Showing papers in "Age and Ageing in 2003"

Community‐based group exercise improves balance and reduces falls in at‐risk older people: a randomised controlled trial

Abstract: Background: recent studies have found that moderate intensity exercise is an effective intervention strategy for preventing falls in older people. However, research is required to determine whether supervised group exercise programmes, conducted in community settings with at-risk older people referred by their health care practitioner are also effective in improving physical functioning and preventing falls in this group. Objectives: to determine whether participation in a weekly group exercise programme with ancillary home exercises over one year improves balance, muscle strength, reaction time, physical functioning, health status and prevents falls in at-risk community-dwelling older people. Methods: the sample comprised 163 people aged over 65 years identified as at risk of falling using a standardised assessment screen by their general practitioner or hospital-based physiotherapist, residing in South Western Sydney, Australia. Subjects were randomised into either an exercise intervention group or a control group. Physical performance and general health measures were assessed at baseline and repeated 6-months into the trial. Falls were measured over a 12-month follow-up period using monthly postal surveys. Results: at baseline both groups were well matched in their physical performance, health and activity levels. The intervention subjects attended a median of 23 exercise classes over the year, and most undertook the home exercise sessions at least weekly. At retest, the exercise group performed significantly better than the controls in three of six balance measures; postural sway on the floor with eyes open and eyes closed and coordinated stability. The groups did not differ at retest in measures of strength, reaction time and walking speed or on Short-Form 36, Physical Activity Scale for the Elderly or fear of falling scales. Within the 12-month trial period, the rate of falls in the intervention group was 40% lower than that of the control group (IRR=0.60, 95% CI 0.36‐0.99). Conclusions: these findings indicate that participation in a weekly group exercise programme with ancillary home exercises can improve balance and reduce the rate of falling in at-risk community dwelling older people.

Identifying a cut‐off point for normal mobility: a comparison of the timed ‘up and go’ test in community‐dwelling and institutionalised elderly women

Abstract: Background: physical mobility testing is an essential component of the geriatric assessment. The timed up and go test measures basic mobility skills including a sequence of functional manoeuvres used in everyday life. Objectives: to create a practical cut-off value to indicate normal versus below normal timed up and go test performance by comparing test performance of community-dwelling and institutionalised elderly women. Setting and participants: 413 community-dwelling and 78 institutionalised mobile elderly women (age range 65–85 years) were enrolled in a cross-sectional study. Measurements: timed up and go test duration, residential and mobility status, age, height, weight and body mass index were documented. Results: 92% of community-dwelling elderly women performed the timed up and go test in less than 12 seconds and all community-dwelling women had times below 20 seconds. In contrast only 9% of institutionalised elderly women performed the timed up and go test in less than 12 seconds, 42% were below 20 seconds, 32% had results between 20 and 30 seconds and 26% were above 30 seconds. The 10 th –90 th percentiles for timed up and go test performance were 6.0–11.2 seconds for community-dwelling and 12.7–50.1 seconds for institutionalised elderly women. When stratifying participants according to mobility status, the timed up and go test duration increased significantly with decreasing mobility (Kruskall-Wallis-test: p-0.0001). Linear regression modelling identified residential status (p-0.0001) and physical mobility status (p-0.0001) as significant predictors of timed up and go performance. This model predicted 54% of total variation of timed up and go test performance. Conclusion: residential and mobility status were identified as the strongest predictors of timed up and go test performance. We recommend the timed up and go test as a screening tool to determine whether an in-depth mobility assessment and early intervention, such as prescription of a walking aid, home visit or physiotherapy, is necessary. Community-dwelling elderly women between 65 and 85 years of age should be able to perform the timed up and go test in 12 seconds or less.

Age‐related differences in walking stability

Abstract: Background: a large proportion of falls in older people occur when walking; however the mechanisms underlying impaired balance during gait are poorly understood. Objective: to evaluate acceleration patterns at the head and pelvis in young and older subjects when walking on a level and an irregular walking surface, in order to develop an understanding of how ageing affects postural responses to challenging walking conditions. Methods: temporo-spatial gait parameters and variables derived from acceleration signals were recorded in 30 young people aged 22–39 years (mean 29.0, SD 4.3), and 30 older people with a low risk of falling aged 75–85 years (mean 79.0, SD 3.0) while walking on a level and an irregular walking surface. Subjects also underwent tests of vision, sensation, strength, reaction time and balance. Results: older subjects exhibited a more conservative gait pattern, characterised by reduced velocity, shorter step length and increased step timing variability. These differences were particularly pronounced when walking on the irregular surface. The magnitude of accelerations at the head and pelvis were generally smaller in older subjects; however the smoothness of the acceleration signals did not differ between the two groups. Older subjects performed worse on tests of vision, peripheral sensation, strength, reaction time and balance. Conclusion: the adoption of a more conservative basic gait pattern by older people with a low risk of falling reduces the magnitude of accelerations experienced by the head and pelvis when walking, which is likely to be a compensatory strategy to maintain balance in the presence of age-related deficits in physiological function, particularly reduced lower limb strength.

Is grip strength a useful single marker of frailty

Abstract: Background: chronological age is widely used as a marker of frailty in clinical practice. However there can be wide variation in frailty between individuals of a similar age. Grip strength is a powerful predictor of disability, morbidity and mortality which has been used in a number of frailty scores but not as a single marker of frailty. Objective: to investigate the potential of grip strength as a single marker of frailty in older people of similar chronological age. Design: cross-sectional study with prospective collection of mortality data. Setting: North Hertfordshire, UK. Subjects: 717 men and women, aged 64–74, born and still living in North Hertfordshire, who took part in a previous study to investigate the relationship between size at birth and ageing processes in later life. Methods: the number of significant associations between grip strength and the ageing markers was compared with numbers between chronological age and the ageing markers. Results: in men, lower grip strength correlated significantly with ten ageing markers compared to chronological age which was significantly associated with seven. In women, there were six significant relationships for grip compared to three for age. The greater number of relationships between grip strength and ageing markers was not explained by the association between grip strength and age, and remained after adjustment for adult size. Conclusions: grip strength was associated with more markers of frailty than chronological age within the narrow age range studied. Grip strength may prove a more useful single marker of frailty for older people of similar age than chronological age alone. Its validity in a clinical setting needs to be tested.

Caregiver burden and health‐related quality of life among Japanese stroke caregivers

Abstract: Objective: the present study had two main purposes: 1. To examine the relationship between caregiver burden and health-related quality of life in family caregivers of older stroke patients in Japan; and 2. To examine which characteristics of the caregiving situation significantly relate to increased burden. Methods: subjects (n=100) were recruited from seven randomly selected neurological hospitals with out-patient rehabilitation clinics in western Japan and interviewed using the Zarit Burden Interview, the Modified Barthel Index, the Geriatric Depression Scale and the SF-12 Health Survey for health-related quality of life. Results: increased caregiver burden was significantly related to worsening health-related quality of life, particularly worsening mental health (Geriatric Depression Scale and SF-12 items), even after controlling for caregiver age, sex, chronic illness, average caregiving hours/day, and functional dependence of the care-recipient. Discussion: findings indicate that increased burden significantly relates to decreased health-related quality of life among stroke caregivers. In addition, the prevalence of depressive symptoms among caregivers was twice that of community dwelling older people. Roughly 52% of caregivers had Geriatric Depression Scale scores that warranted further evaluation. Despite the prevalence of depressive symptoms only one caregiver had received any psychiatric care during their caregiving tenure.

Diagnosing cognitive impairment and dementia in primary health care – a more active approach is needed

Abstract: Objective to determine the documentation rate of dementia in primary health care, the clinical characteristics of patients with documented and undocumented dementia, and the diagnostic evaluations made in cognitive impairment. Design cross-sectional population-based study with a retrospective review of medical history. Setting primary health care in the municipality of Lieto, Southwestern Finland. Subjects all the inhabitants aged 64 and over in Lieto. Participation rate 82%, numbers = 1260. Measurements assessment of dementia according to DSM-IV criteria, and severity according to Clinical Dementia Rating. Possible documentation of dementia and evaluations done were reviewed from primary health care medical records. Results 112 patients with dementia were found. The sensitivity of the general practitioners' judgment of dementia was 48.2% and the specificity 99.6%. The documentation rate of dementia was 73% in severe, 46% in moderate and 33% in mild dementia. A greater proportion of the patients with undocumented dementia were male (P = 0.003), lived at home (P = 0.003), coped better with the instrumental activities of daily living (P = 0.006), had more depression (P = 0.029) and milder dementia (P = 0.005) than patients with documented dementia. Thyroid stimulating hormone was measured in 51% of the patients with suspected memory impairment or dementia, B12 vitamin in 20%, and serum calcium in 18%. Twenty-eight per cent of the patients had been tested for cognitive function, 68% for depressive symptoms, and 88% for social abilities. Forty-two per cent of patients were referred to a specialist, 32% of patients who were over 75 years. Conclusions less than half of the patients with dementia had their diagnosis documented in primary care medical records. Documentation increased in more advanced dementia. The diagnostic evaluations for reversible causes of dementia were insufficient in primary care, and they were done at a late phase of cognitive impairment.

Relationship between changes in depressive symptoms and unhealthy lifestyles in late middle aged and older persons: results from the Longitudinal Aging Study Amsterdam

Abstract: Background: depressed mood is common in late life, more prevalent among the chronically diseased than in the general population, and has various health-related consequences. So far, the association between depression and unhealthy lifestyles among chronically diseased has not been examined longitudinally in older persons. Primary objective: to determine if depressed mood is associated with unhealthy lifestyles in late middle aged and older people, with or without chronic somatic diseases. Methods: in a sample of 1,280 community-dwelling people from the Netherlands, the associations between depressive symptoms and lifestyle domains were analysed cross-sectionally and longitudinally – using logistic regression analyses and multivariate analyses of variance. Results: after controlling for confounders, depressed people (n=176 at baseline) were more likely to be smokers (odds ratio 1.71; 95% confidence interval 1.17–2.52). A persistent depression was associated with an increase in cigarette consumption (P=0.036). Having an emerging depression (n=155) was most likely to co-occur with a person’s change from being physically active to being sedentary (relative risk-ratio 1.62; 95% confidence interval 1.05–2.52), and was associated with the largest decrease in minutes of physical activity (P=0.038). This effect was not modified or confounded by chronic somatic disease. A persistent depression tended to be associated with incident excessive alcohol use (relative risk-ratio 4.04; 95% confidence interval 0.97–16.09; P=0.056). Conclusions: depression is associated with smoking behaviour, and with an increase in cigarette consumption. An emerging depression is associated with becoming sedentary, irrespective of a person’s disease status at baseline, and is associated with decrease in minutes of physical activity.

Dietary quality, lifestyle factors and healthy ageing in Europe: the SENECA study

Abstract: Objective: to identify dietary and lifestyle factors that contribute to healthy ageing. Subjects: for the analyses, data of the longitudinal SENECA study were used. The study population consisted of 1091 men and 1109 women aged 70-75 years from Belgium, France, Denmark, Italy, The Netherlands, Portugal, Spain, Switzerland, and Poland. Methods: this European study started with baseline measurements in 1988-1989 and lasted until 30 April 1999. The study includes data on diet, lifestyle and health. The study population is followed for 10 years, and measurements were performed in 1988/1989 (baseline), 1993, and 1999. The relationships of the three lifestyle factors diet, physical activity, and smoking habits to survival and maintenance of health at old age were investigated. Finally it is discussed whether the relationships of healthy lifestyle habits to survival and health contribute to healthy ageing. Results: the unhealthy lifestyle habits smoking, having a low-quality diet, and being physically inactive were singly related to an increased mortality risk (hazard ratios ranged from 1.2 to 2.1). In addition, inactive and smoking persons had an increased risk for a decline in health status as compared with active and non-smoking people. The net effect of a healthy lifestyle on the process of healthy ageing is likely to go together with a compressed cumulative morbidity. Conclusions: a healthy lifestyle at older ages is positively related to a reduced mortality risk and to a delay in the deterioration in health status. This postponement of the onset of major morbidity is likely to go together with a compressed cumulative morbidity. Therefore, health promotion at older ages can contribute to healthy ageing.

Acquisition and short‐term retention of inhaler techniques require intact executive function in elderly subjects

Abstract: Background: patients with dementia are almost invariably unable to use any form of inhaler. Some elderly patients are unable to learn to use a metered dose inhaler or Turbohaler despite a normal abbreviated mental test score. Studies have shown that in many people this is due to unrecognised cognitive impairment and/or dyspraxia. The executive domains of cognition are particularly important in planning and sequencing; it might be expected therefore that disordered frontal (executive) function could be a predictor of poor inhaler technique in subjects with no overt features of dementia. Objective: to explore the relationship between cognitive, and executive, function and the ability to acquire metered dose inhaler and Turbohaler technique in old age. Design: a prospective randomised observational study with blinded evaluation. Subjects: 30 inhaler-naive inpatients (21 female) with a mean age of 85 (range 75–94) and having a normal (8–10) abbreviated mental test score. Methods: subjects received standardised metered dose inhaler and Turbohaler training and were scored on an analogue scale (for metered dose inhaler) or for competence (Turbohaler) the following day. The Mini-Mental State Examination and EXIT25 (for executive function) were performed by separate observers. Results: significant correlation was found between the metered dose inhaler score and Mini-Mental State Examination (r 0.540, P-0.002) and EXIT25 (r –0.702, P-0.0001). Threshold effects emerged for the metered dose inhaler in that 18/19 with a competent score compared to 2/11 scored as incompetent had a Mini-Mental State Examination of )23 (P-0.01) and 19/19 compared to 0/11 had an EXIT25 of -15 (P-0.01). Similarly, for the Turbohaler 21/21 of the competent subjects had a Mini-Mental State Examination of )23 compared with 3/9 incompetent subjects (P-0.01), with 21/21 competent compared with 0/9 incompetent having an EXIT25 -15 (P-0.01). Conclusion: acquisition and short-term retention of metered dose inhaler and Turbohaler techniques is unlikely to be successful in frail elderly people who have an abnormal Mini-Mental State Examination and/or EXIT25 test. The latter test, when abnormal, is probably the superior predictor of inability to learn inhaler techniques.

Medication use and falls in community-dwelling older persons

Abstract: Background: the association between injurious falls requiring a visit to the emergency department and various classes of medications was examined in a case-control study of community living persons aged 66 years and older. Methods: administrative databases from an urban health region provided the information used. Five controls for each case were randomly selected from community dwelling older persons who had not reported an injurious fall to one of the six regional emergency departments in the study year. Two series of analyses on medication use within 30 days of the fall were conducted using logistic regression, the first controlling for age, sex, and median income, the second controlling for co-morbid diagnoses as well. Results: during the study year there were 2,405 falls reported by 2,278 individuals to six regional emergency departments giving a crude fall rate of 31.6 per 1,000 population per year. The initial analysis identified seven medication classes that were associated with an increased risk of an injurious fall, while controlling for age, gender and income. However, with further analyses controlling for the additional effects of co-morbid disease, narcotic pain-killers (odds ratio 1.68), anti-convulsants (odds ratio 1.51) and anti-depressants (odds ratio 1.46) were significant independent predictors of sustaining an injurious fall. Conclusion: these results are based on a Canadian population-based study with a large community sample. The study found that taking certain medications were independent predictors of sustaining an injurious fall in our elderly population - in addition to the risk associated with their medical condition.

Suitability of the WHOQOL-BREF for community-dwelling older people in Taiwan

Abstract: Background: while life expectancy among older people has been lengthened due to improved public health and medical interventions, the importance of health-related quality of life in later life has also increased. However, the application of a generic health-related quality of life measure for older people needs to be carefully validated. Objective: to evaluate the practicality, reliability, validity, and responsiveness of the use of the brief version of the World Health Organization Quality of Life for people aged 65 years or older. Design: a prospective study. Methods: for a baseline assessment, 1200 community-dwelling older people living in Shin-Sher Township of Taichung County, Taiwan, completed the brief version of World Health Organization Quality of Life at their residences either by themselves or with the assistance of an interviewer. Furthermore, score changes in each health-related quality of life domain after a fall were followed up for assessing its responsiveness. Results: the average length of time required to complete the questionnaire was short (10.6 minutes for self-administration and 15.3 minutes for personal interview), and the score distribution in each domain was symmetrical with no Xoor or ceiling effect. Furthermore, all domain scores indicated excellent discriminant validity, construct validity, and responsiveness as well as good internal consistency and intra- and inter-observer test-retest reliabilities. Nevertheless, two items related to work capacity and sexual activity had higher missing values (4.5% and 16.5%) and poor interobserver test-retest reliabilities (0.43 and 0.20). Suggested modiWcations to the two items for older people are discussed. Conclusion: with a few modiWcations, the brief World Health Organization Quality of Life is a suitable health-related quality of life instrument for older people.

Effects of physical training on the physical capacity of frail, demented patients with a history of falling: a randomised controlled trial

Abstract: Background: to develop a physical training programme to improve balance in dependent, demented, people with a history of falling, and so decrease falls and increase autonomy. Methods: the study was undertaken on 20 demented elderly people with a history of falling with an average age of 81.4 ′ 4,7 years and an average mini mental state score of 16.3′6.5. They had all passed 'get up and go', 'chair sit and reach', walking speed and static balance tests. They were assigned to a control group or a training group; the latter were trained with two sessions a week for 16 weeks. Results: walking, mobility, flexibility and static balance were significantly improved in the training group (P<0.05), but not in the controls. The trained subjects did not suffer a relapse, while the controls did during the training period. Conclusion: the balance of frail, demented, elderly patients with a history of falling can be improved by training.

Medical conditions as risk factors for pressure ulcers in an outpatient setting

Abstract: Objectives: the purpose of this study was to evaluate the likelihood that the presence of certain medical conditions in older ambulatory patients are associated with the risk of developing a new pressure ulcer. Design: a cohort study. Setting and subjects: a large outpatient record database from the United Kingdom called the General Practice Research Database. Methods: the frequency of disease was reported as simple percentages and the associations between the medical conditions and the development of a pressure ulcer as instantaneous rate ratios. Results: we studied 75,168 older individuals. Pressure ulcers occurred in 1,211 individuals. The medical conditions that were significantly associated with the development of a pressure ulcer after adjustment were: Alzheimer’s disease, congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, diabetes mellitus, deep venous thrombosis, hip fracture, hip surgery, limb paralysis, lower limb oedema, malignancy, malnutrition, osteoporosis, Parkinson’s disease, rheumatoid arthritis, and urinary tract infections. Angina, hypertension, and pneumonia were inversely associated with the development of a pressure ulcer. Conclusions: it is important that physicians recognise that patients with many medical conditions may be at higher risk for pressure ulcers so that even in the ambulatory care environment appropriate prevention and detection strategies can be directed towards the patients who are most likely to benefit.

An evaluation of footwear worn at the time of fall‐related hip fracture

Abstract: Background: a range of footwear features have been shown to influence balance in older people, however, little is known about the relationships between inappropriate footwear, falls and hip fracture. Objectives: to describe the characteristics of footwear worn at the time of fall-related hip fracture and establish whether the features of the shoe influenced the type of fall associated with the fracture. Methods: 95 older people (average age 78.3 years, SD 7.9) who had suffered a fall-related hip fracture were asked to identify the footwear they were wearing when they fell. Footwear characteristics were then evaluated using a standardised assessment form. Information was also collected on the type and location of fall. Results: the most common type of footwear worn at the time of the fall was slippers (22%), followed by walking shoes (17%) and sandals (8%). Few subjects were wearing high heels when they fell (2%). The majority of subjects (75%) wore shoes with at least one theoretically sub-optimal feature, such as absent fixation (63%), excessively flexible heel counters (43%) and excessively flexible soles (43%). Subjects who tripped were more likely to be wearing shoes with no fixation compared to those who reported other types of falls [x 2 =4.21, df=1, P=0.033; OR=2.93 (95%CI 1.03‐8.38)]. Conclusions: many older people who have had a fall-related hip fracture were wearing potentially hazardous footwear when they fell. The wearing of slippers or shoes without fixation may be associated with increased risk of tripping. Prospective studies into this proposed association appear warranted.

Visual factors should be assessed in older people presenting with falls or hip fracture

Abstract: Visual impairment, although not routinely assessed, is an important risk factor for falls and hip fracture in older people. Impaired vision is highly prevalent and commonly unreported in the elderly population particularly in women and those living in nursing homes. Measurement of visual functions such as visual acuity, contrast sensitivity and depth perception may identify older people at risk of falls and hip fracture. Visual loss in older people is correctable in most cases. Intervention strategies, for example, change of glasses or cataract extraction may have the potential of improving visual function and preventing falls in older people.

Ageism in the management of lung cancer

Abstract: Background: age-related differences in the treatment of lung cancer patients have been reported in the past, but most previous studies have not recorded case-mix factors, nor have they studied the impact of such ageism on survival. Methods: a questionnaire-based study of diagnostic and case-mix factors was carried out across 48 hospital Trusts in the UK between 1997 and 1998. We identified 1,652 patients and followed through with regard to their treatment and survival for 6 months after diagnosis. Results: the median age of the population was 69 years, and for this analysis, was divided into three age groups: under 65 years, 65‐74 and 75 years and over. There were significant inverse correlations between age and histological diagnosis, any active treatment and survival, even when corrected for case-mix factors and non-cancer causes of death. For example, the surgical resection rate in patients with confirmed non-small cell lung cancer with good performance status, no chronic obstructive pulmonary disease and limited disease was 37% in the younger patients compared with 15% in those 75 and over. The overall mortality rates at 6 months ranged from 42% in patients under 65 to 58% in the over 75s. Conclusions: this national study of lung cancer care in the UK has shown large age-related differences in management and survival in patients with lung cancer, largely independent of case-mix factors. The reasons for this are complex but such under-treatment in the elderly may be one factor underlying the poor outcomes in lung cancer patients in the UK.

Prevention of malnutrition in older people during and after hospitalisation: results from a randomised controlled clinical trial

Abstract: Objective: to prevent the occurrence of weight loss during hospitalisation and following discharge by daily oral supplementation. Design: in a prospective, randomised, controlled study of 80 patients aged 75 or more, and at risk of undernutrition based on their initial Mini Nutritional Assessment score, patients were randomised into a control group or one receiving oral supplementation. The intervention was a prescription of 200 ml sweet or salty sip feed twice daily (500 kcal, 21 g protein per day) throughout hospitalisation and convalescence. Nutritional status was assessed at baseline and after 2 months using Mini Nutritional Assessment and body weight record. Results: compliance with oral supplementation was good and daily extra energy intake was 407"184 kcal. On day 60, significant weight loss from upon admission was observed in the control group (1.23"2.5 kg; P=0.01), but not in the supplemented group (0.28"3.8 kg; NS). At the end of the study, Mini Nutritional Assessment scores were higher in the supplemented group than in the control group (23.5"3.9 versus 20.8"3.6; P-0.01). Conclusion: use of daily oral supplementation during and after hospitalisation maintains body weight and increases Mini Nutritional Assessment score in patients at risk of undernutrition.

Onset of mobility disability among community-dwelling old men and women. The role of tiredness in daily activities

Abstract: Background: in the primary prevention of disability among older adults it might be useful to identify individuals at high risk for functional decline before it occurs Objective: to examine whether tiredness in daily activities is an independent determinant of onset of mobility disability at 1½-year follow-up among non-disabled older men and women Design: a prospective study with 1½-year follow-up Setting: 34 communities in four counties in Denmark Subjects: 1396 older non-disabled adults (74–75 and 80 years old) living in 17 of the participating communities Methods: questionnaire surveys at baseline and at 1½-year follow-up Tiredness in daily activities was measured by questions about tiredness in six mobility activities Onset of mobility disability was measured as onset of need for help in one to six mobility activities Results: men and women who felt tired in their daily activities at baseline had a higher risk of onset of mobility disability at 1½-year follow-up, when adjusted by the covariates In addition, low social participation, poor psychological function, and physical inactivity were independent risk factors of onset of mobility disability among men, and home help, low sense of coherence and physical inactivity were independent risk factors of onset of mobility disability among women Conclusion: older people who complain about tiredness are at higher risk of becoming disabled than others This highlights the need for alertness and management of this early sign of functional decline in a preventive perspective

Impact of age on QT interval and QT dispersion in healthy subjects: a regression analysis

Abstract: Objective: although the isolated effects of age on QT interval and QT dispersion (QTd) have been previously investigated, no data are available on the simultaneous effects of age and other physiological or lifestyle factors on QT interval and QTd in healthy subjects. We studied the effects of age, gender, body mass index, smoking status, and blood pressure on these electrocardiographic parameters. Design: observational study. Setting: academic medical centre. Participants and measurements: age, gender, body mass index, smoking status, and blood pressure were obtained from 191 consecutive healthy subjects (101 males and 90 females, age range 19–89 years). The subjects were divided into three groups according to their age: -30 (n=56), 30–65 (n=49), and )65 years (n=86). Results: heart-rate corrected QT interval (QTc, Bazett’s formula) progressively increased with advancing age (389" 3v s. 411"4 vs. 418"3 ms, means"SEM; P-0.01). By contrast, no differences in QTd were observed across the three groups (36" 2v s. 35" 3v s. 40" 2m s,P=NS). A multivariate regression analysis showed that age (P-0.01) and body mass index (P=0.04) independently predicted QT interval while gender was a weak (P=0.09) predictor of QTd. Conclusions: after adjusting for gender, smoking status, and blood pressure, age and body mass index independently predicted QT interval in healthy subjects. By contrast, age is not a predictor of QTd. The increase of QT interval associated with ageing and body mass index might be secondary to cardiac hypertrophy and myocardial action potential prolongation.

The effects of improving hearing in dementia

Abstract: Background: audiological function is impaired in people with dementia and poor hearing is known to exaggerate the effects of cognitive deficits. Objective: the objective of this study was to assess the effects of increasing auditory acuity by providing hearing aids to subjects with dementia who have mild hearing loss. Method: subjects were screened for hearing impairment and fitted with a hearing aid according to standard clinical practice. Measures of cognition and psychiatric symptoms, activities of daily living, and burden on carers were made over 6 months. Hearing aid diaries were kept to record the acceptability of the hearing aids to the subjects. Results: more than 10% of eligible subjects were excluded as removal of wax restored hearing. Subjects showed a decline in cognitive function, no change in behavioural or psychiatric symptoms over the study period. Forty-two percent of subjects showed an improvement on an independently rated measure of change. The hearing aids were well accepted. Both carers and subjects reported overall reduction in disability from hearing impairment. Conclusions: all patients with hearing impairment require thorough examination. The presence of dementia should not preclude assessment for a hearing aid as they are well tolerated and reduce disability caused by hearing impairment. Hearing aids do not improve cognitive function or reduce behavioural or psychiatric symptoms. There is evidence that patients improved on global measures of change.

Quality of spirometric performance in older people

Abstract: Objectives: chronic obstructive pulmonary disease and asthma are major causes of hospitalisation and mortality among older patients but respiratory diseases are often under- or misdiagnosed because spirometry is not extensively used at this age. Design: we examined 715 elderly subjects with respiratory symptoms; all underwent a spirometric test and were administered the Mini Mental State Examination, Activities of Daily Living, Instrumental Activities of Daily Living and Geriatric Depression Scale questionnaires for cognitive, functional and effective evaluation. Their educational level and Body Mass Index were also taken into consideration. Results: a total of 585 patients (81.8%) were able to perform spirometry according to ATS’94 criteria while 130 (18.2%) were unable to do it. As regards educational level, Mini Mental State Examination, Activities of Daily Living and Instrumental Activities of Daily Living scores showed a significant difference (P-0.001) between the groups of patients with high-quality spirometries and those with inadequate ones. There was no difference between the two groups in terms of age, Body Mass Index or Geriatric Depression Scale score. Conclusions: the majority of elderly subjects can perform spirometry according to international guidelines; age itself cannot be considered a risk factor for a bad spirometric performance, but it becomes influential if it is associated with cognitive and functional impairment.

Study of the relationship between cigarette smoking, alcohol drinking and cognitive impairment among elderly people in China

Abstract: Objective: the incidence of cognitive impairment is increasing; however, little is known about the prevalence and risk factors for cognitive impairment of elderly people in China. This report focuses on investigating the relationship between cigarette smoking, alcohol drinking and cognitive impairment in elderly people. Methods: 3012 participants aged 60 years old and over were enrolled from six communities of Chongqing. Cognitive function was measured by the Mini-Mental State Examination and Activities of Daily Living. The x 2 test and logistic regression was used to find the relationship between cigarette smoking, alcohol drinking and cognitive impairment. Result: the rate of abnormal cognitive function in elderly people was 11.95%. Smoking was closely related to cognitive impairment (x 2 =6.59, P=0.027). Alcohol drinking was also associated with cognitive impairment (x 2 =6.31, P=0.025). In all smokers, current smoking was associated with a significantly increased risk of cognitive impairment (RR 2.33; 95% CI=1.37‐5.82). In all people who drink every day, there was a significantly increased risk of cognitive impairment (RR 3.47; 95% CI=1.79‐6.71). Conclusion: smoking and drinking are risk factors for cognitive impairment among elderly people. Cessation of smoking and reduction of drinking could be considered as part of a strategy to reduce the incidence of cognitive impairment.

Colour vision deficiencies in Alzheimer's disease

Abstract: Objective: visual disorders are among the earliest symptoms of Alzheimer’s disease. It is, however, still controversial as to whether Alzheimer’s disease impairs colour vision. In this study, colour vision of Alzheimer’s disease patients was tested using the Ishihara test and the PV-16 choice test. The latter test, primarily designed for children, was chosen in order to avoid problems due to cognitive decline. Methods: 26 patients with mild to severe Alzheimer’s disease (M:F=5:21; mean age: 80"9 years, range: 53–95 years) and 25 controls (M:F=5:20; mean age 80"10 years, range: 56–100 years) were rated after undergoing complete neuro-ophthalmologic examination. Results: the Alzheimer’s disease patients made significantly more unspecific errors in the Ishihara test (P=0.02) and in the PV-16 choice test (P=0.0008) than the controls. No relation between test performance and severity of Alzheimer’s disease was found. Conclusions: Alzheimer’s disease patients have an unspecific colour vision deficiency independent of the severity of the disease.

Do guidelines improve the process and outcomes of care in delirium

Abstract: Objective: to develop consensus guidelines for management of delirium and to assess their effectiveness in improving the outcomes and process of care in delirium. Method: guidelines for delirium were developed following a literature search and a formal multi-disciplinary consensus process using a two-stage Delphi technique. The process and outcomes of patients with delirium were then observed in a ‘ before’ (211 patients) and an ‘ after’ study (125 patients). Three levels of intervention were made in the ‘ after’ study. (i) Feedback of baseline data only (low intensity intervention). (ii) As in (i), but also formal distribution of the guidelines to nurses and doctors (medium intensity intervention). (iii) As in (ii), but in addition the guidelines were reinforced with teaching sessions for the nurses and doctors (high intensity intervention). Setting: older people (aged over 65 years) with delirium admitted to acute medical or acute elderly care wards in Wve district general hospitals in England. Results: only in the high intervention group was there an improvement in process and outcome of care, but this failed to reach statistical signiWcance. Conclusion: delirium is a poorly managed condition in older people and guidelines alone fail to improve the process and outcomes of care.

A comparison of health-related quality of life of elderly and younger insulin-treated adults with diabetes

Abstract: Background: diabetes is a signiWcant disease of elderly people, an age group whose numbers will double over the next 20–30 years. Yet studies which assess diabetes-related quality of life have rarely included elderly participants. Objectives: to compare and contrast the health-related quality of life of elderly (≥ 65 years) and younger individuals with diabetes using reliable and valid assessment tools. Methods: 191 adults (≥ 30 years) with diabetes currently on an insulin regimen were recruited. Medical and demographic data were gathered from the medical chart. Participants completed a generic quality of life measure (SF-36) and 3 diabetesspeciWc measures. Statistical analyses compared adults (30–64 years) to elderly adults (≥ 65 years). Results: on the generic SF-36, physical and mental summary scores did not differ. However, elderly participants reported greater role limitations due to physical problems, and better social function. On diabetes-speciWc measures, elderly participants reported higher satisfaction with diabetes-related aspects of their lives, less diabetes-related emotional distress, and better ability to cope with their diabetes. Conclusions: the differences that did emerge between the two groups suggest that, though experiencing more limitations in their ability to function in their roles, elderly individuals with diabetes may still feel that they can cope with these limitations and thus manage the distress and lifestyle demands of the diabetes. The value of subscale analysis of the SF-36 and use of diabetes-speciWc health-related quality of life measures is also afWrmed.

Non‐pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments

Abstract: Background: primary and secondary insomnia, especially among older adults, is frequently encountered by family physicians. Pharmacological interventions, although effective in some circumstances, can be detrimental in others. Non-pharmacological management of insomnia may allow the patients to self-administer the treatment. Objectives: review of published literature of assessment tools and treatments for primary and secondary insomnia. Results: two frequently used self-reporting methods for obtaining sleep data are sleep diaries and Pittsburg Sleep Quality Index. A large amount of research supports the use of non-pharmacological treatments such as stimulus control, sleep restriction, sleep hygiene education, cognitive therapy, multi-component therapy and paradoxical intention. Conclusion: assessing the nature of insomnia by using an effective assessment tool and providing patients with a non-pharmacological treatment should be the first intervention for insomnia. It is shown that non-pharmacological treatments for primary and secondary insomnia are feasible and effective alternatives to the use of benzodiazepines, and that family physicians should consider these when managing older patients with insomnia.

Predictors of depressive symptoms in older people—a survey of two general practice populations

Abstract: BACKGROUND: Studies have shown strong associations between disability, social support and depressive symptoms in older people; but socio-economic effects are less clear and little is known about the role of health locus of control. OBJECTIVE: To examine the roles of physical health, disability, social support, socio-economic factors and health locus of control as predictors of depressive symptoms in older people. METHOD: A postal survey of patients aged >/= 65 years from two London practices. Outcome measure was a score of > 5 on the 15-item Geriatric Depression Scale. Associations with other factors were examined using logistic regression and expressed as odds ratios. RESULTS: 70.4% (1602/2276) responded and provided Geriatric Depression Score 15 data, with 23.8% (381/1602) scoring > 5. After adjusting for age, sex and practice, high depression scores were associated with: (i) physical health and disability [e.g. severe versus no disability odds ratio 26.9 (15.7-46.2)]; (ii) social support [e.g. dissatisfaction with support odds ratio 4.2 (3.2-5.6)]; (iii) socio-economic [e.g. no occupational pension odds ratio 1.9 (1.5-2.4)]; (iv) health locus of control [e.g. internality 0.6 (0.6-0.7)]. After adjusting for disability, associations with general measures of physical health were reduced but still significant, while associations with social support, socio-economic factors, and health locus of control were unaffected. All four groups of factors were included in a final model for predicting depressive symptoms. CONCLUSIONS: Disability, physical health, social support, socio-economic factors, and health locus of control were all independent depression score predictors in this study. This has implications for measures to reduce depressive symptoms in older people

Proximal femur fracture in older patients – rehabilitation and clinical outcome

Abstract: Background: hip fracture is a major cause of morbidity and mortality in older people; optimal post-surgical treatment is a matter of controversy. Objective: to examine the effects of rehabilitation on the clinical outcome following surgical treatment of hip fracture. Design: prospective longitudinal study in three groups of patients with different post-surgical care. Methods: initial screening of 283 elderly patients with proximal femur fracture; documentation of medical and social history and clinical data; geriatric assessments (Activities of Daily Living and Instrumental Activities of Daily Living) during hospital stay and follow-up for 12 months. One hundred and forty-five patients (065 years) of normal mental status were eligible for the study. Successful follow-up could be monitored in 120 and 117 patients for 6 and 12 months, respectively. Sixty-nine and 39 patients underwent supervised inpatient rehabilitation in an orthopaedic or geriatric hospital, respectively (intervention groups A and B, respectively) whereas 34 patients received no special rehabilitation as they were directly discharged home (control group C). Results: initially a fall-/surgical-induced reduction (P-0.001) of the main outcome measure (Activities of Daily Living) was observed in all patients. Within 6 months of rehabilitation there was an improvement (P-0.01) in Activities of Daily Living; however the pre-fracture scores were not reached. The same time pattern was seen in group C. Therefore no significant differences between the three groups of patients in approaching the baseline status was visible. Moreover, the one-year total mortality in the studied population with normal mental status averaged 11.7% and did not differ between the three groups. Conclusion: based on our measured outcome variables institutional rehabilitation after surgical treatment of hip fracture apparently had no significant impact on mortality and morbidity in older patients of normal mental status.

Pulmonary embolism: differences in presentation between older and younger patients

Abstract: Background: the incidence of pulmonary embolism increases with age but the ‘ classical’ presentation of acute pulmonary embolism may not occur in older persons. Objectives: to compare the clinical presentation of younger and older patients with acute pulmonary embolism. Design: retrospective identiWcation of 60 consecutive cases of spiral computed tomography conWrmed acute pulmonary embolism over a 3-year period, with blinded review of radiological Wlms and electrocardiographs, and analysis of clinical presentation. Setting: a district general hospital serving a population of 200,000 people. Subjects: 31 younger and 29 older patients with acute pulmonary embolism. Results: older persons less often complained of pleuritic chest pain (P < 0.02), particularly as their primary presenting complaint (P < 0.002). Twenty-four percent of older but just 3% of younger persons presented with collapse (P < 0.02), despite similar proportions of central and peripheral emboli in the two groups. Older persons were more often cyanosed (P = 0.05) and hypoxic (P < 0.04) than younger persons but there were no signiWcant differences with respect to heart rate, respiratory rate or mean arterial blood pressure. Conclusions: older people present atypically with acute pulmonary embolism, potentially leading to delays in diagnosis and initiation of treatment. Collapse is a particularly important symptom of acute pulmonary embolism in older persons, even in the absence of pain.

Potentially reversible risk factors and urinary incontinence in frail older people living in community

Abstract: Background urinary incontinence is a common problem among older people living in different community settings. The multifactorial origin of urinary incontinence has been largely addressed and many previous studies have identified several reversible factors associated with incontinence. However, few data exist concerning the potentially reversible causes of this condition among frail community-dwelling older individuals. Objective the aim of the present study is to estimate, in a large population of frail elderly people living in the community, the prevalence of urinary incontinence and to determine physical, social, and psychological factors associated with it. Design observational study. Subjects and methods we analysed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programmes (n=5418). A total of 22 Home Health Agencies participated in this project evaluating the implementation of the Minimum Data Set for Home Care instrument. The main outcome measures were the prevalence and factors associated with urinary incontinence. Results urinary incontinence was recorded in 51% of patients, and it was more common in women than men (52% versus 49%, respectively; P=0.01). After adjustment for each of the variables considered in this study, three potentially reversible factors were strongly associated with urinary incontinence: urinary tract infection (adjusted odds ratio, 3.46; 95% confidence interval, 2.65-4.51), use of physical restraints (adjusted odds ratio, 3.20; 95% confidence interval, 2.19-4.68), environmental barriers (adjusted odds ratio, 1.53; 95% confidence interval, 1.15-2.02). These associations were consistent in both men and women. Conclusions the major finding of our study is that potentially reversible factors were strongly and independently associated with urinary incontinence. Failure to make all reasonable efforts to assess and to treat all these factors among frail elderly people should be considered one of the most important indicators of poor quality of care.