Showing papers in "Journal of the American Geriatrics Society in 1999"

Drugs and Falls in Older People: A Systematic Review and Meta‐analysis: I. Psychotropic Drugs

Abstract: OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people. DESIGN: Fixed-effects meta-analysis. DATA SOURCES: English-language articles in MEDLINE (1966 – March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers. STUDY SELECTION: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older. DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non-fallers taking specific classes of psychotropic drugs. RESULTS: Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52-1.97) for any psychotropic use; 1.50 (95%CI, 1.25-1.79) for neuroleptic use; 1.54 (95%CI, 1.40-1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4-1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14-2.00) for only TCA use; and 1.48 (95%CI, 1.23-1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21-.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38-2.00). Comparing ≥1 with ≥ 2 falls, mean subject age >75 versus ≥ 75 years old, communities with >35% versus ≥35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug. CONCLUSION: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.

Serum IL-6 level and the development of disability in older persons.

Abstract: BACKGROUND: The serum concentration of interleukin 6 (IL-6), a cytokine that plays a central role in inflammation, increases with age. Because inflammation is a component of many age-associated chronic diseases, which often cause disability, high circulating levels of IL-6 may contribute to functional decline in old age. We tested the hypothesis that high levels of IL-6 predict future disability in older persons who are not disabled. METHODS: Participants at the sixth annual follow-up of the Iowa site of the Established Populations for Epidemiologic Studies of the Elderly aged 71 years or older were considered eligible for this study if they had no disability in regard to mobility or in selected activities of daily living (ADL), and they were re-interviewed 4 years later. Incident cases of mobility-disability and of ADL-disability were identified based on responses at the follow-up interview. Measures of IL-6 were obtained from specimens collected at baseline from the 283 participants who developed any disability and from 350 participants selected randomly (46.9%) from those who continued to be non-disabled. FINDINGS: Participants in the highest IL-6 tertile were 1.76 (95% CI, 1.17-2.64) times more likely to develop at least mobility-disability and 1.62 (95% CI, 1.02-2.60) times more likely to develop mobility plus ADL-disability compared with to the lowest IL-6 tertile. The strength of this association was almost unchanged after adjusting for multiple confounders. The increased risk of mobility-disability over the full spectrum of IL-6 concentration was nonlinear, with the risk rising rapidly beyond plasma levels of 2.5 pg/mL. INTERPRETATION: Higher circulating levels of IL-6 predict disability onset in older persons. This may be attributable to a direct effect of IL-6 on muscle atrophy and/or to the pathophysiologic role played by IL-6 in specific diseases. J Am Geriatr Soc 47:639–646, 1999.

Drugs and Falls in Older People: A Systematic Review and Meta‐analysis: II. Cardiac and Analgesic Drugs

Abstract: OBJECTIVES: To evaluate critically the evidence linking specific classes of cardiac and analgesic drugs to falls in older people. DESIGN: Fixed-effects meta-analysis. DATA SOURCES: English-language articles in MEDLINE (1966 – March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers. STUDY SELECTION: Systematic evaluation of cardiac or analgesic drug use and any fall in people aged 60 years and older. DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and nonfallers taking specific classes of cardiac and analgesic drugs. RESULTS: Twenty nine studies met inclusion criteria. None were randomized controlled trials. For one or more falls, the pooled Odds Ratio (95% Confidence Interval) was 1.08 (1.02-1.16) for diuretic use, 1.06 (0.97-1.16) for thiazide diuretics, 0.90 (0.73-1.12) for loop diuretics, 0.93 (0.77-1.11) for beta-blockers, 1.16 (0.87-1.55) for centrally acting antihypertensives, 1.20 (0.92-1.58) for ACE inhibitors, 0.94 (0.77-1.14) for calcium channel blockers, 1.13 (0.95-1.36) for nitrates, 1.59 (1.02-2.48) for type la antiarrhythmics, and 1.22 (1.05-1.42) for digoxin use. For analgesic drugs, the pooled OR was 0.97 (0.78-1.20) for narcotic use, 1.09 (0.88-1.34) for nonnarcotic analgesic use, 1.16 (0.97-1.38) for NSAID use, and 1.12 (0.80-1.57) for aspirin use. There was no statistically significant heterogeneity of pooled odds ratios. There were no differences between the pooled odds ratios for studies with mean subject age <75 versus ≥75 years old or for studies in communities with <35% versus ≥35% fallers. In studies of the relationship between psychotropic, cardiac, or analgesic drugs and falls, subjects reporting the use of more than three or four medications of any type were at increased risk of recurrent falls. CONCLUSION: Digoxin, type IA antiarrhythmic, and diuretic use are associated weakly with falls in older adults. No association was found for the other classes of cardiac or analgesic drugs examined. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. Older adults taking more than three or four medications were at increased risk of recurrent falls. As a result of the incidence of falls and their consequences in this population, programs designed to decrease medication use should be evaluated for their impact on fall rates.

Development and testing of a five-item version of the Geriatric Depression Scale.

Abstract: OBJECTIVE: To develop and test the effectiveness of a 5-item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community-dwelling older population. DESIGN: A cross-sectional study. SETTING: A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California. PARTICIPANTS: A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial. MEASUREMENTS: Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5-item version of the GDS was created from the 15-item GDS by selecting the items with the highest Pearson x1 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15-item GDS and the new 5-item scale. RESULTS: Subjects had a mean GDS score of 6.2 (range 0–15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5-item GDS (compared with the 15-item GDS results shown in parentheses) had a sensitivity of. 97 (.94), specificity of. 85 (.83), positive predictive value of. 85 (.82), negative predictive value of. 97 (.94), and accuracy of. 90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5-item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5- and 15-item GDS were. 9 and 2.7 minutes, respectively. CONCLUSIONS: The 5-item GDS was as effective as the 15-item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.

Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool.

Abstract: OBJECTIVES: To develop a self-report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long-term hospitalization, or a clinically significant decrease in functional status. DESIGN: Prospective (6-month) follow-up study of a cohort of ED patients aged 65 and older. SETTING: The EDs of four acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available. MEASUREMENTS: Measures ascertained at the ED visit included: 27 self-report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow-up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained. RESULTS: Among 1673 patients who completed the follow-up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self-report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub-groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics. CONCLUSIONS: The ISAR is a short self-report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.

Psychotropic Medication Withdrawal and a Home‐Based Exercise Program to Prevent Falls: A Randomized, Controlled Trial

Abstract: OBJECTIVE: To assess the effectiveness of psychotropic medication withdrawal and a home-based exercise program in reducing falls in older people. DESIGN: A randomized controlled trial with a two by two factorial design. SETTING: Seventeen general practices in Dunedin, New Zealand. PARTICIPANTS: Women and men aged 65 years registered with a general practitioner and currently taking psychotropic medication (n = 93). INTERVENTIONS: Two interventions: (1) gradual withdrawal of psychotropic medication versus continuing to take psychotropic medication (double blind) and (2) a home- based exercise program versus no exercise program (single blind). MEASUREMENTS: Number of falls and falls risk during 44 weeks of follow-up. Analysis was on an intent to treat basis. RESULTS: After 44 weeks, the relative hazard for falls in the medication withdrawal group compared with the group taking their original medication was. 34 (95% CI,. 16–74). The risk of falling for the exercise program group compared with those not receiving the exercise program was not significantly reduced. CONCLUSIONS: Withdrawal of psychotropic medication significantly reduced the risk of falling, but permanent withdrawal is very difficult to achieve.

Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention.

Abstract: OBJECTIVE: To determine whether occupational therapist home visits targeted at environmental hazards reduce the risk of falls DESIGN: A randomized controlled trial SETTING: Private dwellings in the community in Sydney, Australia PARTICIPANTS: A total of 530 subjects (mean age 77 years), recruited primarily before discharge from selected hospital wards INTERVENTION: A home visit by an experienced occupational therapist, who assessed the home for environmental hazards and facilitated any necessary home modifications MEASUREMENTS: The primary study outcome was falls, ascertained over a 12-month follow-up period using a monthly falls calendar RESULTS: Thirty six percent of subjects in the intervention group had at least one fall during follow-up, compared with 45% of controls (P = 050) The intervention was effective only among subjects (n = 206) who reported having had one or more falls during the year before recruitment into the study; in this group, the relative risk of at least one fall during follow-up was 064 (95% confidence interval, 050-083) Similar results were obtained when falls data were analyzed using survival analysis techniques (proportional and multiplicative hazards models) and fall rates (mean number of falls per person per year) About 50% of the recommended home modifications were in place at a 12-month follow-up visit CONCLUSIONS: Home visits by occupational therapists can prevent falls among older people who are at increased risk of falling However, the effect may not be caused by home modifications alone Home visits by occupational therapists may also lead to changes in behavior that enable older people to live more safely in both the home and the external environment J Am Geriatr Soc 47:1397–1402, 1999

Once-weekly resistance exercise improves muscle strength and neuromuscular performance in older adults.

Abstract: OBJECTIVE: To determine the effect of frequency of resistive training on gain in muscle strength and neuromuscular performance in healthy older adults. DESIGN: A randomized controlled trial with subjects assigned either to high-intensity resistance training 1 (EXl), 2 (EX2), or 3 (EX3) days per week for 24 weeks or to a control group (CO). SETTING: An exercise facility at an academic medical center. SUBJECTS: Forty-six community-dwelling healthy men (n = 29) and women (n = 17) aged 65 to 79 years. INTERVENTION: Progressive resistance training consisting of three sets of eight exercises targeting major muscle groups of the upper and lower body, at 80% of one-repetition maximum (1-RM) for eight repetitions, either 1,2, or 3 days per week. MEASURES: Dynamic muscle strength (1-RM) using iso-tonic equipment every 4 weeks, bone mineral density and body composition by dual energy X-ray absorptiometry (DXA), and neuromuscular performance by timed chair rise and 6-meter backward tandem walk. RESULTS: For each of the eight exercises, muscle strength increased in the exercise groups relative to CO (P < .01), with no difference among EXl, EX2 and EX3 groups at any measurement interval. Percent change averaged 3.9 ± 2.4 (CO), 37.0 ± 15.2 (EXl), 41.9 ± 18.2 (EX2), and 39.7 ± 9.8 (EX3). The time to rise successfully from the chair 5 times decreased significantly (P < .01) at 24 weeks, whereas improvement in the 6-meter backward tandem walk approached significance (P = .10) in the three exercise groups compared with CO. Changes in chair rise ability were correlated to percent changes in quadriceps strength (r = −0.40, P < .01) and lean mass (r = −0.40, P < .01). CONCLUSIONS: A program of once or twice weekly resistance exercise achieves muscle strength gains similar to 3 days per week training in older adults and is associated with improved neuromuscular performance. Such improvement could potentially reduce the risk of falls and fracture in older adults.

Clinico-Neuropathological Correlation of Alzheimer's Disease in a Community-Based Case Series

Abstract: OBJECTIVES: Most clinico-neuropathological correlative studies of Alzheimer's Disease (AD) are based on research cohorts that are not necessarily generalizable to patients seen in the general medical community. In this study, we examine the accuracy of the criteria used in diagnosing AD in a community-based case series of patients with memory complaints. DESIGN AND PARTICIPANTS: Clinical and neuropathological diagnoses were obtained from 134 patients evaluated for dementia who subsequently underwent autopsy. SETTING: Subjects who exhibited new symptoms of dementia and were enrolled in the University of Washington/Group Health Cooperative Alzheimer's Disease Patient Registry were eligible for this study. MEASUREMENTS: Clinico-pathological correlation was performed using NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and CERAD (Consortium to Establish a Registry for Alzheimer's Disease) criteria. RESULTS: Ninety-five of the 134 cases studied met CERAD neuropathological criteria for AD. The sensitivity of NINCDS-ADRDA “probable AD” was 83% (diagnosing AD correctly) and overall clinical diagnostic accuracy was 75%. However, there was a high rate of additional neuropathological findings. Only 34 of the 94 cases had pure AD on neuropathology, whereas the remainder frequently had coexisting vascular or Parkinson's disease lesions. CONCLUSIONS: This study of a large series of community-based incident dementia cases provides a way of judging the adequacy of currently available clinical diagnostic criteria. It also shows that co-existing neuropathological findings are common in community-based AD. J Am Geriatr Soc 47:564–569, 1999.

Lateral stability, sensorimotor function and falls in older people.

Abstract: AIMS: To design simple tests of lateral stability for assessing balance in older people and to determine whether poor performances in these tests are associated with impaired vision, lower limb sensation, quadriceps strength, simple reaction time, and falling in this group. DESIGN: A cross-sectional and retrospective study. SETTING: Falls and Balance Laboratory, Prince of Wales Medical Research Institute. PARTICIPANTS: One hundred fifty-six community-dwelling men and women aged 63–90 years (mean age 76.5, SD = 5.1). OUTCOME MEASURES: The maximal lateral sway in a near-tandem stability test with eyes open and closed and the necessity of taking a protective step in the near-tandem stability test with eyes closed. RESULTS: All 156 subjects could complete the near-tandem stability test with eyes open, but only 99 subjects (63.5%) could undertake the test with eyes closed without taking a protective step. Subjects with a history of falls had increased lateral sway both with eyes open and eyes closed as well as poorer visual acuity, proprioception, and quadriceps strength. Fallers were also significantly more likely to take a protective step when undertaking the near-tandem stability test with eyes closed. Multiple regression analysis revealed that impaired lower limb proprioception, quadriceps strength, and reaction time were the best predictors of increased maximal sway in the near-tandem stability test with eyes open. Reduced proprioception and quadriceps strength, in addition to age, were also found to be the best determinants of the necessity of taking a protective step in the near-tandem stability test with eyes closed. CONCLUSIONS: The study findings identify simple new tests that are associated with falling in older people and elucidate the relative importance of specific physiological systems in the maintenance of lateral stability. J Am Geriatr Soc 47:1077–1081, 1999.

Influence of companion animals on the physical and psychological health of older people: an analysis of a one-year longitudinal study

Abstract: OBJECTIVE: To examine whether companion animals or attachment to a companion animal was associated with changes in physical and psychological health in older people and whether the relationships between physical and psychological health and human social networks were modified by the presence or absence of a companion animal. DESIGN: A 1-year longitudinal study with standardized telephone interview data collected at baseline and repeated at 1-year SETTING: Wellington County, Ontario, Canada PARTICIPANTS: An age- and sex stratified random sample (baseline n = 1054; follow-up n = 995) of noninstitutionalized adults aged 65 and older (mean age = 73, SD ± 6.3) MEASUREMENTS: Social Network Activity was measured using a family and non-family social support scale, participation in an organized social group, involvement in the affairs of the social group, the practice of confiding in others, feelings of loneliness, and the perceived presence of support in a crisis situation. Chronic conditions were measured as the current number of selected health problems. Pet ownership was assessed by the report of owning a dog or a cat and the Lexington Attachment to Pets Scale score. Physical health was assessed as the ability to perform Activities of Daily Living (ADLs). Psychological health was measured as a summed score comprising the level of satisfaction regarding one's health, family and friend relationships, job, finances, life in general, overall happiness, and perceived mental health. Sociodemographic variables assessed include subject age, sex, marital status, living arrangements, education, household income, and major life events. RESULTS: Pet owners were younger, currently married or living with someone, and more physically active than non-pet owners. The ADL level of respondents who did not currently own pets deteriorated more on average (β = −.270, P = .040) than that of respondents who currently owned pets after adjusting for other variables during the 1-year period. No statistically significant direct association was observed between pet ownership and change in psychological well-being (P > .100). However, pet ownership significantly modified the relationship between social support and the change in psychological well-being (P = .001) over a 1-year period. CONCLUSIONS: The results demonstrate the benefits of pet ownership in maintaining or slightly enhancing ADL levels of older people. However, a more complex relationship was observed between pet ownership and an older person's well-being.

Assessment and control for confounding by indication in observational studies.

Abstract: In the evaluation of pharmacologic therapies, the controlled clinical trial is the preferred design. When clinical trial results are not available, the alternative designs are observational epidemiologic studies. A traditional concern about the validity of findings from epidemiologic studies is the possibility of bias from uncontrolled confounding. In studies of pharmacologic therapies, confounding by indication may arise when a drug treatment serves as a marker for a clinical characteristic or medical condition that triggers the use of the treatment and that, at the same time, increases the risk of the outcome under study. Confounding by indication is not conceptually different from confounding by other factors, and the approaches to detect and control for confounding--matching, stratification, restriction, and multivariate adjustment--are the same. Even after adjustment for known risk factors, residual confounding may occur because of measurement error or unmeasured or unknown risk factors. Although residual confounding is difficult to exclude in observational studies, there are limits to what this "unknown" confounding can explain. The degree of confounding depends on the prevalence of the putative confounding factor, the level of its association with the disease, and the level of its association with the exposure. For example, a confounding factor with a prevalence of 20% would have to increase the relative odds of both outcome and exposure by factors of 4 to 5 before the relative risk of 1.57 would be reduced to 1.00. Observational studies have provided important scientific evidence about the risks associated with several risk factors, including drug therapies, and they are often the only option for assessing safety. Understanding the methods to detect and control for confounding makes it possible to assess the plausibility of claims that confounding is an alternative explanation for the findings of particular studies.

Correlates and Management of Nonmalignant Pain in the Nursing Home

Abstract: OBJECTIVE Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home. DESIGN A cross-sectional study. SETTING Nursing Home in four US states. PARTICIPANTS A total of 49,971 nursing home residents from 1992 to 1995. MEASUREMENTS We used the SAGE database (Systematic Assessment of Geriatric drug use via Epidemiology), which linked information from the Minimum Data Set and nursing home drug utilization data. The MDS items measured included pain, activities of daily living (ADL) function, mood, and time involved in activities. The use of analgesics, anxiolytics, and antidepressants was also documented. RESULTS Daily pain was reported in 26% of nursing home residents. The prevalence was lower among men, persons more than age 85, and racial minorities. Persons suffering pain daily were more likely to have severe ADL impairment, odds ratio (OR) (2.47 (95% CI, 2.34–2.60)), more depressive signs and symptoms (OR 1.66 (95% CI, 1.57–1.75)), and less frequent involvement in activities (OR 1.35 (95% CI, 1.29–1.40)). Approximately 25% of persons with daily pain received no analgesics. Residents who were more than 85 years old (OR 1.15 (95% CI 1.02–1.28)), cognitively impaired, (OR 1.44 (95% CI, 1.29–1.61)), of male gender (OR 1.17 (95% CI, 1.06–1.29)), or a racial minority (OR 1.69 (95% CI, 1.40–2.05) and OR 1.56 (95% CI, 0.70–1.04) for blacks and Hispanics, respectively) were at greater risk of not receiving analgesics. Approximately 50% of those in pain used physical and occupational therapies, which was more than two times higher (OR 2.44 (95% CI, 2.34–2.54)), than use for those not in pain. CONCLUSIONS Daily nonmalignant pain is prevalent among nursing home residents and is often associated with impairments in ADL, mood, and decreased activity involvement. Even when pain was recognized, men, racial minorities, and cognitively impaired residents were at increased risk for undertreatment. More education and research is necessary to improve the recognition and management of pain in the nursing home, remembering that attention should be paid to populations at increased risk for underrecognition and undertreatment.

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients

Abstract: BACKGROUND: Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status. OBJECTIVE: To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use. DESIGN: Prospective cohort study SETTING: A tertiary care hospital PATIENTS: A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service MEASUREMENTS: Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review. RESULTS: 219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06–7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05–9.87). CONCLUSION: Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission. J Am Geriatr Soc 47:532–538, 1999.

Association of Interleukin‐6 and Other Biologic Variables with Depression in Older People Living in the Community

Abstract: OBJECTIVES: The prevalence of depression increases with age, as does the prevalence of higher levels of the cytokine interleukin-6 (IL-6). This analysis was performed to determine the association between increased levels of this cytokine and depression in a population-based sample. DESIGN: Cross-sectional cohort study. SETTING: Rural and urban counties in North Carolina. PARTICIPANTS: Community-dwelling older people. MEASUREMENTS: The association between IL-6 and other biologic variables with self-report depression was examined in 1686 persons aged 70 years and older in the third in-person survey wave (1991) of the Duke Established Population for Epidemiologic Studies of the Elderly (EPESE). Bivariate associations were established by the Spearman correlation, adjusted for age. A stepwise linear logistic regression model was used to derive a final model to assess multivariable effects on CES-D scores. RESULTS: Depression was correlated with IL-6 (P = .011), D-Dimer (P = .017), alpha-l-globulin (P = .023), alphas-2-globulin (P = .002), and beta globulin (P = .012). After controlling for age, race, and gender, IL-6 levels remained the only biologic variable significantly associated with depression (P = .035). CONCLUSION: These data suggest that the inflammatory marker, IL-6, is associated with depression in older people in this cross-sectional study. These results are compatible with the hypothesis of cytokine (IL-6) stimulation in geriatric depression as part of an overall immunoendocrine dysregulation.

The effect of visual and hearing impairments on functional status.

Abstract: OBJECTIVES: To describe the prevalence of visual and auditory impairment in frail older persons and to evaluate the association between sensory impairment and overall functional status. DESIGN: Prospective patient evaluation and retrospective analysis of data SETTING: The outpatient geriatric assessment clinic of a university medical center. PARTICIPANTS: Consecutive patients seen in the University of Nebraska Medical Center Outpatient Geriatric Assessment Clinic from 1986 to 1992 for whom both vision and hearing information were available (n = 576). MEASUREMENTS: Visual acuity was measured by the Lighthouse Near Visual Acuity Test, and auditory acuity was evaluated with the whisper test. Functional status was determined by Lawton-Brody activities of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comoro-bid illness was classified by the Cumulative Illness Rating Scale, and mental status was assessed by the Feldstein Mini-Mental State Exam. RESULTS: Eighteen percent of patients had visual impairment of 20/70 or worse. Hearing impairment was found in 64%. The mean ADL and IADL scores were 20/24 and 12/23, respectively, for patients with visual acuity better than 20/70, compared with 18/24 and 8/23 for visually impaired patients (P < .001 for both comparisons). ADL and IADL scores were also higher in hearing intact patients compared with those with hearing impairment: respectively, 21/24 vs 19/24 (P < .001) and 13/23 vs 11/23 (P < .001). The effects of visual acuity and hearing acuity on IADL score are independent of mental status and co morbid illness (P < .001). The effect of visual acuity on ADL score is independent of mental status and co morbid illness (P < .001), whereas the effect of hearing on ADL score is not. Subjects with both hearing and vision impairment had mean IADL (P < = .05) and ADL (P < = .05) scores significantly lower than those with no impairment CONCLUSIONS: Impairments of vision and hearing are common in this frail older outpatient population. Functional status, as measured by IADL and ADL scores, is diminished for sensory impaired subjects. Combined vision and hearing impairments have a greater effect on function than single sensory impairments and influence functional status independent of mental status and comorbid illness. Overall, these results suggest that interventions to improve sensory function may improve functional independence. J Am Geriatr Soc 47:1319–1325,1999.

The importance of subsyndromal depression in older primary care patients: prevalence and associated functional disability.

Abstract: OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions. METHODS: Subjects were 224 patients, aged 60 years and older, recruited from private internal medicine offices or a family medicine clinic. Validated measures of psychopathology, medical burden, and functional status were used. The subsyndromal depression group was defined by a score of more than 10 on the Hamilton Rating Scale for Depression and by the absence of major or minor depressive disorder. Analyses included multiple regression techniques to determine the presence of group differences adjusted for demographic covariates. RESULTS: Subsyndromal depression was common (estimated point prevalence of 9.9% compared with 6.5% for major depression, 5.2% for minor depression, and .9% for dysthymic disorder), associated with functional disability and medical comorbidity to a degree similar to major or minor depression, and often treated with antidepressant medications. CONCLUSIONS: Although depressive conditions are common and are associated with considerable functional and medical morbidity in older primary care patients, many patients with clinically significant depressive symptoms are not captured by criteria-based syndromic diagnostic categories. Future work should include intervention studies of subsyndromally depressed older persons as well as attention to the course and biopsychosocial concomitants of diagnosable and subsyndromal depressions in this population. J Am Geriatr Soc 47:647–652, 1999.

Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice.

Abstract: OBJECTIVE: To investigate the prevalence of coronary artery disease (CAD), ischemic stroke, and peripheral arterial disease (PAD), alone and in combination, in older persons. DESIGN: A retrospective analysis of charts from all older persons seen from April 1, 1998, through December 31, 1998, at an academic hospital-based geriatrics practice. SETTING: An academic hospital-based geriatrics practice staffed by fellows in a geriatrics training program and full-time faculty geriatricians. PATIENTS: A total of 474 men and 1328 women, mean age 80 ± 9 years (range 60 to 102 years) were included in the study. MEASUREMENTS AND MAIN RESULTS: Of 1802 persons studied, 612 (34%) had CAD, 351 (19%) had ischemic stroke, 236 (13%) had PAD, and 816 (45%) had either CAD, stroke, or PAD. Three hundred twenty-eight (18%) of the 1802 persons had CAD alone, 128 (7%) had stroke alone, 50 (3%) had PAD alone, 123 (7%) had CAD + stroke and no PAD, 86 (5%) had CAD + PAD and no stroke, 25 (1%) had PAD + stroke and no CAD, 75 (4%) had CAD + stroke + PAD, and 986 (55%) had no CAD, PAD, or stroke. If CAD was present, coexistent PAD was present in 26% and coexistent stroke in 32% of persons studied. If stroke was present, coexistent CAD was present in 56% and coexistent PAD in 28%. If PAD was present, coexistent CAD was present in 68% and coexistent stroke in 42% of persons studied. CONCLUSIONS: These data showed that if CAD was present, ischemic stroke was also present in 32% and PAD in 26% of the population. If ischemic stroke was present, CAD was also present in 56% and PAD in 28% of the population. If PAD was present, CAD was also present in 68% and ischemic stroke in 42% of the population.

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

Abstract: BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Perfomance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

The power of ageism on physical function of older persons: reversibility of age-related gait changes.

Abstract: OBJECTIVE: To test the hypothesis that age-associated changes in physical function, particularly walking performance, are influenced by ageism and that the activation of positive stereotypes of aging can partially reverse these changes. DESIGN: Randomized intervention study. SETTING: General community. PARTICIPANTS: Forty-seven community-dwelling men and women (63–82 years old) who walked independently and described themselves as healthy. INTERVENTION: Thirty-minute exposure to the subconscious reinforcement of either a positive or negative stereotype of aging while subjects played a computer game. MEASUREMENTS: Pre- and post intervention measures of gait speed and percent swing time (the time spent with one foot in the air during walking). Health and psychosocial status were also evaluated. RESULTS: Significant increases in walking speed (9% ± 2%; P < .001) and percent swing time (percent change: 1.1% ± 0.4%; P = .023) were observed in subjects who received reinforcement of positive stereotypes of aging. Gait speed and swing time did not change in those who received reinforcement of negative stereotypes of aging. The observed improvements in gait were related to the positive intervention, but were not related to age, gender, health status, or psychosocial status. CONCLUSIONS: Stereotypes of aging apparently have a powerful impact on the gait of older persons. Interventions designed to enhance perceptions of old age may prove beneficial in helping to improve gait and functional independence among older persons. In the future, positive changes in society's view of aging may also help to reduce and prevent age-related declines in function and the associated deleterious consequences. J Am Geriatr Soc 47:1346–1349, 1999.

Medication adherence in rheumatoid arthritis patients: older is wiser.

Abstract: OBJECTIVES: To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34–84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. DESIGN: A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. PARTICIPANTS AND SETTING: A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. MEASUREMENTS AND RESULTS: Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. CONCLUSION: Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly. J Am Geriatr Soc 47:172–183, 1999.

Prevalence of Combined Fecal and Urinary Incontinence: A Community-Based Study

Abstract: OBJECTIVE: To assess the prevalence of combined fecal and urinary incontinence. DESIGN: A cross-sectional, community-based study. SETTING: Olmsted County, Minnesota. PARTICIPANTS: Men (n = 778) and women (n = 762), aged 50 years or older, selected randomly from the population. MEASUREMENTS: Participants completed a previously validated self-administered questionnaire that assessed the occurrence of fecal and urinary incontinence in the previous year. RESULTS: The age-adjusted prevalence of incontinence was 11.1% (95% Confidence Interval (CI), 8.8–13.5) in men and 15.2% (95% CI, 12.5–17.9) in women for fecal incontinence; 25.6% (95% CI, 22.5–28.8) in men and 48.4% (95% CI, 44.7–52.2) in women for urinary incontinence; and 5.9% (95% CI, 4.1–7.6) in men and 9.4% (95% CI, 7.1–11.6) in women for combined urinary and fecal incontinence. The prevalence of fecal incontinence increased with age in men but not in women, from 8.4% among men in their fifties to 18.2% among men in their eighties (P for trend =. 001). For women, the prevalence increased from 13.1% among 50- year-old women to 20.7% among women 80 years or older (P for trend =. 5). Among persons with fecal incontinence, the prevalence of concurrent urinary incontinence was 51.1% among men and 59.6% among women (P =. 001 and P =. 003, respectively). Cross-sectionally, the age-adjusted, relative odds of fecal incontinence among persons with urinary incontinence was greater in men than in women (Odds Ratio (OR) = 3.0; 95% CI, 1.9–4.8 in men and OR = 1.8; 95% CI, 1.2–2.7 in women, P =. 04). CONCLUSIONS: These findings suggest that persons with one form of incontinence are likely to have the other form as well. Despite the higher prevalence of urinary and fecal incontinence among women, the association between fecal incontinence and urinary incontinence was stronger among men than women. This finding, and the significant association between fecal incontinence and age observed in men but not in women, suggest that the etiologies may be more closely linked in men than in women.

Chronic Care Clinics: A Randomized Controlled Trial of a New Model of Primary Care for Frail Older Adults

Abstract: OBJECTIVE: To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults. DESIGN: Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care. SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State. PARTICIPANTS: Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline. INTERVENTION: Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care. MEASUREMENTS: Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention- to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed. RESULTS: After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P =. 10). CONCLUSIONS: Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.

Factors Contributing to Dehydration in Nursing Homes: Inadequate Staffing and Lack of Professional Supervision

Abstract: OBJECTIVE: To investigate the factors that influenced fluid intake among nursing home residents who were not eating well. DESIGN: A prospective, descriptive, anthropological study. SETTING: Two proprietary nursing homes with 105 and 138 beds, respectively. PARTICIPANTS: Forty nursing home residents. MEASUREMENTS: Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3- day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg). RESULTS: The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration. CONCLUSIONS: When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

Falls Relate to Vitamin D and Parathyroid Hormone in an Australian Nursing Home and Hostel

Abstract: OBJECTIVES: To determine whether falling relates to serum levels of vitamin D and parathyroid hormone. DESIGN: A cross-sectional study with retrospective analysis. SETTING: An aged-care institution in Melbourne Australia. PARTICIPANTS: Ambulant nursing home and hostel residents (n = 83). MEASUREMENTS: Frequency of falling, frequency of going outdoors, use of cane or walker, age, sex, weight, type of accommodation, and duration of residence. Serum concentrations of 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and parathyroid hormone (PTH). Plasma concentrations of albumin, calcium, phosphate, and creatinine. Use of furo-semide or non-benzodiazepine anticonvulsants. RESULTS: Median age of residents was 84 years. The cohort was vitamin D deficient with a median (interquartile range) 25-hydroxyvitamin D level of 27 (18–37) nmol/L (one-third the reference range median), P < .001. The median (interquartile range) PTH of 5.2 (3.8-7.7) pmol/L exceeded the reference range median, P < .001. Residents who fell (n = 33) had lower serum 25-hydroxyvitamin D levels than other residents (medians 22 vs 29 nmol/L, P = .02) and higher serum PTH levels (medians 6.2 vs 4.8 pmol/L, P < .01). Sixty residents lived in the hostel (72%), and 41 (49%) walked without any walking aid. In a multiple logistic regression for falling, higher serum PTH remained independently associated with falling, with an odds ratio (95% confidence interval) for falling of 5.6 (1.7–18.5) per unit of the natural logarithm of serum PTH. Other terms in the regression were hostel accommodation, odds ratio .04 (.01-.25), and ability to walk without aids, odds ratio .07 (.01-.37). CONCLUSIONS: In ambulant nursing home and hostel residents, residents who fall have lower serum 25-hydroxyvitamin D and higher serum parathyroid hormone levels than other residents. The association between falling and serum PTH persists after adjustment for other variables.

A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve?

Abstract: OBJECTIVES: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents. DESIGN: A randomized trial. SETTING: One community nursing home in the Los Angeles, California area. PARTICIPANTS: Twenty-nine incontinent residents (mean age 88.3 years, 90% female). INTERVENTION: Subjects were randomized to receive either (1) an intervention combining increased daytime physical activity (14 weeks in duration) plus a nighttime program (5 nights in duration) to decrease noise and sleep-disruptive nursing care practices (intervention group), or (2) the nighttime program alone (control group). MEASUREMENTS: Daytime physical activity monitors and structured physical function assessments; nighttime wrist activity monitors to estimate nighttime sleep; and timed day time behavioral observations of sleep versus wakefulness, either in or out of bed, and agitation. RESULTS: Physical function measures did not change significantly (MANOVA for repeated measures, group by time effect). Wrist actigraphy estimation of nighttime percent sleep (time asleep over time monitored in bed at night) increased in intervention subjects from 51.7% at baseline to 62.5% at follow-up compared with 67.0% at baseline to 66.3% at follow-up in controls (MANOVA, group by time, F = 4.42, P =. 045, df = 27). At follow-up, intervention subjects averaged a 32% decrease in the percent of daytime observations in bed compared with baseline, with essentially no change in controls (MANOVA, group by time, F = 5.31, P =. 029, df = 27). Seven of 15 intervention subjects had a decrease in observed agitation at follow-up, compared with baseline, versus only 1 of 14 controls with a decrease in observed agitation. CONCLUSIONS: This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents.

The Effects of Aerobic Exercise and T'ai Chi on Blood Pressure in Older People: Results of a Randomized Trial

Abstract: OBJECTIVE: To compare the effects on blood pressure of a 12-week moderate-intensity aerobic exercise program and a T'ai Chi program of light activity. DESIGN: A randomized clinical trial. SETTING: A suburban clinic in the Baltimore, MD, area. PARTICIPANTS: Sixty-two sedentary older adults (45% black, 79% women, aged > 60 years) with systolic blood pressure 130–159 mm Hg and diastolic blood pressure < 95 mm Hg (not on antihypertensive medication). INTERVENTION: Participants were randomized to a 12-week aerobic exercise program or a light intensity T'ai Chi program. The goal of each condition was to exercise 4 days per week, 30 minutes per day. MEASUREMENTS: Blood pressure was measured during three screening visits and every 2 weeks during the intervention. Estimated maximal oxygen uptake and measures of physical activity level were determined at baseline and at the end of the intervention period. RESULTS: Mean (SD) baseline systolic and diastolic blood pressures were 139.9 (9.3) mm Hg and 76.0 (7.3) mm Hg, respectively. For systolic blood pressure, adjusted mean (SE) changes during the 12-week intervention period were −8.4 (1.6) mm Hg and −7.0 (1.6) mm Hg in the aerobic exercise and T'ai Chi groups, respectively (each within-group P < .001; between-group P = .56). For diastolic blood pressure, corresponding changes were −3.2 (1.0) mm Hg in the aerobic exercise group and −2.4 (1.0) mm Hg in the T'ai Chi group (each within-group P < .001; between-group P = .54). Body weight did not change in either group. Estimated maximal aerobic capacity tended to increase in aerobic exercise (P = .06) but not in T'ai Chi (P = .24). CONCLUSIONS: Programs of moderate intensity aerobic exercise and light exercise may have similar effects on blood pressure in previously sedentary older individuals. If additional trials confirm these results, promoting light intensity activity could have substantial public health benefits as a means to reduce blood pressure in older aged persons.

Endogenous levels of dehydroepiandrosterone sulfate, but not other sex hormones, are associated with depressed mood in older women: the Rancho Bernardo Study.

Abstract: OBJECTIVE: The purpose of this study was to determine whether endogenous steroid hormone levels are associated with depressed mood in community-dwelling older women. DESIGN: A cross-sectional population-based study. SETTING: Rancho Bernardo, California PARTICIPANTS: A total of 699 non-estrogen using, community-dwelling, postmenopausal women (aged 50 to 90 years) from the Rancho Bernardo cohort who were screened for depressed mood and had plasma obtained for steroid hormone assays in 1984–1987. MEASUREMENTS: Plasma levels of total and bioavailable (non-SHBG-bound) estradiol and testosterone, estrone, androstenedione, cortisol, dehydroepiandrosterone, and (DHEA) and its sulfate (DHEAS) were measured by radioimmunoassay. Mood and depression were assessed using the Beck Depression Inventory. RESULTS: Only DHEAS levels were significantly and inversely associated with depressed mood, and the association was independent of age, physical activity, and weight change (P = .0002). Age, sedentary lifestyle, and weight loss were positively associated with depressed mood. Alcohol intake, cigarette smoking, marital status, type of menopause, and season of testing were unassociated with depressed mood. A subset of 31 women with categorically defined depression had lower DHEAS levels compared with 93 age-matched nondepressed women (1.17 ± 1.08 vs 1.57 ± .98 μmol/L; P = .01). CONCLUSIONS: These results add to the evidence that DHEA/S is a neuroactive steroid and point to the need for careful long-term clinical trials of DHEA therapy in older women with depressed mood. J Am Geriatr Soc 47:685–691, 1999.

Body mass index and mortality among older people living in the community.

Abstract: OBJECTIVES: To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study. DESIGN: A prospective cohort study. SETTING: Rovereto, a town in northern Italy. PARTICIPANTS: A consecutive sample of 214 patients aged 81.2 ± 7.3 years receiving community care services. MAIN OUTCOME MEASURES: Malnutrition and mortality. RESULTS: According to logistic regression analysis, malnutrition status, expressed by a BMI 27 Kg/m2) was not significantly related to risk of mortality. CONCLUSIONS: Nutrition variables are a cardinal component of comprehensive geriatric assessment. Our results suggest that BMI, a simple anthropometric measure of nutritional status, is an important predictor of mortality among older people living in the community. Even when controlling for clinical and functional variables, a low BMI remained a significant and independent predictor of shortened survival. J Am Geriatr Soc 47:1072–1076, 1999.

Lower incidence of tardive dyskinesia with risperidone compared with haloperidol in older patients

Abstract: OBJECTIVE: To compare the 9-month cumulative incidence of tardive dyskinesia (TD) with risperidone to that with haloperidol in older patients DESIGN: A prospective longitudinal study SETTING: An outpatient psychiatric clinic PARTICIPANTS: Subjects were middle-aged and older (mean age 66 years) patients with schizophrenia, dementia, mood disorders, or other conditions with psychotic symptoms or severe behavioral disturbances Sixty-one patients on risperidone were matched with 61 patients from a larger sample of haloperidol-treated patients in regard to age, diagnosis, and length of preenrollment neuroleptic intake to create clinically comparable groups The median daily dose of each medication was 10 mg MEASUREMENTS: Abnormal Involuntary Movement Scale, modified Simpson-Angus' scale for extrapyramidal symptoms, Brief Psychiatric Rating Scale, and Mini-Mental State Examination were administered at baseline, 1 month, and 3, 6, and 9 months The diagnosis of TD was based on specific research criteria The raters were blind to the patient's medication status RESULTS: Life table analysis revealed that patients treated with haloperidol were significantly more likely to develop TD than patients treated with risperidone (P < 05, Peto-Prentice) CONCLUSIONS: The atypical antipsychotic risperidone is significantly less likely to result in TD than the conventional neuroleptic haloperidol in a high-risk group of older patients, at least over a 9-month period J Am Geriatr Soc 47:716–719, 1999