores or a single index figure. Design: the PDQ-39 was administered in two surveys: a postal survey of patients registered with local branches of the Parkinson's Disease Society of Great Britain (n = 405) and a survey of patients attending neurology clinics for treatment for Parkinson's disease (n = 146). Data from the eight dimensions of the PDQ-39 were factor-analysed. This produced a single factor on the data from both surveys. Outcome measures: the eight dimensions of the PDQ-39 and the new single index score—the Parkinson's disease summary index (PDSI), together with clinical assessments (the Columbia rating scale and the Hoehn and Yahr staging score). Results: in the postal survey 227 patients returned questionnaires (58.2%). All 146 patients approached in the clinic sample agreed to take part. Higher-order principal-components factor analysis was undertaken on the eight dimensions of the PDQ-39 and produced one factor on both datasets. Consequently it was decided that the scores of the eight domains could be summed to produce a single index figure. The psychometric properties of this index were explored using reliability tests and tests of construct validity. The newly derived single index was found to be both internally reliable and valid. Discussion: data from the PDQ-39 can be presented either in profile form or as a single index figure. The profile should be of value in studies aimed at determining the impact of treatment regimes upon particular aspects of functioning and well-being in patients with Parkinson's disease, while the PDSI will provide a summary score of the impact of the illness on functioning and well-being and will be of use in the evaluation of the overall effect of different treatments. Furthermore, the PDSI reduces the number of statistical comparisons and hence the role of chance when exploring data from the PDQ-39.

Fear of falling and restriction of mobility in elderly fallers

Abstract: Objectives To identify the characteristics of elderly persons who develop a fear of falling after experiencing a fall and to investigate the association of this fear with changes in health status over time. Design A prospective study of falls over a 2-year period (1991-92). Falls were ascertained using bimonthly postcards plus telephone interview with a standardized (World Health Organisation) questionnaire for circumstances, fear of falling and consequences of each reported fall. Each participant underwent a physical exam and subjective health assessment each year form 1990 to 1993. Setting New-Mexico Aging Process Study, USA. Subjects 487 elderly subjects (> 60 years) living independently in the community. Main outcome measures Fear of falling after experiencing a fall. Results 70 (32%) of 219 subjects who experienced a fall during the 2 year study period reported a fear of falling. Women were more likely than men to report fear of falling (74% vs 26%). Fallers who were afraid of falling again had significantly ore balance (31.9% vs 12.8%) and gait disorders (31.9% vs 7.4%) at entry in the study in 1990. Among sex, age, mental status, balance and gait abnormalities, economic resource and physical health, logistic regression analysis show gait abnormalities and poor self-perception of physical health, cognitive status and economic resources to be significantly associated with fear of falling. Subjects who reported a fear of falling experienced a greater increase in balance (P = 0.08), gait (P Conclusion The study indicated that about one-third of elderly people develop a fear of falling after an incident fall and this issue should be specifically addressed in any rehabilitation programme.

Unstable disability and the fluctuations of frailty

Abstract: Despite increasing use in the literature of old age,'frailty' remains an ill-defined term. The components offrailty have not been sufficiently defined to be used toidentify a research population or a group requiring apublic health intervention. It is currently too indefinitea state to be used to identify particular needs in anindividual, indeed being 'too frail' may be used tojustify investigative and therapeutic nihilism. However,we contend that, properly defined, with the majorcontributing factors to frailty teased out, it is a usefulconcept and is the essential component of thatimportant condition of old age—unstable disability.

Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality

Abstract: Objectives: this study examined the association between medically recognized urinary incontinence and risk of several disease conditions, hospitalization, nursing home admission and mortality. Design: review and abstraction of medical records and computerized data bases from 5986 members, aged 65 years and older, of a large health maintenance organization in northern California. Results: there was an increased risk of newly recognized urinary incontinence following a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure in both men and women, after adjustment for age and cohort. The risk of hospitalization was 30% higher in women following the diagnosis of incontinence [relative risk (RR) = 1.3, 95% confidence interval (CD = 1.2-1.5] and 50% higher in men (RR= 1.5, 95% CI = 1.3-1.6) after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women (95% CI = 1.7-2.4) and 3.2 times greater for incontinent men (95% CI = 2.7-3-8). In contrast, the adjusted risk of mortality was only slightly greater for women (RR= 1.1; 95% CI = 0.99-1-3) and men(RR=1.2; 95% CI = 1.1-1.4). Conclusions: urinary incontinence increases the risk of hospitalizati on and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality.

Nursing homes in 10 nations: a comparison between countries and settings

Abstract: Aim: to illustrate demographic differences and recent trends in the provision and structure of long-term care systems in the 10 countries participating in the Resident Assessment Instrument studies (Denmark, France, Iceland, Italy, Japan, The Netherlands, Sweden, Switzerland, the UK and the USA). Method: data were assembled from government documents, statistical yearbooks and articles from journals; supplemental data on long-term care and nursing homes were solicited from colleagues. Results: All 10 countries are developed nations with high life-expectancies. Sweden has the oldest and Iceland the youngest population in this study, with Japan showing the highest ageing rates over the next three decades. Between 2 and 5% of elderly people reside in nursing homes. Interestingly, Iceland, as the youngest country' in this study, has the highest rate of institutionalization (living in residential or nursing homes), while the 'oldest country' (Sweden) has a low rate of institutionalization. In all countries the support ratio (number of elderly people per 100 younger adults) is high and increasing rapidly. Conclusions: no relation appears to exist between the ageing status of a country and the number of nursing home beds. Institutionalization rates among the nations studied differ even more, due at least in part to differences in the organization and financing of long-term care services, in the amount of responsibilit y assumed in the care for disabled elderly people by each sector and the availability of long-term care beds. Facing a rapid ageing of their population, many countries are in the process of health and social care reforms.

Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis

Abstract: Objective: to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture. Design: randomized placebo-controlled trial. Assessments of bone mineral density were made before and at 1 and 2 years after intervention. Standardized and validated measures of physical capacity, self-rated health status and falls were used. Setting: district general hospital outpatient department. Subjects: 165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years. Women were randomly allocated to intervention (self-paced brisk walking) or placebo (upper limb exercises) groups. Intervention: both groups were seen at 3-monthIy intervals to assess progress, measure physical capacity and maintain enthusiasm. The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them. The upper limb exercise placebo group were asked to carry out a series of exercises designed to improve flexibility and fine hand movements, appropriate for a past history of upper limb fracture. Results: drop-outs from both intervention and placebo groups were substantial (41%), although there were no significant differences in bone mineral density, physical capacity or health status between drop-outs and participants. At 2 years, among those completing the trial, bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [mean net difference between intervention and placebo groups 0.019 g/cm2, 95% confidence interval (CI) -0.0026 to +0.041 g/cm2, P = 0.056]. Lumbar spine bone mineral density had increased to a similar extent (+0.017 g/cm2) in both groups. The cumulative risk of falls was higher in the brisk-walking group (excess risk of 15 per 100 person-years, 95% CI 1.4-29 per 100 person-years, P < 0.05). There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups. Conclusion: the promotion of exercise through brisk-walking advice given by nursing staff may have a small, but clinically important, impact on bone mineral density but is associated with an increased risk of falls. Self-paced brisk walking is difficult to evaluate in randomized controlled trials because of drop-outs, placebo group exercise, limited compliance and lack of standardization of the duration and intensity of walking. Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups, such as older women and those at high risk of fractures.

Development of the Nursing Home Resident Assessment Instrument in the USA

Abstract: Background the nursing home Resident Assessment Instrument (RAI) includes a set of core assessment items, known as the Minimum Data Set (MDS), for assessment and care screening and more detailed Resident Assessment Protocols in 18 areas that represent common problem areas or risk factors for nursing home residents. Its primary use is clinical, to assess residents on admission to the nursing home, at least annually thereafter and on any significant change in status and to develop individualized, restorative plans of care. Aim to describe the content and development of the RAI, including US testing for MDS item reliability and validity of the RAI, and the results of a 4-year evaluation of the effects of its clinical use. Conclusions the evaluation found that implementation of the RAI was associated with significant improvements in a variety of measures of process quality, resident functional outcomes and reduced hospitalization. Other uses of the RAI data in the USA-including payment using resident classification systems and, with RAI-based outcome-oriented quality indicators, quality assurance activities-and the status of RAI use in other countries are also summarized.

Environmental hazards in the homes of older people

Abstract: Objectives: to investigate (i) the prevalence of environmental safety hazards in the homes of people aged 70 years and over, (ii) their knowledge of causes of injuries to older people and the safety measures they can implement to prevent such injuries and (iii) the relationship between socio-demographic characteristics of this population group and levels of home environmental hazards. Method: a cross-sectional survey of 425 people aged 70 years and older living in a defined geographical area of Australia. Participants were recruited through their general practitioners. A structured interview completed with each participant included questions on demographics and home safety issues. A home safety inspection was also undertaken using a predetermined rating format. Results: 80% (n = 542) of homes inspected had at least one hazard and 39% (n = 164) had >5 hazards. The bathroom was identified as the most hazardous room, with 66% (n = 279) of bathrooms having at least one hazard. Hazards relating to floor surfaces (62% of homes had one 'flooring' hazard) and absence of appropriate grab or handrails (60% of homes had one or more hazards relating to this) were prevalent. Eighty-eight percent (n — 374) of older people were able to identify falls as the most common cause of injury and 87% (n — 368) were able to accurately name at least one safety measure. Although a significant association was found between the older people's self-assessment of their home's safety and the presence of more than 5 hazards, 30% of those rating their homes as very safe (n = 289) had more than 5 hazards. Logistic regression analysis identified one variable — contact with healthcare service providers—as predictive of the hazard level in older people's homes. Older people who were never visited by service providers were twice as likely to have more than 5 hazards as those who were visited weekly or more often (OR 2.12, 95% CI 1.104, 4.088). Conclusion: many older people are living in potentially hazardous environments. As yet, a causal link between the presence of environmental hazards and falls in older people has not been established. More definitive work in this area needs to be carried out.

Efforts to establish the reliability of the Resident Assessment Instrument

Abstract: Background: since its original implementation in the USA, the Resident Assessment Instrument (RAI) has been used in many countries in languages other than English. This paper describes the efforts that have been made to test the inter-rater reliability of the core set of items forming the minimum data set items in the USA and in non-English speaking countries (Denmark, Iceland, Italy, Japan, Sweden and Switzerland). Results: a large proportion (from 70 to 96%) of the items in the RAI achieved an adequate to excellent level of reliability, with no substantial differences across countries. The RAI met the standard for good reliability (i.e. a K value of 0.6 or higher) in crucial areas of functional status, such as memory, activities of daily living self-performance and support, and bowel and bladder continence in most of the countries. Indicators of mood and behavioural problems achieved adequate reliability levels of 0.4 or higher.

Causes and prognosis of delirium in elderly patients admitted to a district general hospital

Abstract: Background: delirium is common and is associated with a high early mortality, but less is known about the longer term prognosis. Design: case-controlled prospective study. Methods: all relevant wards were contacted weekly by a research nurse and the nurses were asked to report all patients presenting with confusion. Patients satisfying the American Psychiatric Association's Diagnostic and Statistical Manual HI criteria were included. The diagnosis of delirium was confirmed by a consultant physician. Delirious patients were then followed-up throughout their hospital admission to ascertain the cause of their delirium, and assessed for visual and hearing impairment. The patients were assessed again at 6 and 12 months. Control patients, who -were in hospital at the same time and on similar -wards, but were not confused, were also examined and followed-up. Results: 171 patients with delirium were identified (78 men and 93 women, mean age 81 years). The commonest cause of delirium was infection (34% of cases), but in 25% there were multiple equally contributory causes. Vision and hearing impairment was significantly more common in patients with delirium [odds ratio (OR) 12.62; confidence intervals (CI) 2.86-114.04, P < 0.001). After 1 year, patients presenting with delirium had an increased mortality (OR 2.30; 95% CI 1.25-4.35, P — 0.006), an increased institutionalization rate (OR 4.53; 95% CI 1.8013-56, P = 0.001) and an increased likelihood of having been re-admitted (OR 2.05; 95% CI 1.19-3.54, P- 0.008). Conclusion: delirium has a poor long-term prognosis and may be a marker for functional deterioration and decline in elderly people.

Screening for depression among acutely ill geriatric inpatients with a short geriatric depression scale

Abstract: Background: depression is not uncommon among acutely ill geriatric inpatients. Method: the performances of shorter versions of the Geriatric Depression Scale (GDS) in screening for depression among acutely ill geriatric inpatients were examined. Results: a cut-off of 2/3 gives the best sensitivity (88%) and specificity (75%) for the 10-item version (GDS10). A cutoff of 0/1 gives the best sensitivity (72%) and specificity (90%) for the 4-item version (GDS4). A positive response to item 6 ("Do you often feel helpless?") on the GDS10 gave a sensitivity of 76% and specificity of 75%. Patients found the GDS10 tolerable and acceptable. Conclusion: both shorter versions of the GDS may be utilized in screening for depression among acutely ill geriatric inpatients.

Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassessment

Abstract: Introduction: although drug-related problems (DRPs) are known to be prevalent in elderly patients, the literature on prevention of iatrogenic disease is sparse. The present study addresses this requirement. Objectives: to assess the incidence of DRPs in elderly patients admitted to Tayside hospitals before (phase I) and after (phase H) implementation of preventive strategies. Design: all elderly people admitted to hospital were screened by a pharmacist; individual case reviews were prepared for all those with a potential DRP and reviewed by a three-member panel which made a final decision on the presence of a DRP and its contribution to admission. Setting: all hospital wards admitting elderly patients in the Tayside region of Scotland. Subjects: 1011 elderly patient admissions over a 9-month period (phase I); 857 elderly patient admissions over an 8-month period (phase II). Main outcome measures: incidence of DRPs before and after targeted intervention strategies (information bulletin for general practitioners, patient information leaflet, oral presentation to trainee general practitioners). Results: in phase I, the incidence of DRPs was 144/1011 (14.2%), with 54/1011 (5.3%) of the admissions identified as being definitely or probably drug-related. Non-steroidal anti-innammatory drugs (NSAIDs) were the main drug group involved, being responsible for 15/54 (28%) of admissions primarily due to a DRP. Over 66% of admissions due to adverse effects of NSAIDs were considered to be definitely preventable. In phase n, after targeted intervention strategies, there was no significant reduction in total incidence of DRPs or incidence of DRPs related to NSAIDs. However, there appeared to be an improvement in the first 4 months, and a significant drop in NSAID prescribing in Tayside compared with the rest of Scotland was observed. Conclusion: DRPs remain a significant problem in elderly patients and NSAIDs are the major contributor. The intervention strategies used in the study were not demonstrably effective, but a continuous programme of education may be necessary to limit NSAID use.

Reported activities of daily living: agreement between elderly subjects with and without dementia and their caregivers

Abstract: Objectives: to determine how accurately information on disability provided by a caregiver (proxy respondent) reflected the opinion of subjects themselves, and if this agreement varied by severity of dementia or relationship of the caregiver to the subject. Setting and participants: the study was based on data from the Canadian Study of Health and Aging, a multicentre study of dementia and health of Canadians age 65 and over. Eight hundred study subjects and their caregivers were independently interviewed regarding the subjects' activities of daily living (ADL). Measurements: the percentage of subjects who were independent for individual ADL items and the agreement in these reports between subjects and caregivers were investigated using three-level K statistics. Results: index subjects with caregivers other than spouses or offspring required more assistance with ADL. The reported percentage of independence decreased with increasing severity of dementia. There was more agreement between self- and proxy-reported level of independence for physical ADL than for instrumental ADL items. Agreement decreased with increasing severity of dementia. Few statistically significant differences were noted between level of agreement and caregiver relationship. Conclusion: satisfactory levels of agreement on ADL between cognitively normal subjects and their caregivers indicate that proxy respondents are a reasonable source of information on ADL when data collection from the subjects themselves is not feasible. Since agreement decreases as the severity of dementia increases, caregiver reports may be preferred for elderly patients even with mild dementia in order to facilitate longitudinal assessment of ADL ratings as the dementia progresses.

Activities of daily living: changes in functional ability in three samples of elderly and very elderly people

Abstract: Objectives: to investigate changes in functional ability and physical health, psychiatric morbidity, life satisfaction, service use and social support. Design: a structured interview survey of three samples of elderly people living at home at two points in time. The three samples comprised one census of people aged 85 and over [City (of London) and Hackney], and two random samples of people aged 65–84 (City and Hackney and Braintree). The follow-up interviews took place 2.5–3 years after the baseline interviews. Setting: City and Hackney (East London) and Braintree (Essex). Respondents were interviewed at home by one of 12 trained interviewers. Subjects: 630 people aged 85+ at baseline (70% response rate), and 78% of survivors re-interviewed at follow-up; 464 people aged 65–84 in Hackney at baseline (67% response rate), and 83% of survivors re-interviewed; 276 people aged 65–84 in Braintree at baseline (82% response rate), and 78% of survivors re-interviewed. Main outcome measures: scores on scales of functional ability, psychiatric morbidity, life satisfaction and social support, and items measuring number and type of health symptoms and services used. Conclusions: decreasing levels of physical functioning were associated with poor mental health, trouble with feet and problems with muscles and joints. There were no associations with level of physical functioning and use of rehabilitative or general medical services, use of social worker or carer relief. Few respondents used preventive or rehabilitation services

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity.

Abstract: Objectives: to determine the presentation, course and duration of delirium in hospitalized older people. Design: observational cohort study. Setting: inpatient surgical and medical wards at a university hospital. Participants: 432 people over the age of 65. Measurements: all participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) HI-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. Results: about 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (/• = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. Conclusions: delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

Functional assessment scales in detecting dementia

Abstract: Ainu to evaluate the use of different functional scales in detecting dementia in a population study. Methods: the study is part of the Helsinki Ageing Study. A random sample of 795 subjects aged 75 (n = 274), 80 (« = 266) and 85 years (n = 255) was taken. The prevalences of dementia (DSM-EI-R criteria) in these age groups were 4.6, 13.1 and 26.7% respectively. The functional scale scores were known for 71% of the non-demented and 66% of the demented subjects. A structured questionnaire completed by a close informant included four functional scales: the index of activities of daily living (ADL), the modified Blessed dementia scale (DS), the instrumental activities of daily living scale (IADL) and the Functional Assessment Questionnaire (FAQ). Results: all the functional scales discriminated demented from non-demented subjects. Based on receiver operating characteristics analysis, the area under the curve (95% confidence interval) was 0.90 (0.80-0.94) for the ADL, 0.94 (0.87-0.97) for the DS, 0.95 (0.90-0.98) for the IADL and 0.96 (0.92-0.98) for the FAQ. The effects of age, sex and education in detecting dementia were minor or non-existent in the ADL, DS and FAQ scales, but age had an effect on the performance of the IADL scale. All the scales detected even mild dementia adequately. Conclusions: functional scales can be used in detecting dementia when functional assessment is already used for other purposes, such as among elderly primary care patients.

Influence of dental status on dietary intake and survival in community-dwelling elderly subjects

Abstract: Objective to evaluate the relationships between a functional measure of dental status (FDS), the nutrients intake profile (NIP) and mortality in a community elderly population. Design cross-sectional analysis for FDS and NIP and a prospective study for mortality. Setting the central district of Brescia, northern Italy. Participants of the entire cohort of 70-75-year-old elderly subjects living in the district (n = 1303), 1189 subjects were interviewed and examined at baseline. Fifty-two of these were lost to follow-up; data are presented for the remaining 1137 subjects. Measurements baseline data were collected by a door-to-door interview using a standardized questionnaire which included a section about the dietary intake in the 24 h preceding the interview. The 24-h NIP was calculated and compared with the US Food and Drug Administration's 1980 Recommended Dietary Allowances to obtain a percentage value of each nutrient for each respondent. The dental examination considered the direct assessment of the number and position of residual teeth as well as the use of dentures; subjects were classified into three groups: naturally adequate or naturally inadequate dentition and denture wearers. Association of NIP with FDS was computed using ANCOVA and multiple logistic regression models. Mortality data were collected over a 78-month follow-up period. Association of survival with FDS was estimated by Kaplan-Meier analysis and multivariate Cox proportional hazard models. Results multiple logistic regression showed a significant and independent association between the dental status and the intake of micronutrients, but not of macronutrients. Moreover, denture wearers had a dietary intake very similar to adequate dentition and substantially better than inadequate dentition. Inadequate dentition in women was associated with higher mortality than adequate dentition. In elderly women, both inadequate dental status and folate intake were significant and independent predictors of mortality in a multivariate analysis based on nutritional parameters. However, inadequate dentition did not remain an independent predictor of mortality in a general multivariate model. Conclusion in this cohort of urban elderly people, FDS is significantly associated with the NIP and indirectly with mortality.

Why do healthy elderly people fail to comply with influenza vaccination

Abstract: Objective: to assess motivating factors of healthy elderly people to comply with influenza vaccination. Design: survey of healthy elderly people invited by mail by their general practitioner to come for influenza vaccination. Compliance and the personal characteristics of gender, age and medical insurance were recorded by the general practitioner. A postal questionnaire assessing socio-psychological factors was sent to all non-compliant patients and to a random sample of 30% of the compliant patients. Setting: seven family practices with a total of 26 000 patients in The Netherlands. Patients: 505 healthy elderly people over 65. Main outcome measures: odds ratios (ORs) for non-compliance by personal characteristics and socio-psychological factors, adjusted by multiple logistic regression analysis; decisive reason whether to comply. Results: non-compliance was 16%. Correlations between personal characteristics and non-compliance were low, except for age: those under 75 were less compliant than those over 75. Elderly people endorsing the statement about the vaccine's serious side-effects displayed the highest non-compliance [adjusted OR 216; 95% confidence interval (CI) 16.2 to 2883]; patients judging their own health to be good were also less compliant (adjusted OR 57.9; 95% CI 4 A to 770). The belief of not being susceptible to influenza was the most frequently mentioned reason for not complying, while the general practitioner's mail cue was the most common reason for complying. Conclusions: in healthy elderly people, fear of the side-effects of influenza vaccination and perceived good health seem to be the main factors leading to non-compliance. Better and more specific information about the paucity of systemic side-effects should accompany the invitations.

The effect of chronic diseases on physical function. Comparison between activities of daily living scales and the Physical Performance Test

Abstract: Aim: to verify the capacity of basic and instrumental activities of daily living (BADL and IADL) disability scales and of a performance-based test (Physical Performance Test; PPT) to detect the effect on the functional capacity of several common chronic conditions in elderly people. Method: a cross-sectional survey of the entire population aged 70 and over, living in Ospitaletto (Brescia, northern Italy)—549 subjects; 89.6% of the eligible population; 179 males and 370 females—was carried out in 1992. A multi-dimensional questionnaire administered at the subject's home was used to collect information on demographics, presence of several common chronic diseases and BADL and IADL. Objective physical capacity was assessed using the PPT. Results: only cognitive deterioration and depression were independently associated -with disability, as detected by BADL or IADL scales. Cognitive deterioration, stroke, parkinsonism, heart disease and hearing and visual loss were independently associated with PPT. The performance at PPT remained statistically associated with most of the same diseases when the analysis was restricted to subjects with no BADL or IADL disability. Conclusion: a performance-based measure, such as PPT, may detect a functional limitation before it becomes measurable by traditional self-reported BADL and IADL scales.

Ageing, defence mechanisms and the immune system.

Abstract: Of all the systems in the body, the immune system is probably the best understood, both in mechanistic terms and in the ways in which it changes during ageing. Studies of the ageing immune system (immuno gerontology) can be traced back to the early part of this century (and even earlier), and the literature has burgeoned in the last three decades. Perhaps the first publication was of the investigation undertaken by Peter Ludwig Panum (a Danish physician and discoverer of endotoxin) on the outbreak of measles in the Faroes in 1846. The Faroes had been free of measles since the previous epidemic of 1781. The 1846 outbreak affected 75-95% of the population although "of the many aged people still living on the Faroes who had had measles in 1781, not one was attacked a second time" [1]. This experiment of nature seems out of step with traditional thought about ageing and immunity, which views ageing as an immunodeficiency state that predisposes the host to infectious diseases (and possibly neoplasms).

An International Study of Social Engagement Among Nursing Home Residents

Abstract: Method: data using the Resident Assessment Instrument (RAI) from nursing home populations in five countries (Denmark, Iceland, Italy, Japan, USA) were assembled from 396 277 residents. The distribution of a new quality of life measure, 'social engagement', embedded in the RAI and found to be reliable and valid in the USA, was examined and compared in the international samples. Results: in all five countries' nursing home populations engagement was highest among residents with adequate functioning in activities of daily living (ADL) and cognition, but the level of social engagement differed considerably by country among residents with poor ADL functioning, who had adequate cognition. The lowest scores were in Italy and Japan. The amount of time residents spend in activities stratified by ADL and cognition reveal the same pattern cross-culturally—cognitively impaired residents are least actively involved. Conclusions: the Minimum Data Set measure of social engagement is stable across types of residents and across nations and can serve as a marker of nursing home quality.

Evaluation of treatment for congestive heart failure in patients aged 60 years and older using generic measures of health status (SF-36 and COOP charts)

Abstract: Objectives: to assess the functioning and well-being of older patients presenting with congestive heart failure (CHF) using established generic health status measures—the short form 36 health survey (SF-36) and Dartmouth COOP charts. Methods: patients aged 60 or older with CHF were asked if they would take part. They were requested to complete interviewer-administered questionnaires before angiotensin converting enzyme (ACE) inhibitor treatment and at follow-up 4 weeks later. The interviewer administered the SF-36, COOP charts, the oxygen cost diagram and also asked patients to assess their health state overall and, after treatment, to assess changes, if any, in overall health. Results: multi-dimensional health status measures indicate that patient's functioning and well-being is substantially compromised by CHF, especially in areas relating to physical functioning, and that treatment with ACE inhibitors has only limited effect in improving health-related quality of life. However, on simple single-item global assessments of health, patients report that their overall health-related quality of life is good and many report improvements in overall health status at foliow-up. Conclusions: ACE inhibitor treatment, whilst lengthening life, has a relatively limited impact on its quality. While multidimensional health status measures indicate CHF to be associated with poor health as measured by the SF-36 and COOP charts. However, when patients are asked simple single-item questions relating to their overall health state and the extent of change experienced after treatment, they report relatively good health and positive improvements as a consequence of therapy. Since elderly patients' expectations of improvement may be modest and their expectations of physical ability relatively limited, relatively small improvements, which may not appear large when reported in effect size statistics, may be important. Standardized questionnaires, and standardized statistical methods of assessing change, may not be appropriate for this patient group. A fuller understanding of their expectations and assessment of treatment outcomes is necessary.

Cognitive impairment in medical inpatients. I: Screening for dementia-is history better than mental state?

Abstract: BACKGROUND evaluation of the short version of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and the Abbreviated Mental Test (AMT) as screening tools for dementia in medical inpatients. METHODS 201 patients over 65 were assessed. Assessment included administration of the AMT, a delirium screening instrument and a brief psychiatric interview. Relatives were interviewed and the IQCODE administered. Diagnostic and Statistical Manual (DSM) IIIR diagnoses of various causes of cognitive impairment were made. Sensitivity and specificity values of the screening tests for a DSM IIIR diagnosis of dementia were calculated. RESULTS our study suggests that the IQCODE is more accurate than the AMT as a screening instrument for dementia. Using a cut-off point of > 3.44, sensitivity and specificity of the IQCODE for diagnosing dementia were 100 and 86% respectively. Equivalent values for the AMT (cut-off point < 8) were 96 and 73%. It was possible to use the IQCODE in eight of the 10 patients unable to complete the AMT. CONCLUSION using both the IQCODE and a brief cognitive function test when screening for dementia in medical inpatients will maximize the number of patients who can be screened.

Comparisons of restraint use in nursing homes in eight countries.

Abstract: Background: the use of restraints in nursing homes varies among countries and institutions. However, in many countries, no reliable data exist, although restraints use is acknowledged. Method: we compare data of the type of restraints used (trunk, limb or chair that prevents rising) and the intensity of its use in eight countries: Denmark, France, Iceland, Italy, Japan, Spain, Sweden and the USA. We report these data in total and for groups of residents with similar functional abilities and cognitive performance, thus avoiding to a certain extent the case-mix differences between samples from different countries. Results: the total use of restraints in these cross-sectional samples showed a very low prevalence in Denmark, Iceland and Japan (less than 9%). Between 15 and 17% were seen in France, Italy, Sweden and the USA, while Spain showed almost 40%. These major differences among the countries persist, even when one controls for physical and cognitive abilities. There are also differences in the types and intensity of restraints used in different countries. In all countries, there is a constant increase in use of restraints with increasing activities of daily living difficulties and cognitive dysfunction.

Age-associated cognitive decline in healthy old people

Abstract: Background: disease often confounds the identification of risk factors for age-associated cognitive decline in elderly subjects. If the cognitive effects of ageing are to be distinguished from those of disease, healthy people need to be studied. Methods: we examined the effects of incident disease and drug prescription on cognitive change in a sample of initially healthy old people in a longitudinal study and related these to age, education, social class and blood pressure. We screened general practice case notes of 10 000 patients aged 70 years and over resident in Edinburgh to identify potentially healthy subjects. We visited 1467 potential subjects at home and enquired directly about health problems and medications, administered the Mini-Mental State Examination (MMSE) and National Adult Reading Test and recorded educational attainment, occupation and blood pressure. Results: 603 subjects (237 male, 366 female), mean age 75.7 years (range 70-88 years), reported no health problems and were taking no regular medications. Four years after the initial visit we determined the outcome of all 603 subjects and retested available survivors. Psychometric tests were then administered to the 429 (71.1%) available survivors after a median period of 4.2 years (69 subjects were dead, 15 were too unwell, 12 had moved away and 78 either refused or failed to reply). Forty-two subjects had significant sensory impairment or interrupted testing, 195 remained in good health, 29 reported or had documented disease but were on no regular medication and 163 were on regular medication for diseases diagnosed during the follow-up period. MMSE score declined by 0.3 points in the healthy group (P < 0.048). However, once a single outlier whose MMSE score fell from 29 to 22 was excluded, the mean decline for the remainder was non-significant at 0.2 points (P — 0.079). There was no significant difference in cognitive decline between those who had and those who had not started medication (P = 0.59). Conclusions: the study fails to support the hypothesis that cognitive decline can be attributed to age alone in healthy old people. If such a decline exists, we consider that it is unlikely to account for loss of more than 0.1 MMSE point per year.

Longitudinal trends in late-life insomnia: implications for prescribing

Abstract: OBJECTIVE To assess trends in insomnia and hypnotic drug use in a representative sample of elderly general practice patients. DESIGN Longitudinal study with three interview waves--1985, 1989 and 1993. SETTING Urban and suburban Nottingham. PARTICIPANTS 1042 patients originally aged 65 and over randomly sampled from general practitioner lists. MAIN OUTCOME MEASURES Point prevalence estimates, status (case/non-case/died) at 4-year follow-up, episode incidence and survival functions. RESULTS At baseline (1985) 221 respondents met the survey criteria for insomnia. Of these, 36.1% continued to report severely disrupted sleep in 1989. Within this period 84 new cases of insomnia were identified (an incidence rate of 3.1% per person-year at risk). Controlling for age and sex, insomnia was unrelated to survival among prevalent cases, but significantly related to survival among incident cases (odds ratio = 1.7; 95% confidence interval = 1.1-2.5). Of 166 respondents using prescription hypnotics in 1985, 31.7% continued to report usage in 1989. Similarly, out of 41 new hypnotic drug users identified in 1989, 29.3% continued to report usage in 1993. CONCLUSIONS Important clinical differences in the natural history of insomnia are evident when incident and prevalent cases are compared. Nevertheless, outcomes at 4-year follow-up suggest that, for the majority of surviving cases identified in a prevalence screen and for a substantial minority of incident cases, late-life insomnia shows a level of chronicity incompatible with hypnotic drug therapy as currently recommended.

Cognitive testing of elderly Chinese people in Singapore: influence of education and age on normative scores

Abstract: Aim: to establish age- and education-adjusted mean psychometric test scores of cognitively normal elderly Chinese people in Singapore. Method: 155 community-living, cognitively intact elderly Chinese subjects, stratified according to age and education, were selected from the membership lists of senior citizens' clubs and were administered a neuropsychological assessment battery. The mean test scores were then analysed for correlations with demographic characteristics. Results: only education and age were independent variables; gender and language spoken were strongly correlated with education by the x2 method (i><10~5). Subsequent statistical analysis of education and age on the psychological test scores by the general linear model procedure enabled the formulation of a table of age- and education-adjusted normative cognitive scores. Conclusion: the derivation of age- and education-adjusted normative scores of a selected neuropsychological assessment battery on elderly Chinese people enables a more accurate diagnosis of dementia to be made and may facilitate better international comparisons of this condition. As our subjects are representative of many others from China, these results may serve not only as a local, but also as a regional, reference source.