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Showing papers in "Journal of the American Geriatrics Society in 1991"


Journal ArticleDOI
TL;DR: This study evaluated a modified, timed version of the “Get‐Up and Go” Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital and suggested that the timed “Up & Go’ test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time.
Abstract: This study evaluated a modified, timed version of the "Get-Up and Go" Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and timed while he rises from an arm chair, walks 3 meters, turns, walks back, and sits down again. The results indicate that the time score is (1) reliable (inter-rater and intra-rater); (2) correlates well with log-transformed scores on the Berg Balance Scale (r = -0.81), gait speed (r = -0.61) and Barthel Index of ADL (r = -0.78); and (3) appears to predict the patient's ability to go outside alone safely. These data suggest that the timed "Up & Go" test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time. The test is quick, requires no special equipment or training, and is easily included as part of the routine medical examination.

12,004 citations


Journal ArticleDOI
TL;DR: Whether a battery of 13 sensorimotor, vestibular, and visual tests discriminates between elderly fallers and elderly non‐fallers is investigated.
Abstract: OBJECTIVE: To determine whether a battery of 13 sensorimotor, vestibular, and visual tests discriminates between elderly fallers and elderly non-fallers. DESIGN: One-year prospective study. SETTING: Conducted at a 124-bed Hostel for Aged Persons, in Sydney, Australia. PARTICIPANTS: Ninety-five persons aged between 59 and 97 years (mean age 82.7 years) took part in the study. Of the 29 non-participants, four were ill, five were absent (on holidays, etc), and 20 declined. Residents were generally independent in activities of daily living although personal care assistance was available. RESULTS: Eighty-four participants were available for follow-up. In the follow-up year, 40 subjects experienced no falls, 11 subjects fell one time only, 33 residents fell on two or more occasions. There was a total of 145 falls. Discriminant function analysis identified proprioception in the lower limbs visual contrast sensitivity, ankle dorsiflexion strength, reaction time, and sway with the eyes closed as the variables that significantly discriminated between subjects who experienced multiple falls and subjects who experienced no falls or one fall only. This procedure correctly classified 79% of subjects into multiple faller or non-multiple faller groups. Quadriceps strength was poorer in the multiple fallers compared with the non-fallers and once-only fallers, although the difference was not statistically significant. There was little difference in the mean scores for the tests of vestibular function in the non-fallers, once-only fallers, and multiple fallers. CONCLUSION: It appears that this approach highlights some key physiological factors that predispose elderly individuals to falls. Language: en

568 citations


Journal ArticleDOI
TL;DR: It is suggested that fall‐related injuries can be a serious health problem for vigorous as well as frail elderly persons and injury prevention should be directed at all elderly persons but tailored to expected differences in fall circumstances.
Abstract: Identification of different types of falls and fallers among elderly persons might aid in the targeting of preventive efforts. In a representative sample of 336 community elderly, subjects were assigned to Frail, Vigorous, or Transition groups based on observed patterns of clustering among demographic, physical, and psychological variables. The frequency and circumstances of falls in these three groups were then ascertained. As expected, the observed incidence of falling in one year of follow-up was highest in the Frail group (52%) and lowest in the Vigorous group (17%). However, 22% (5/23) of falls by vigorous subjects, but only 6% (5/89) of falls by frail subjects, resulted in a serious injury. Compared with frail subjects, vigorous fallers were somewhat more likely to fall during displacing activity (53% vs 31%), with an environmental hazard present (53% vs 29%), and on stairs (27% vs 6%). These findings suggest that fall-related injuries can be a serious health problem for vigorous as well as frail elderly persons. Injury prevention, therefore, should be directed at all elderly persons but tailored to expected differences in fall circumstances.

550 citations


Journal ArticleDOI
TL;DR: The varied patterns of GEM program organization are described and the literature of studies examining GEM effectiveness is reviewed, suggesting that much of the variability in findings is due to sample size limitations.
Abstract: Comprehensive geriatric assessment is a technique for multidimensional diagnosis of frail elderly people with the purpose of planning and/or delivering medical, psychosocial, and rehabilitative care. When comprehensive geriatric assessment is coupled with some therapy, then the term geriatric evaluation and management (GEM) will be used. Following a brief history of comprehensive geriatric assessment, we describe the varied patterns of GEM program organization and review the literature of studies examining GEM effectiveness. Program diversity complicates drawing firm conclusions about GEM effects; however, the vast majority of studies report positive, if not uniformly significant, results. Our analysis suggests that much of the variability in findings is due to sample size limitations. In order to reach conclusions of program effects across studies and to avoid problems of small sample sizes, we undertook a formal meta-analysis. In this initial meta-analysis, we sought to evaluate the effect of GEM programs on a single outcome: mortality. We pooled all published GEM controlled trials into four major groups: inpatient consultation services, inpatient GEM units, home assessment services, and outpatient GEM programs. Meta-analysis of 6-month mortality demonstrates a 39% reduction of mortality for inpatient consultation services (odds ratio 0.61, 95% confidence interval 0.46-0.81, P = 0.0008) and a 37% reduction of mortality for inpatient GEM units (odds ratio 0.63, 95% CI 0.42-0.93, P = 0.02). Home assessment services reduced mortality by 29% (odds ratio 0.71, 95% CI 0.55-0.90, P = 0.005). On the other hand, no significant survival effect was found for outpatient GEM programs (odds ratio 0.96, 95% confidence interval 0.61-1.49).(ABSTRACT TRUNCATED AT 250 WORDS)

504 citations


Journal ArticleDOI
TL;DR: It is concluded that urinary incontinence in women adversely affects quality of life to a significant degree; the extent depends on the nature ofincontinence and the age of the person.
Abstract: The objectives of this paper were to assess the quality of life of community-living women with urinary incontinence according to age, symptom group, amount of leakage, and duration, by use of the Sickness Impact Profile (SIP). Thirty-six women aged between 40 and 60 years and 40 women aged 70 years or more were randomly selected from the clients attending an incontinence clinic and interviewed using the SIP questionnaire. Urge and stress incontinence subgroups were defined by means of a symptom questionnaire. Total, psychosocial, and physical dysfunctions were moderate (8%, 7%, and 8% respectively) in general, but major differences were found when age and symptom groups were analysed. Urge symptoms were associated with more impairment than symptoms of stress incontinence. The elderly women with symptoms of stress incontinence were relatively little affected, while their younger counterparts were severely affected, especially in the categories of emotional behavior and recreation and pastimes. We conclude that urinary incontinence in women adversely affects quality of life to a significant degree; the extent depends on the nature of incontinence and the age of the person.

407 citations


Journal ArticleDOI
TL;DR: To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients, a large number of patients have been admitted to hospital and the standard of care has changed significantly over time.
Abstract: OBJECTIVE To determine the reliability of rapid screening by clinically derived geriatric criteria in predicting outcomes of elderly hospitalized patients. DESIGN Prospective cohort study of 985 patients screened at the time of hospital admission and followed for 1 year with respect to the outcomes of mortality, hospital readmission, and nursing home utilization. SETTING Palo Alto Veterans Affairs Medical Center, a tertiary care teaching hospital. SUBJECTS Male patients 65 years of age and older admitted to the Medical and Surgical services during the period from October 1, 1985 through September 30, 1986. RESULTS Patients were grouped by specific screening criteria into three groups of increasing frailty: Independent, Frail, and Severely Impaired. Each criterion focused on a geriatric condition and was designed to serve as a marker for frailty. Increasing frailty was significantly correlated with increasing length of hospital stay (P less than 0.0001), nursing home utilization (P less than 0.0001), and mortality (P less than 0.0001). Multivariate analyses revealed that the clinical groups were more predictive of mortality and nursing home utilization than were age or Diagnosis-Related Groups (DRGs). Rehospitalization was unrelated to age, clinical group, or DRG, suggesting that utilization may not be driven by the clinical factors measured in this study. CONCLUSIONS Rapid clinical screening using specific geriatric criteria is effective in identifying frail older subjects at risk for mortality and nursing home utilization. Our findings suggest that geriatric syndromes are more predictive of adverse outcomes than diagnosis per se. This well operationalized screening process is inexpensive as well as effective and could easily be introduced into other hospital settings.

391 citations


Journal ArticleDOI
TL;DR: The animal model for accelerated senescence named the Senescence-Accelerated Mouse (SAM) was developed in the laboratory (Department ofSenescence Biology, formerly Department of Pathology, Chest Disease Research Institute, Kyoto University) beginning in 1970.
Abstract: n animal model for accelerated senescence named the Senescence-Accelerated Mouse (SAM) was developed in our laboratory (Department of Senescence Biology, formerly Department of Pathology, Chest Disease Research Institute, Kyoto University) beginning in 1970. In this review, the circumstances related to development of SAM, characteristics of aging, pathologic phenotypes, and genetic background of this model are described.

356 citations


Journal ArticleDOI
TL;DR: Pain and its management have major implications for quality of life and quality of care, especially for terminal patients" and residents of long-term-care facilities.
Abstract: atient comfort and the control of pain are important goals in geriatric care. Pain is the most common symptom of disease and the most P common complaint in physicians' offices.' However, the management of chronic pain can be perplexing for physicians. With no objective biological markers for pain, assessment remains based on the patient's perceptions and self-report, and these are often clouded by individual interpretation of sensation, affective reactions, and behavioral responses. Several studies have documented that many physicians and nurses lack information about pain assessment and may have an inaccurate knowledge base about common pharmacological agents used in pain Consequences of pain are widespread in the elderly population. Depre~sion,~-~ decreased so~ialization,~-' sleep di~turbance,~ impaired amb~lation,~-' and increased health care utilization and costs' have all been associated with the presence of pain among elderly people. Though less thoroughly explored, deconditioning, gait disturbances, falls, slow rehabilitation, polypharmacy, cognitive dysfunction, and malnutrition are among the many geriatric conditions potentially worsened by the presence of pain. Finally, pain and its management have major implications for quality of life and quality of care, especially for terminal patients\" and residents of long-term-care facilities.' Pain is extremely common among older people. Population-based studies have estimated that 25% to 50% of community-dwelling elderly people suffer important pain problems.\"-'3 In a survey by Crook et a1 of 500 randomly selected households in Burlington, Ontario, 16% of the total population aged 18 to 105 reported a \"significant\" painful problem in the preceding 2 weeks. In this study, the incidence of pain was twice as great (250 per thousand vs 125 per thousand) in those over age 60 than in those 60 and under.\" Among nursing

326 citations


Journal ArticleDOI
TL;DR: Objective: To study the incidence and the risk factors of adverse drug reactions and the impact of prescription drug use on these factors in patients with history of adverse reactions.
Abstract: Objective: To study the incidence and the risk factors of adverse drug reactions. Design: Multicenter survey. Setting: Hospitalized care: 22 internal medicine and 19 geriatric wards. Patients: All patients (n = 9,148) consecutively admitted during two observation periods of 2 months. Main Outcome Measure: Incidence of adverse drug reactions. Results: The mean age was 67.1 ± 0.17 years (median 72); the mean duration of hospital stay was 18.1 ± 0.19 days (median 14). Each patient was administered 5.1 ± 0.03 (median 5) drug prescriptions. The incidence of probable or definite adverse drug reactions was 5.8% (532/9,148). In univariate analysis, the incidence of adverse drug reactions increased from 3.3% at under age 50 to 6.5% at age 70–79 and decreased over age 80 (5.8%). In multivariate logistic regression, taking more than four drugs (OR = 2.94, CI = 2.38–3.62), staying in hospital more than 14 days (OR = 2.82, CI = 2.26–3.52), having more than 4 active medical problems (OR = 1.78, CI = 1.29–2.45), staying in a medical ward instead of geriatric ward (OR = 1.33, CI = 1.09–1.63), and drinking alcohol (OR = 1.28, CI = 1.03–1.58) were positively correlated with adverse drug reactions occurrence (P < 0.05). Age, gender, and smoking cigarettes were not significant predictors of adverse drug reactions. Conclusion: Age is not an independent risk factor of adverse drug reactions, and good geriatric care can reduce the incidence of adverse drug reactions.

305 citations


Journal ArticleDOI
TL;DR: A prospective longitudinal study was devised to answer whether race or level of education affects scores on the Mini‐Mental State (MMS) exam in non‐demented people and what numerical cutpoints maximize the sensitivity and specificity of utilizing the MMS to help diagnose dementia in blacks of varying educational attainment.
Abstract: Previous studies have suggested that education and race may affect performance on standardized mental status tests. In order to more clearly define these relationships, a prospective longitudinal study was devised to answer two questions: (1) whether race or level of education affects scores on the Mini-Mental State (MMS) exam in non-demented people and (2) what numerical cutpoints maximize the sensitivity and specificity of utilizing the MMS to help diagnose dementia in blacks of varying educational attainment. A total of 100 white and 258 black individuals, recruited from two city hospital primary care geriatric clinics, were evaluated and subsequently followed longitudinally over a 2 1/2 year period in order to assess accurately the presence or absence of dementia. In the non-demented, total MMS scores and performance on each item of the MMS were analyzed, revealing that people with an 8th grade or less education consistently had significantly (P < .01) worse results than the better educated (9th grade or better) on borough, attention items, recall of table and dog, copying, sentence writing, phrase repeating, and total score. Furthermore, a total of 25% of the lower education group had an MMS score in the 18–23 range, traditionally thought to suggest dementia. There were no consistently significant differences between blacks and whites of equal education. In the better educated groups, using a score of 23 or less to define dementia maximizes the sensitivity and specificity of using the MMS in this diagnosis at 93% and 100%, respectively. In the lower education group, using 17 or less to define dementia maximizes sensitivity and specificity at 81% and 100%, respectively. It is concluded that MMS results are affected by education but not by race, that only certain MMS items are educationally related and perhaps could be modified, and that on the unmodified MMS a score of 17 or less should be used as the outpoint for suggesting the presence of dementia in the poorly educated.

293 citations


Journal ArticleDOI
TL;DR: It is concluded that hypogonadal elderly white men may be at increased risk for MTHF.
Abstract: The risk of MTHF in hypogonadal elderly men was investigated with a case-control model. Cases and controls were selected from males age 65 years and older residing in the 120-bed McGuire Veterans Affairs Medical Center Nursing Home Care Unit over a 5-day interval. Historical data and serum free testosterone (fTe) were available on 17 subjects with MTHF and 61 controls. When groups were compared for differences in age, race, alcohol abuse, cigarette abuse, and diseases or drugs that may be associated with MTHF, only race was significantly different. Although 25.6% of residents were black, 100% of MTHF subjects were white (P = 0.004). Hypogonadism was defined as a random fTe less than 9 pg/mL (normal 9 to 46 pg/mL) and was found in 21 subjects (26.9%). Of cases with a MTHF, 58.8% were hypogonadal compared with only 18.0% of controls. Utilizing logistic regression, a highly significant association was found between hypogonadism and MTHF (P = 0.008), and using the odds ratio, subjects with hypogonadism were 6.5 times more likely to have a MTHF (95% CI 2.0 to 20.6). To adjust for race, the odds ratio was repeated excluding black subjects, and the results remained highly significant (4.6, 95% CI 1.3 to 16.2). We conclude that hypogonadal elderly white men may be at increased risk for MTHF.

Journal ArticleDOI
TL;DR: It is concluded that education‐specific norms optimize performance of the MMSE as a screening test for Alzheimer's dementia in elderly outpatients.
Abstract: We studied whether Mini-Mental State Examination (MMSE) norms for detecting dementia in elderly outpatients vary according to educational attainment. Subjects were 109 elderly outpatients with Alzheimer's dementia and 100 non-demented outpatient controls. Receiver operating characteristics (ROC) of the MMSE were examined among three strata of educational attainment: middle school, high school, and college/graduate school. MMSE ROC curve areas were .95-.96 in the three educational strata. Assuming a dementia prevalence of 10%-30%, the most accurate lower limits of normal for MMSE scores and their attendant sensitivities and specificities were 21 for middle school (.82/.94), 23 for high school (.79/.97), and 24 for college/graduate school (.83/1.00) attainment. These norms accurately classified over 90% of subjects in all three educational strata. We conclude that education-specific norms optimize performance of the MMSE as a screening test for Alzheimer's dementia in elderly outpatients.

Journal ArticleDOI
TL;DR: It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.
Abstract: The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Journal ArticleDOI
TL;DR: It is concluded that although muscle mass correlates with muscle strength in a healthy older population, use of simple age‐independent clinical measurements of body mass should not be used to predict muscle strength.
Abstract: To determine the extent that muscle mass is predictive of muscle strength in the elderly, anthropomorphic estimates of muscle area and impedance measurements of muscle mass and peak isometric muscle strength were obtained in a relatively healthy older population over 65 years of age (mean age = 71.7; n = 218). Midarm muscle area correlated strongly with upper arm strength (r = 0.68, P less than 0.0001) while midthigh muscle area had a much lower correlation with thigh muscle strength (r = 0.29, P less than 0.0001). These muscle area calculations also include bone area. Lean body mass calculated by bioelectric impedance correlated highly with cumulative muscle strength measured by summing all muscle groups (r = 0.79, P less than 0.0001). To determine whether aging alters muscle strength per unit of muscle mass, additional middle-aged subjects were included, and three groups, middle-aged (55-64) (n = 78), young-old (65-74) (n = 161), and old-old (75+) (n = 57), were compared. A significant age-related trend of decreasing muscle strength per unit of lean body mass was noted. It is concluded that although muscle mass correlates with muscle strength in a healthy older population, use of simple age-independent clinical measurements of body mass should not be used to predict muscle strength.

Journal ArticleDOI
TL;DR: The hypothesis for study is that sleep apnea causes deficits in brain function, possibly due to global effects rather than any particular cortical or subcortical structure, and there is a strong relationship between dementia andsleep apnea when theSleep apnea and dementia are severe.
Abstract: Sleep apnea is characterized by transient hypoxemias which are thought to affect mental functioning. Accordingly, speculation and research have focussed on relationships between sleep apnea and dementia. We studied 235 nursing home (ie institutionalized) patients (152 women with a median age of 83.5; 83 men with a median age of 79.7) with portable sleep recording equipment. The Mattis Dementia Rating Scale and the Geriatric Depression Scale were given to each. Seventy percent of the patients had five or more respiratory disturbances per hour of sleep and 96 percent showed some dementia. Sleep apnea was significantly correlated with all subscales on the dementia rating scale. There were trivial differences in dementia ratings between those with mild-moderate apnea and those with no apnea. There were significant differences, however, between the latter two groups and those with severe apnea. In particular, items reflecting attention, initiation and perseveration, conceptualization, and memory tasks on the DRS distinguished between those with and without severe sleep apnea. Among those patients with no depression, all patients with severe sleep apnea were also severely demented. Our data suggest that there is a strong relationship between dementia and sleep apnea when the sleep apnea and dementia are severe. Although causality cannot be inferred from associations, our hypothesis for study is that sleep apnea causes deficits in brain function, possibly due to global effects rather than any particular cortical or subcortical structure.

Journal ArticleDOI
TL;DR: The NOSGER is currently being used in a number of European and North American centers and should turn out to be a useful instrument for longitudinal studies in psychogeriatrics.
Abstract: Although a great number of psychometric tests and rating scales for the assessment of psychogeriatric patients is available, there is still an urgent need, in research and practice, for a clinical rating instrument that meets the following main requirements: (1) applicable to institutionalized and community patients and covering a wide range of behavioral pathology; (2) acceptable and easy to use for professionals and lay persons alike; (3) covering a wide range of behavior relevant to daily functioning but independent of sex or social status of the individual assessed. The NOSGER contains 30 items of behavior, each rated on a 5-point scale according to frequency of occurrence. Item scores are summarized into 6 Dimension scores (memory, instrumental activities of daily life, self-care, mood, social behavior, and disturbing behavior) which are clinically relevant in dementia, depression, and other psychiatric disorders of old age. Validation studies with a preliminary version of the NOSGER indicated good acceptance of the scale, high inter-rater and test-retest reliability, and high correlations of all NOSGER Dimension scores with results of a variety of established assessment instruments. The NOSGER is currently being used in a number of European and North American centers and should turn out to be a useful instrument for longitudinal studies in psychogeriatrics.

Journal ArticleDOI
TL;DR: To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture, a large number of patients have had hip fracture.
Abstract: tudy Objective To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture. Design The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies. Setting Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital. Subjects Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively). Measurements and Main Results All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients. Conclusions ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.

Journal ArticleDOI
TL;DR: In this population of persons with unexplained falls who demonstrated substantial impairments in functional balance, effector factors appear more impaired than automatic postural responses, which may require further development before it can be useful to study balance problems in older persons.
Abstract: Automatic postural responses and effector factors were examined in 10 persons with unexplained falls after clinical examination and 24 older controls. Fallers were more unstable than controls on clinical tests of balance (20% of fallers vs 79.2% of controls were able to stand on one foot (P less than .005), 40% of fallers and 100% of controls were stable while turning in place (P less than .001), postural stress test median score was 12 for fallers and 20 for controls (P less than 0.001). We found prolonged tibialis anterior latency (fallers 158.8 +/- 23.7, controls 143.2 +/- 15.7 milliseconds, P = 0.03), marked losses in ankle strength (dorsiflexion: faller 3.2 +/- 2.9, controls 8.9 +/- 4.2 foot-pounds, P less than 0.001; plantarflexion: fallers 7.9 +/- 5.3, controls 21.4 +/- 11.1 foot-pounds, P less than 0.001), and decreases in range of motion (ankle plantarflexion: fallers 29.2 +/- 7.0, controls 37.8 +/- 12.4 degrees, P = 0.02). Gastrocnemius latency and electromyographic (EMG) measures of sequence showed no differences between fallers and controls. Sequence measures were not symmetric between the lower extremities in either fallers or controls. In this population of persons with unexplained falls who demonstrated substantial impairments in functional balance, effector factors appear more impaired than automatic postural responses. Alternatively, contemporary analysis of automatic postural responses may require further development before it can be useful to study balance problems in older persons.

Journal ArticleDOI
TL;DR: A fall classification system was developed and tested for interrater reliability and provides operational definitions for types of falls and a reliable and flexible method for classifying falls in the elderly.
Abstract: To determine risk factors for falls, previous studies have classified falls according to the contribution of factors both intrinsic and extrinsic to the host. Due partly to the lack of operational definitions and the absence of information on reliability, no consensus on classification has been reached. Consequently, in a 3-year prospective study of falls occurring in a probability sample of community-dwelling elderly (n = 1,358), a fall classification system was developed and tested for interrater reliability. The 366 falls in the first year of the study were independently classified by two reviewers on the basis of a narrative description and structured interview. The falls in the four major categories of the classification system included: falls related to extrinsic factors (55%), falls related to intrinsic factors (39%), falls from a non-bipedal stance (8%) and unclassified falls (7%). The interrater reliability for the four major categories was 89.9% with a kappa of 0.828. The system provides operational definitions for types of falls and a reliable and flexible method for classifying falls in the elderly.

Journal ArticleDOI
TL;DR: The extent to which patients with objective signs of malnutrition had been diagnosed as such by physicians and the diagnosis documented in the medical record was determined.
Abstract: Objective: To determine the extent to which patients with objective signs of malnutrition had been diagnosed as such by physicians and the diagnosis documented in the medical record. Design: Cross-sectional. Subjects: All non-critically ill patients (n = 121) aged 70 years or older admitted to an Oslo hospital during a 3-week period. Methods: Compared problem list and other elements of the medical record with observations of height, weight, triceps skinfold, midarm circumference, and arm-muscle circumference made on first weekday in hospital. Serum albumin available on 66 subjects. Main Results: Nine patients had weight/height ratios below 60% of normal, 16 patients between 60% and 75%, and 41 patients between 74% and 90% of normal. Of these 66 patients, only 24 were recognized as malnourished on admission, only five received nutritional support, and none was diagnosed as having malnutrition at the time of discharge. Conclusions: Malnutrition is underdiagnosed and under-treated. The consequences of this are likely to be deleterious to health.

Journal ArticleDOI
TL;DR: Only half of the reported instances of behavior disorders were considered distressful by nursing home staff, and wandering was seen as distressful to staff only 50% of the time.
Abstract: Newly enacted Federal regulations have focused increasing attention on the use of psychoactive drugs and on the treatment of disruptive behavior in the nursing home. To study the interaction between resident behavior and staff distress in nursing homes, we measured the frequency of seven types of behavior problems among 346 residents of intermediate care facilities who were receiving some form of psychoactive medication. Nurses were interviewed on two shifts to determine their perception of the frequency and severity of each behavior in each patient as well as the level of distress it caused among caregivers. The most common behavior problems noted were agitation (42%), withdrawal (33%), and noisiness (27%). Only half of the reported instances of behavior disorders were considered distressful by nursing home staff. While physical abuse caused distress 92% of the time and verbal abuse 90% of the time, wandering was seen as distressful to staff only 50% of the time. Nearly a third of "wandering" patients were restrained; they produced less distress than non-restrained wanderers. There was substantial disagreement, ranging from 6% to 22% for individual residents, over the presence of distress-causing behavior, although day and evening nursing shifts rated the frequencies of behavior and the degrees of distress equally on average. Residents with higher cognitive function were less likely to cause distress for all behaviors, except for verbal abuse where the reverse was true. Age and dependency in activities of daily living were not associated with problematic behavior or staff distress. These findings indicate that the existence of "problematic" behaviors in a given resident is often perceived differently by different staff, and its impact on staff also differs widely.

Journal ArticleDOI
TL;DR: Dopaminergic agents share the property of stimulation of D2 dopamine receptors, and this action may play an essential role in mediating their neuropsychiatric effects, and lithium may help control drug‐induced mania.
Abstract: A variety of neuropharmacologic agents, including anticholinergic drugs, amantadine hydrochloride, levodopa, selegiline, bromocriptine, and pergolide, are now available for the treatment of Parkinson's disease. Of patients treated with dopaminergic agents, 30% develop visual hallucinations, 10% exhibit delusions, 10% have euphoria, 1% have mania, 10% to 15% experience increased anxiety, 15% have confusional periods, and a few exhibit altered sexual behavior. Anticholinergic drugs have a greater tendency to produce confusional states than dopaminergic compounds. Elderly patients and those with underlying dementia are most likely to have untoward side effects with anti-parkinsonism treatment. Dosage reduction is the optimum management strategy, although anti-psychotic agents may be necessary in patients with delusions, and lithium may help control drug-induced mania. Dopaminergic agents share the property of stimulation of D2 dopamine receptors, and this action may play an essential role in mediating their neuropsychiatric effects.

Journal ArticleDOI
TL;DR: The most prevalent diagnosis in this group of ambulatory elderly patients did not prove to be cancer, as often thought, but rather “unexplained weight loss", and CT scans were not found to be helpful as screening tests in the evaluation of weight loss.
Abstract: Significant unexplained and unintentional weight loss was found in 45 elderly patients who were identified by computer search of the diagnostic files of seven family practice centers. We performed a case series chart review study which revealed that 24% of the 45 cases had no definitive etiology for the weight loss after two years of extensive clinical investigation. Depression was found to be the most common diagnosis made (18%) followed by cancer (16%). Only four patients died during the study period and all had cancer. The most prevalent diagnosis in this group of ambulatory elderly patients did not prove to be cancer, as often though, but rather "unexplained weight loss." CT scans were not found to be helpful as screening tests in the evaluation of weight loss. Using the data from this study, the diagnostic evaluations of elderly patients with unexplained weight loss may be more efficiently directed.

Journal ArticleDOI
TL;DR: To measure the prevalence, incidence, types, and certain characteristics of antibiotics prescribed in nursing homes, a large number of antibiotics are prescribed in hospitals and nursing homes across the United States.
Abstract: Objective. To measure the prevalence, incidence, types, and certain characteristics of antibiotics prescribed in nursing homes. Design and Setting. Periodic survey over 1 year of patient charts in 53 stratified, randomly selected nursing homes in the state of Maryland. Patients. All patients 65 years of age or more residing in these nursing homes on the first day of study. Results. Of 4,165 patients in 53 nursing homes, records over the year were satisfactory in 3,899 patients in 52 nursing homes. The prevalence of antibiotic use on the first day of the study was 8%. Over the next 12 months, observations of more than one million patient-days revealed an incidence of 0.46 antibiotic courses/100 patient-days; 54% of the 3,899 patients received at least one antibiotic course. For presumed active infections, beta lactam antibiotics were the most commonly used, 54% of antibiotic orders. For all antibiotics, urinary tract infection was the most common indication, eliciting 36% of orders including 9% for asymptomatic bacteriuria. Skin, lower respiratory, and upper respiratory infections comprised 14%–17% each. Physicians prescribed 94% of courses but documented examinations of only 44% of patients at the outset of these courses. Consensus criteria for minimal diagnostic evaluation of four selected infections were met in only 11% of episodes of infection. Although the most serious infections tended to be better evaluated than others, 31% of the former were not noted to have been examined by a physician. Three percent of orders were for prophylaxis and two-thirds of these antibiotics were administered for more than 2 days. Conclusions. Antibiotics are frequently prescribed for aged nursing home patients, often in the absence of a physician's examination and other features commonly performed in evaluation of specific infectious diseases. More than one-fifth of antibiotics prescribed by presumed active infections were for two infections usually thought not to require antibiotic therapy, “viral” upper respiratory infection (13%) and asymptomatic bacteriuria (9%). To optimize antibiotic use in nursing homes, greater attention should be directed to appropriate durations of prophylaxis for urologic, dental, and minor surgical procedures; to standards for diagnostic evaluations of common infections; and to the roles of antibiotics in upper respiratory infections and in asymptomatic bacteriuria.

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TL;DR: The properties of endogenous rhythms differ in older organisms as compared to young adults, suggesting that timekeeping systems are altered during aging.
Abstract: iological rhythms are cyclic changes which correspond to the temporal organization of the environment. The frequencies of the rhythms are synchronized by daily, tidal, lunar, and seasonal cycles that serve to adapt organisms to rhythmic environmental changes. They also, in the absence of signals such as light-dark cycles, enable organisms to anticipate cyclic events. Overt rhythms, for example activity-rest cycles, are often recorded under 24-hour photoperiods which synchronize them to a 24-hour day. They are thus entrained by the photoperiodic input. In contrast, activity-rest rhythms have also been documented under constant conditions, that is with no known periodic changes in the environment that could act as entraining agents (Zeitgebers). The cycles which persist under constant conditions with self-sustained oscillations are called endogenous rhythms. Endogenous rhythms become free-running with periods which deviate from environmental cycles, and because of this they are defined as circadian, circatidal, circalunar or circannual. These free-running rhythms have the unusual property of temperature compensation, that is stability of period over a wide range of physiological temperature^.'-^ Only by analyzing the properties of endogenous rhythms can changes in the biological oscillator driving the rhythms, the pacemaker, be determined. The properties of endogenous rhythms differ in older organisms as compared to young adults, suggesting that timekeeping systems are altered during aging. Many reports have provided evidence for the emergence of rhythmicity during development and changes during maturation, and these have been reviewed re~ e n t l y . ~ While one may argue that aging is a continuation of the developmental process, this review will be confined to studies of both entrained and freerunning biological rhythms in young adults and the changes in the properties of the rhythms during the adult life span.

Journal ArticleDOI
TL;DR: The study by Hirsch et a13 in the December 1990 issue of this journal provides additional descriptive data on this complex problem and attempts to shed light on the causes of hospitalassociated dysfunction.
Abstract: H ospitalization is often a devastating event for elderly patients. In addition to the effects of whatever acute illness brought ' them to the hospital, older people frequently incur major functional setbacks stemming from in-hospital treatment and immobilization. Lamont et all documented that over two-thirds of previously home-living elderly patients deteriorate in their functional levels between hospital admission and discharge, and McVey et a12 documented a functional loss in about one-third of such patients. The study by Hirsch et a13 in the December 1990 issue of this journal provides additional descriptive data on this complex problem and attempts to shed light on the causes of hospitalassociated dysfunction. Reasons for functional decline in the hospital are manifold but can be conceptualized as stemming from three processes: the illness itself, adverse effects of the treatment, and general effects of deconditioning. Although hard to distinguish between the three processes quantitatively, all are of considerable importance. While direct adverse effects of the illness are generally understood and accepted by patients, and adverse effects of treatment are fairly predictable and patients are duly informed about them, the deconditioning effects of immobilization are often unanticipated and particularly disabling and disturbing. Studies of enforced bedrest, mostly performed within the United States space program, have demonstrated that the supine position and immobilization can have considerable effects on nearly every system in the body, effects likely to be more pronounced in elderly persons with illness4 While these effects were mostly reversible in young subjects, older persons have considerably more difficulty recovering. The systems most

Journal ArticleDOI
TL;DR: The hypothesis that many nursing home residents with an apparently blunted fever response may actually have a significant change in temperature which is not recognized because of a low baseline temperature is tested.
Abstract: OBJECTIVE To test the hypothesis that many nursing home residents with an apparently blunted fever response (maximum temperature less than 101 degrees F) may actually have a significant change in temperature (delta T greater than or equal to 2.4 degrees F) which is not recognized because of a low baseline temperature. DESIGN Retrospective chart review for cases of infection that met specific criteria and for chart-recorded baseline and infection temperatures. Chart-recorded baseline temperatures were prospectively compared with re-measurement of morning temperatures. SETTING Nursing Home Care Unit of the VAMC West Los Angeles. PATIENTS Random review of 40 residents' charts resulted in the detection of 69 infections among 26 residents over a 20-month period. Fifty randomly selected residents prospectively underwent comparison of chart-determined and actual re-measurement of baseline temperatures. RESULTS In 50 randomly selected residents, the mean oral baseline temperature of 97.4 +/- 0.2 (degrees F +/- SEM) closely approximated the mean nurse-recorded measures in the charts (97.6 +/- 0.1). Chart review detected 69 infections among 26 residents, with 53 episodes having a temperature recorded during the infection. The mean maximum temperature (Tmax) during an infection was 101.3 +/- 0.3 (degrees F +/- SEM) but 47% (25/53) of the episodes had a "blunted" fever response (Tmax less than 101 degrees F). Of the 25 "blunted" fevers (Tmax less than 101 degrees F), about one-fourth demonstrated an adequate change in temperature from baseline (delta T greater than or equal to 2.4 degrees F) but failed to reach 101 degrees F because of a low baseline. Most infections (89%) had a Tmax greater than 99 degrees F. CONCLUSION Establishing a nursing home patient's basal temperature and monitoring for changes in temperature (delta T greater than 2.4 degrees F) and/or lowering the threshold for recognition of fevers (to 99 degrees or 100 degrees F) in nursing home residents with a change in function should assist in early recognition of infections.

Journal ArticleDOI
TL;DR: Examination of the prevalence and correlates of postural hypotension in a cohort of elderly persons with isolated systolic hypertension found a drop in syStolic blood pressure of ≥20 mm Hg was common.
Abstract: Objective The objective of this study was to examine the prevalence and correlates of postural hypotension (defined as a drop in systolic blood pressure of greater than or equal to 20 mm Hg) in a cohort of elderly persons with isolated systolic hypertension (ISH). Design Baseline cross-sectional analysis of the 4,736 persons randomized in the Systolic Hypertension in the Elderly Program (SHEP). Setting A randomized multi-center double-blind outpatient clinical trial of the impact of treating ISH. Participants Men and women age greater than or equal to 60 years with the systolic blood pressure (SBP) greater than or equal to 160 mm Hg and diastolic blood pressure (DBP) less than 90 mm Hg. Measures Medical histories were obtained using interviewer-administered, standardized clinical history forms. At entry into the study, seated and standing BP was measured by certified BP technicians using a random zero sphygmomanometer. Postural hypotension (PH) was assessed at 1 and 3 minutes after the participant arose from a seated position. Main results PH was found in 10.4% of participants at 1 minute and in 12.0% of participants at 3 minutes. 5.3% of participants demonstrated PH at both time intervals while 17.3% demonstrated PH at either or both of the time intervals. Factors significantly (P less than 0.05) associated with the presence of PH were higher mean SBP and a lower mean body mass index. Conclusions Somewhat different persons were defined as having PH based upon the 1 minute and 3 minute standing measures of BP, and prevalence estimates of PH can vary depending on whether one or more intervals of measurement are used. Cross-sectional data analysis indicated that PH, in healthy community-dwelling older persons with ISH, may not be associated with a history of disorders or problems usually thought to be related to PH. However, prospective data are needed to determine the prognostic significance of PH, and whether one or multiple measurements carry more significance.

Journal ArticleDOI
TL;DR: The hypothesis that age-associated GH deficiency contributes to the aging process is hypothesis that GH replacement therapy in aging humans has become a feasible option.
Abstract: he decline of growth hormone (GH) secretion with aging and its impact on physiological functions are currently subjects of considerable T interest. In addition to promoting growth, GH has anabolic and lipolytic effects and actions on various metabolic and physiologic functions.' It has recently been shown that in adults (18 to 51 years old) with GH deficiency, GH replacement increases lean body and reduces fat mass, increases muscle mass, lowers plasma cholesterol, and improves renal The onset of age-related alterations of GH secretion occurs prior to other manifestations of aging. The blunted secretion of GH in adult and aging humans, the actions of GH, and similarities in manifestations of aging and of GH deficiency have prompted the hypothesis that age-associated GH deficiency contributes to the aging process. Table 1 summarizes the possible relationship of GH to the aging process. Because of the limited supply of GH extracted from human pituitaries, its use was previously restricted to treatment of growth hormone deficiency during childhood. In recent years, development of recombinant technology has permitted synthesis of bioactive GH,4,5 and GH replacement therapy in aging humans has become a feasible option. Effects of GH treatment for 7 days in healthy humans over 60 years old have recently been reported by Marcus et a1.6 Exogenous GH significantly increased nitrogen retention, decreased serum cholesterol, and increased serum triglyceride concentrations. It should be noted that a mild impairment of glucose tolerance was observed during oral glucose challenging. Rudman et a17 reported on

Journal ArticleDOI
TL;DR: Change in cognitive function was assessed over 12 months in 110 patients over the age of 65 satisfying the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) criteria for “probable” Alzheimer's disease.
Abstract: Change in cognitive function was assessed over 12 months in 110 patients over the age of 65 satisfying National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) criteria for "probable" Alzheimer's Disease. A highly significant deterioration in cognitive function was observed. Decline in cognitive scores was relatively normally distributed. Patients who died during the follow-up had more apraxia at entry to the study than survivors. A greater rate of decline was seen in patients whose parents suffered from dementia (but not in those where a sibling or other relative was affected), in subjects who had moderate dementia, and those who had been ill for less than 24 months. Age, age of onset, and the presence or absence of aphasia or apraxia had no influence on rate of progression. A cluster analysis revealed three patterns of decline.