Showing papers in "Journal of the American Geriatrics Society in 2002"

Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability.

Abstract: OBJECTIVES: To establish the prevalence of sarcopenia in older Americans and to test the hypothesis that sarcope- nia is related to functional impairment and physical dis- ability in older persons. DESIGN: Cross-sectional survey. SETTING: Nationally representative cross-sectional sur- vey using data from the Third National Health and Nutri- tion Examination Survey (NHANES III). PARTICIPANTS: Fourteen thousand eight hundred eigh- teen adult NHANES III participants aged 18 and older. MEASUREMENTS: The presence of sarcopenia and the relationship between sarcopenia and functional impairment and disability were examined in 4,504 adults aged 60 and older. Skeletal muscle mass was estimated from bioimped- ance analysis measurements and expressed as skeletal mus- cle mass index (SMIskeletal muscle mass/body mass � 100). Subjects were considered to have a normal SMI if their SMI was greater than -one standard deviation above the sex-specific mean for young adults (aged 18-39). Class I sarcopenia was considered present in subjects whose SMI was within -one to -two standard deviations of young adult values, and class II sarcopenia was present in subjects whose SMI was below -two standard deviations of young adult values. RESULTS: The prevalence of class I and class II sarcope- nia increased from the third to sixth decades but remained relatively constant thereafter. The prevalence of class I (59% vs 45%) and class II (10% vs 7%) sarcopenia was greater in the older ( � 60 years) women than in the older men ( P � .001). The likelihood of functional impairment and disability was approximately two times greater in the older men and three times greater in the older women with class II sarcopenia than in the older men and women with a normal SMI, respectively. Some of the associations be- tween class II sarcopenia and functional impairment re- mained significant after adjustment for age, race, body mass index, health behaviors, and comorbidity. CONCLUSIONS: Reduced relative skeletal muscle mass in older Americans is a common occurrence that is signifi- cantly and independently associated with functional im- pairment and disability, particularly in older women. These observations provide strong support for the prevailing view that sarcopenia may be an important and potentially re- versible cause of morbidity and mortality in older persons. J Am Geriatr Soc 50:889-896, 2002.

The management of persistent pain in older persons.

Abstract: Pain is an unpleasant sensory and emotional experience. 1 Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions. 2 Pain is usually associated with injury or a pathophysiologic process that causes an uncomfortable experience and is usually described in such terms. Although there are no objective biologic markers of pain, an individual’s description and selfreport usually provides accurate, reliable, and sufficient evidence for the presence and intensity of pain. 3 Persistent pain can be defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for many elderly persons, chronic pain has become a label associated with negative images and stereotypes often associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate suffering. 4 The clinical manifestations of persistent pain are commonly multifactorial. Because of the complex interplay among these factors across several domains (physiologic, psychologic, and social), discriminating which factors are most important for the purpose of treatment can be very challenging. Further complicating this task is the fact that pain expression and hence the importance of specific factors commonly vary, not only across individuals but also over time in one individual. Elderly persons have been defined by demographers, insurers, and employers as those aged 65 years and over. In healthcare discussions, the elderly persons often described are those who are most frail, with health and disability problems typically encountered in the older population. By age 75 many persons exhibit some frailty and chronic illness. In the population above age 75, morbidity, mortality, and social problems rise rapidly, resulting in substantial strains on the healthcare system and societal safety nets. This group represents the fastest growing segment of the total population. 5 The greatest challenges in geriatric medicine are represented by the oldest, sickest, and most frail patients with multiple medical problems and few social supports. The guideline panel focused its attention on this group as it prepared this update. Persistent pain is common in older people. 6 A Louis Harris telephone survey found that one in five older Americans (18%) are taking analgesic medications regularly (several times a week or more), and 63% of those had taken prescription pain medications for more than 6 months. 7 Older people are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. This survey also found that 45% of patients who take pain medications regularly had seen three or more doctors for pain in the past 5 years, 79% of whom were primary care physicians. Previous studies have suggested that 25% to 50% of community-dwelling older people suffer important pain problems. 6,8,9 Pain is also common among nursing home residents. 10,11 It has been estimated that 45% to 80% of them have substantial pain that is undertreated. Studies of both the community-dwelling and nursing home populations have found that older people commonly have several sources of pain, which is not surprising, as older patients commonly have multiple medical problems. A high prevalence of dementia, sensory impairments, and disability in this population make assessment and management more difficult. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Although less thoroughly described, many other conditions are known to be worsened potentially by the presence of pain, including gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. 12 Psychosocial factors affect and are affected by pain in older patients. It has been shown that older adults with good coping strategies have significantly lower pain and This guideline was developed and written under the auspices of the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and approved by the AGS Board of Directors on April 8, 2002.

Falls and Fear of Falling: Which Comes First? A Longitudinal Prediction Model Suggests Strategies for Primary and Secondary Prevention

Abstract: OBJECTIVES: Previous cross-sectional studies have shown a correlation between falls and fear of falling, but it is unclear which comes first. Our objectives were to determine the temporal relationship between falls and fear of falling, and to see whether these two outcomes share predictors. DESIGN: A 20-month, population-based, prospective, observational study. SETTING: Salisbury, Maryland. Each evaluation consisted of a home-administered questionnaire, followed by a 4- to 5-hour clinic evaluation. PARTICIPANTS: The 2,212 participants in the Salisbury Eye Evaluation project who had baseline and 20-month follow-up clinic evaluations. At baseline, subjects were aged 65 to 84 and community dwelling and had a Mini-Mental State Examination score of 18 or higher. MEASUREMENTS: Demographics, visual function, comorbidities, neuropsychiatric status, medication use, and physical performance–based measures were assessed. Stepwise logistic regression analyses were performed to evaluate independent predictors of falls and fear of falling at the follow-up evaluation, first predicting incident outcomes and then predicting fall or fear-of-falling status at 20 months with baseline falling and fear of falling as predictors. RESULTS: Falls at baseline were an independent predictor of developing fear of falling 20 months later (odds ratio (OR) = 1.75; P < .0005), and fear of falling at baseline was a predictor of falling at 20 months (OR = 1.79; P < .0005). Women with a history of stroke were at risk of falls and fear of falling at follow-up. In addition, Parkinson's disease, comorbidity, and white race predicted falls, whereas General Health Questionnaire score, age, and taking four or more medications predicted fear of falling. CONCLUSION: Individuals who develop one of these outcomes are at risk for developing the other, with a resulting spiraling risk of falls, fear of falling, and functional decline. Because falls and fear of falling share predictors, individuals who are at a high risk of developing these endpoints can be identified.

Leg Muscle Mass and Composition in Relation to Lower Extremity Performance in Men and Women Aged 70 to 79: The Health, Aging and Body Composition Study

Abstract: OBJECTIVES: The loss of muscle mass with aging, or sarcopenia, is hypothesized to be associated with the deterioration of physical function. Our aim was to determine whether low leg muscle mass and greater fat infiltration in the muscle were associated with poor lower extremity performance (LEP). DESIGN: A cross-sectional study, using baseline data of the Health, Aging and Body Composition study (1997/98). SETTING: Medicare beneficiaries residing in ZIP codes from the metropolitan areas surrounding Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: Three thousand seventy-five well-functioning black and white men and women aged 70 to 79. MEASUREMENTS: Two timed tests (6-meter walk and repeated chair stands) were used to measure LEP. Muscle cross-sectional area and muscle tissue attenuation (indicative of fat infiltration) were obtained from computed tomography scans at the midthigh. Body fat was assessed using dual-energy x-ray absorptiometry. RESULTS: Blacks had greater muscle mass and poorer LEP than whites. Black women had greater fat infiltration into the muscle than white women. After adjustment for clinic site, age, height, and total body fat, smaller muscle area was associated with poorer LEP in all four race-gender groups. (Regression coefficients, expressed per standard deviation (±55 cm2) of muscle area, were 0.658 and 0.519 in white and black men and 0.547 and 0.435 in white and black women, respectively, P .7) or between race and muscle attenuation (P> .2) were observed. CONCLUSION: Smaller midthigh muscle area and greater fat infiltration in the muscle are associated with poorer LEP in well-functioning older men and women.

Oral care reduces pneumonia in older patients in nursing homes.

Abstract: OBJECTIVES: Aspiration of oral secretions and their bacteria is increasingly being recognized as an important factor in pneumonia. We investigated whether oral care lowers the frequency of pneumonia in institutionalized older people. DESIGN: Survey. SETTING: Eleven nursing homes in Japan. PARTICIPANTS: Four hundred seventeen patients randomly assigned to an oral care group or a no oral care group. INTERVENTION: Nurses or caregivers cleaned the patients’ teeth by toothbrush after each meal. Swabbing with povidone iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week. MEASUREMENTS: Pneumonia, febrile days, death from pneumonia, activities of daily living, and cognitive functions. RESULTS: During follow-up, pneumonia, febrile days, and death from pneumonia decreased significantly in patients with oral care. Oral care was beneficial in edentate and dentate patients. Activities of daily living and cognitive functions showed a tendency to improve with oral care. CONCLUSION: We suggest that oral care may be useful in preventing pneumonia in older patients in nursing homes. J Am Geriatr Soc 50:430‐433, 2002.

Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study

Abstract: OBJECTIVES: To compare persons with and without hip fracture for subsequent mortality and change in disability and nursing home (NH) use. DESIGN: Population-based historical cohort study. SETTING: Olmsted County, Minnesota. PARTICIPANTS: All residents who experienced a first hip fracture between January 1, 1989, and December 31, 1993, and, for each case, a resident of the same sex and similar age who had not experienced a hip fracture and was seen by a local care provider. MEASUREMENTS: Data on disability (Rankin score), comorbidity (Charlson Index), and NH residency before baseline (fracture date for cases and registration date for controls) were obtained by review of complete community-based medical records. The records were then reviewed from baseline through December 31, 1994, for Rankin disability at 1 month and 1 year, all NH admissions and discharges, and date of death for those who died. RESULTS: There were 312 cases and 312 controls (81% female, mean age ± standard deviation = 81 ± 12 years). Before baseline, cases had higher comorbidity (45% vs 30% had Charlson Index ≥ 1, P < .001) and disability (mean Rankin score = 2.5 ± 1.1 vs 2.2 ± 1.1, P < .001) and were more likely to be in a NH (28% vs 18%, P < .001) than controls. One year after baseline, estimated mortality was 20% (95% confidence interval (CI) = 16–24) for cases vs 11% (95% CI = 8–15) for controls, 51% of cases versus 16% of controls had a level of disability one or more units worse than before baseline (P < .001), and the cumulative incidence of first NH admission was 64% (95% CI = 58–71) for cases versus 7% (95% CI = 4–11) for controls. The risk of NH admission for cases relative to controls diminished over time, but remained elevated 5 years after the event (risk ratio = 20.0 at 3 months and 2.1 at 5 years), but, in persons admitted to a nursing home, cases were two times more likely than controls to be discharged alive within a year (P < .001). CONCLUSIONS: Hip fracture is an important contributor to disability and NH use, but the potential savings from hip fracture prophylaxis may be overestimated by studies that fail to consider differential risk, mortality, and long-term follow-up.

Central Nervous System–Active Medications and Risk for Falls in Older Women

Abstract: Background Use of central nervous system (CNS) active medications may increase the risk for fractures. Prior studies are limited by incomplete control of confounders. Methods To determine whether use of CNS active medications, including benzodiazepines, antidepressants, anticonvulsants, and narcotics, increases fracture risk in elderly, community-dwelling women, we examined use of these 4 categories of medications in a cohort of 8127 older women and followed the participants prospectively for incident nonspine fractures, including hip fractures. Current use of CNS active medications was assessed by interview with verification of use from containers between 1992 and 1994 and between 1995 and 1996. Use was coded as a time-dependent variable. Incident nonspine fractures occurring after the initial medication assessment until May 31, 1999, were confirmed by radiographic reports. Results During an average follow-up of 4.8 years, 1256 women (15%) experienced at least one nonspine fracture, including 288 (4%) with first hip fractures. Compared with nonusers, women taking narcotics (multivariate hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.06-1.83) and those taking antidepressants (multivariate HR, 1.25; 95% CI, 0.99-1.58) had increases in the risks for any nonspine fractures. Women taking tricyclic antidepressants and those using selective serotonin reuptake inhibitors (SSRIs) had similar fracture rates. There were no independent associations between benzodiazepine use or anticonvulsant use and risk for nonspine fracture. Women taking antidepressants compared with nonusers had a 1.7-fold increase in the risk for hip fracture (multivariate HR, 1.65; 95% CI, 1.05-2.57). We did not observe independent associations between use of any of the other 3 classes of CNS active medications and risk of hip fracture. Conclusions Community-dwelling older women taking narcotics have an increased risk for any nonspine fracture, and those taking antidepressants have a greater risk for nonspine fractures, including hip fracture. Rates of fracture were similar in women taking tricyclic antidepressants and those using SSRIs. Benzodiazepine use and anticonvulsant use were not independently associated with an increased risk of nonspine fractures, including hip fracture.

Cytokines and cognition--the case for a head-to-toe inflammatory paradigm.

Abstract: The brain is not only immunologically active of its own accord, but also has complex peripheral immune interactions. Given the central role of cytokines in neuroimmmunoendocrine processes, it is hypothesized that these molecules influence cognition via diverse mechanisms. Peripheral cytokines penetrate the blood-brain barrier directly via active transport mechanisms or indirectly via vagal nerve stimulation. Peripheral administration of certain cytokines as biological response modifiers produces adverse cognitive effects in animals and humans. There is abundant evidence that inflammatory mechanisms within the central nervous system (CNS) contribute to cognitive impairment via cytokine-mediated interactions between neurons and glial cells. Cytokines mediate cellular mechanisms subserving cognition (e.g., cholinergic and dopaminergic pathways) and can modulate neuronal and glial cell function to facilitate neuronal regeneration or neurodegeneration. As such, there is a growing appreciation of the role of cytokine-mediated inflammatory processes in neurodegenerative diseases such as Alzheimer's disease and vascular dementia. Consistent with their involvement as mediators of bidirectional communication between the CNS and the peripheral immune system, cytokines play a key role in the hypothalamic-pituitary-adrenal axis activation seen in stress and depression. In addition, complex cognitive systems such as those that underlie religious beliefs, can modulate the effects of stress on the immune system. Indirect means by which peripheral or central cytokine dysregulation could affect cognition include impaired sleep regulation, micronutrient deficiency induced by appetite suppression, and an array of endocrine interactions. Given the multiple levels at which cytokines are capable of influencing cognition it is plausible that peripheral cytokine dysregulation with advancing age interacts with cognitive aging.

The Relationship Between Leg Power and Physical Performance in Mobility-Limited Older People

Abstract: OBJECTIVES: The purpose of this study was to assess the influence of leg power and leg strength on the physical performance of community-dwelling mobility-limited older people. DESIGN: Cross-sectional analysis of baseline data from a 12-week randomized controlled exercise-intervention study. SETTING: Exercise laboratory within the Department of Health Science of an urban university. PARTICIPANTS: Forty-five community-dwelling mobility-limited people (34 women, 11 men), aged 65 to 83. MEASUREMENTS: Health status, depression, cognition, physical activity, and falls efficacy; physiological measures of lower extremity strength and power; and measures of physical performance. RESULTS: Through bivariate analyses, leg power was significantly associated with physical performance as measured by stair-climb time, chair-stand time, tandem gait, habitual gait, maximal gait, and the short physical performance battery describing between 12% and 45% of the variance ( R 2 ). Although leg power and leg strength were greatly correlated ( r � .89) in a comparison of bivariate analyses of strength or power with physical performance, leg power modeled up to 8% more of the variance for five of six physical performance measures. Despite limitations in sample size, it appeared that, through quadratic modeling, the influence of leg power on physical performance was curvilinear. Using separate multivariate analyses, partial R 2 values for leg power and leg strength were compared, demonstrating that leg power accounted for 2% to 8% more of the variance with all measures of physical performance. CONCLUSION: Leg power is an important factor influencing the physical performance of mobility-limited older people. Although related to strength, it is a separate attribute that may exert a greater influence on physical performance. These findings have important implications for clinicians practicing geriatric rehabilitation. J Am Geriatr Soc 50:461‐467, 2002.

Delirium Superimposed on Dementia: A Systematic Review

Abstract: Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

Change in muscle strength explains accelerated decline of physical function in older women with high interleukin-6 serum levels

Abstract: OBJECTIVES: To test whether accelerated sarcopenia in older persons with high interleukin (IL)-6 serum levels plays a role in the prospective association between inflammation and disability found in many studies. DESIGN: Cohort study of older women with moderate to severe disability. PARTICIPANTS: Six hundred twenty older women from the Women's Health and Aging Study in whom information on baseline IL-6 serum level was available. MEASUREMENTS: Self-report of functional status, objective measures of walking performance, and knee extensor strength were assessed at baseline and over six semiannual follow-up visits. Potential confounders were baseline age, race, body mass index, smoking, depression, and medical conditions. RESULTS: At baseline, women with high IL-6 were more often disabled and had lower walking speed. After adjusting for confounders, women in the highest IL-6 tertile (IL-6>3.10 pg/mL) were at higher risk of developing incident mobility disability (risk ratio (RR) = 1.50, 95% confidence interval (CI) = 1.01–2.27), disability in activities of daily living (RR = 1.41, 95% CI = 1.01–1.98), and severe limitation in walking (RR = 1.61, 95% CI = 1.09–2.38) and experienced steeper declines in walking speed (P < .001) than women in the lowest IL-6 tertile (IL-6 ≤1.78 pg/mL). Decline in knee extensor strength was also steeper, but differences across IL-6 tertiles were not significant. After adjusting for change over time in knee extensor strength, the association between high IL-6 and accelerated decline of physical function was no longer statistically significant. CONCLUSIONS: Older women with high IL-6 serum levels have a higher risk of developing physical disability and experience a steeper decline in walking ability than those with lower levels, which are partially explained by a parallel decline in muscle strength.

Effects of exercise training on frailty in community-dwelling older adults: results of a randomized, controlled trial.

Abstract: OBJECTIVES: Although deficits in skeletal muscle strength, gait, balance, and oxygen uptake are potentially reversible causes of frailty, the efficacy of exercise in reversing frailty in community-dwelling older adults has not been proven. The aim of this study was to determine the effects of intensive exercise training (ET) on measures of physical frailty in older community-dwelling men and women. DESIGN: Randomized controlled trial. SETTING: Medical school research center. PARTICIPANTS: One hundred fifteen sedentary men and women (mean age ± standard deviation = 83 ± 4) with mild to moderate physical frailty, as defined by two of the following three criteria: Modified Physical Performance Test (modified PPT) score between 18 and 32, peak oxygen uptake (.VO2 peak) between 10 and 18 mL/kg/min, and self-report of difficulty or assistance with one basic activity of daily living (ADL), or two instrumental ADLs. INTERVENTION: Participants were randomly assigned to a control group that performed a 9-month low-intensity home exercise program (control) or an exercise-training program (ET). The control intervention primarily consisted of flexibility exercises. ET began with 3 months of flexibility, light-resistance, and balance training. During the next 3 months, resistance training was added, and, during the next 3 months, endurance training was added. MEASUREMENTS: Modified PPT score, .VO2 peak, performance of ADLs as measured by the Older Americans Resources and Services instrument, and the Functional Status Questionnaire (FSQ). RESULTS: ET resulted in significantly greater improvements than home exercise in three of the four primary outcome measures. Adjusted 95% confidence bounds on the magnitude of improvement in the ET group compared with the control group were 1.0 to 5.2 points for the modified PPT score, 0.9 to 3.6 mL/kg/min for .VO2 peak, and 1.6 to 4.9 points for the FSQ score. CONCLUSIONS: Our results show that intensive ET can improve measures of physical function and preclinical disability in older adults who have impairments in physical performance and oxygen uptake and are not taking hormone replacement therapy better than a low-intensity home exercise program.

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data.

Abstract: OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) � 0.65, 95% confidence interval (CI) � 0.57‐0.75; and, respectively IRR � 0.65, 95% CI � 0.53‐0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR � 2.34, 95% CI � 1.64‐3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall. J Am Geriatr Soc 50:905‐911, 2002.

Adverse Drug Reactions as Cause of Hospital Admissions: Results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA)

Abstract: OBJECTIVES: To determine the prevalence of adverse drug reaction (ADR)-related hospital admissions in an older population, to describe the most common clinical manifestations and drugs most frequently responsible for ADR-related hospital admissions, and to identify independent factors predictive of these ADRs. DESIGN: Multicenter pharmacoepidemiology survey conducted between 1988 and 1997. SETTING: Eighty-one academic hospitals throughout Italy. PARTICIPANTS: Twenty-eight thousand four hundred eleven patients consecutively admitted to participating centers during the survey periods. MEASUREMENTS: For each suspected ADR at admission, a physician, who coded description, severity, and potentially responsible drugs, completed a questionnaire. RESULTS: Mean age ± standard deviation of the patients was 70 ± 16. One thousand seven hundred four ADRs were identified upon hospital admission. In 964 cases (3.4% of all admissions), ADRs were considered to be the cause of these hospital admissions. Of these, 187 ADRs were coded as severe. Gastrointestinal complaints (19%) represented the most common events, followed by metabolic and hemorrhagic complications (9%). The drugs most frequently responsible for these ADRs were diuretics, calcium channel blockers, nonsteroidal antiinflammatory drugs, and digoxin. Female sex (odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.10–1.54), alcohol use (OR = 1.39, 95% CI = 1.20–1.60), and number of drugs (OR = 1.24, 95% CI = 1.20–1.27 for each drug increase) were independent predictors of ADR-related hospital admissions. For severe ADRs, age (OR = 1.50, 95% CI = 1.01–2.23 for age 65–79 and OR = 1.53, 95% CI = 1.00–2.33 for age ≥80, respectively), comorbidity (OR = 1.12, 95% CI = 1.05–1.20 for each point in the Charlson Comorbidity Index), and number of drugs (OR = 1.18, 95% CI = 1.11–1.25 for each drug increase) were the only predisposing factors. CONCLUSIONS: The most important determinant of risk for ADR-related hospital admissions in older patients is number of drugs being taken. When considering only severe ADRs, risk is also related to age and frailty.

Characteristics Associated with Fear of Falling and Activity Restriction in Community-Living Older Persons

Abstract: Fear of falling is considered a common and potentially serious problem in older persons Approximately 25% to 55% of community-living older persons acknowledge being afraid of falling;1–5 the prevalence is even higher among women and persons with a previous fall history3,6 Fear of falling is thought to contribute to a loss of independence through the restriction of activities,7–9 but fear of falling may not invariably cause older persons to restrict their activities In fact, fear of falling likely has a range of consequences, from increased caution during performance of daily activities, which may be protective against falls, to an excessive restriction of activities, which may be debilitating4,10 In this broadened view, fear of falling may not be damaging unless it interferes with activity performance10 Because it may reduce social interaction2,4 and lead to inactivity and subsequent decline in physical capabilities,4,11,12 activity restriction due to fear of falling (hereafter referred to simply as activity restriction) is a potential threat to the physical and mental well-being of older persons Relatively little is known about older persons who restrict activity because of fear of falling or how they differ from those with fear of falling alone or those with no fear of falling Activity restriction has been examined in only a few previous studies that included nonrepresentative populations and relied exclusively on self-reported measures as candidate predictors4,13 In these studies, older persons who restricted their activities reported poorer physical functioning than those with no fear of falling13 and had less social support than those with fear of falling alone4 The goals of the current population-based study, which included both self-report and performance-based measures, were to identify the characteristics associated with activity restriction in community-living older persons and to determine how older persons with activity restriction differ from those with fear of falling alone We hypothesized that participants with activity restriction would have poorer health status and worse physical and psychosocial function than participants with fear of falling alone or those with no fear of falling

High-Velocity Resistance Training Increases Skeletal Muscle Peak Power in Older Women

Abstract: OBJECTIVES: Peak power declines more precipitously than strength with advancing age and is a reliable measure of impairment and a strong predictor of functional performance. We tested the hypothesis that a high-velocity resistance-training program (HI) would increase muscle power more than a traditional low-velocity resistance-training program (LO).

The GPCOG: A New Screening Test for Dementia Designed for General Practice

Abstract: OBJECTIVES: To design and test a brief, efficient dementia-screening instrument for use by general practitioners (GPs). DESIGN: The General Practitioner Assessment of Cognition (GPCOG) consists of cognitive test items and historical questions asked of an informant. The validity of the measure was assessed by comparison with the criterion standard of diagnoses of dementia derived from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). SETTING: Primary care doctors' offices. PARTICIPANTS: Sixty-seven GPs administered the GPCOG to 283 community-dwelling patients aged 50 to 74 with memory complaints or aged 75 and older. MEASUREMENTS: The Cambridge Mental Disorder of the Elderly Examination, the Abbreviated Mental Test (AMT), the Mini-Mental State Examination (MMSE), the 15-item Geriatric Depression Scale, and the 12-item Short-Form Health Survey. RESULTS: The GPCOG was reliable and superior to the AMT (and possibly to the MMSE) in detecting dementia. The two-stage method of administering the GPCOG (cognitive testing followed by informant questions if necessary) had a sensitivity of 0.85, a specificity of 0.86, a misclassification rate of 14%, and positive predictive value of 71.4%. Patient interviews took less than 4 minutes to administer and informant interviews less than 2 minutes. The instrument was reported by GPs to be practical to administer and was acceptable to patients. CONCLUSION: The GPCOG is a valid, efficient, well-accepted instrument for dementia screening in primary care. J Am Geriatr Soc 50:530–534, 2002.

Validity of divided attention tasks in predicting falls in older individuals: a preliminary study.

Abstract: OBJECTIVES: Although cognitive impairment is known to be a major risk factor for falls in older individuals, the role of cognitive tests in predicting falls has not been established. Limited attentional resources may increase the risk for falls in older individuals. We examined the reliability and validity of divided attention tasks, walking while talking (WWT), in predicting falls. DESIGN: A prospective cohort study of 12-months’ duration. SETTING: Community-based longitudinal aging study, the Einstein Aging Study. PARTICIPANTS: Sixty nondemented community-living

Percentage of Body Fat and Body Mass Index Are Associated with Mobility Limitations in People Aged 70 and Older from NHANES III

Abstract: OBJECTIVES: To assess the association between functional limitations and body composition indices, including percentage of body fat, muscle mass, and body mass index (BMI). DESIGN: A cross-sectional, population-representative sample. SETTING: All noninstitutionalized people living in the United States (National Health and Nutrition Examination Survey). Data were collected between 1988 and 1994. PARTICIPANTS: One thousand five hundred twenty-six women and 1,391 men aged 70 and older. MEASUREMENTS: Independent variables included BMI, muscle mass, and percentage of body fat; the latter two were assessed using predictive equations. The dependent variable, functional limitations, was defined as difficulty in performing at least three of five functional living tasks, such as carrying a 10-pound bag of groceries. RESULTS: Women in the highest quintile for percentage of body fat and women with a BMI of 30 or greater were two times more likely to report functional limitations than women in the comparison groups. Similar, but weaker, relationships were found among men; men in the highest quintile for body fat and men with a BMI of 35 or greater were 1.5 times more likely to report limitations. Low muscle mass (sarcopenia) and sarcopenia in combination with high percentage of body fat (sarcopenic obesity) were not associated with a greater likelihood of reporting functional limitations. CONCLUSIONS: Prevention of excessive accumulation of body fat and maintenance of a BMI in the normal range may reduce the likelihood of functional limitations in old age.

Profiles of Older Medicare Decedents

Abstract: OBJECTIVES: To evaluate the usefulness of a clinical scheme to classify older decedents to better understand the issues associated with healthcare use and costs in the last year of life. DESIGN: We analyzed Medicare claims data for a random sample of 0.1% of all Medicare beneficiaries with expenditures between 1993 and 1998. This sample yielded 7,966 deaths. SETTING: Medicare claims data. PARTICIPANTS: Medicare beneficiaries. MEASUREMENTS: We classified decedents into groups representing four trajectories at the end of life: sudden death, terminal illness, organ failure, and frailty. RESULTS: Ninety-two percent of decedents were captured by the profiling strategy. The four trajectory groups had distinct patterns of demographics, care delivery, and Medicare expenditures. Frailty was a dominant pattern, with 47% of all decedents, whereas sudden death claimed only 7%; cancer claimed 22%, and organ system failure, 16%. CONCLUSIONS: The clinical scheme to classify decedents appears to fit most decedents and to form groups with substantial clinical differences. Acknowledging the differences among these groups may be a fruitful way to evaluate expenditures and develop strategies to improve care at the end of life.

Cognitive impairment after stroke: clinical determinants and its associations with long-term stroke outcomes.

Abstract: OBJECTIVES: To identify factors that were associated with cognitive impairment 3 months after stroke, and to examine the associations of cognitive impairment with stroke outcomes up to 4 years after stroke. DESIGN: Observational study. SETTING: Population-based stroke register. PARTICIPANTS: Six hundred forty-five subjects with first-ever stroke, identified from the register. MEASUREMENTS: Subjects were assessed for cognition using the Mini-Mental State Examination (MMSE) 3 months after stroke. Cognitively impaired subjects (MMSE <24, n = 248 (38%)) were compared with cognitively intact subjects (MMSE 24–30, n = 397) in terms of demographic details, stroke risk factors, laterality of stroke, and initial poststroke impairments. Outcome data collected at 1, 3, and 4 years poststroke included disability assessed by the Barthel Index (BI) and the Frenchay Activity Index, case fatality, and institutionalization. RESULTS: Two hundred forty-eight (38%) of 645 subjects were cognitively impaired 3 months after stroke. Using multivariate analyses, cognitive impairment was associated with age of 75 and older (odds ratio (OR) = 2.5, 95% confidence interval (CI) = 1.5–4.2), ethnicity (Caribbean/African (OR = 1.9, 95% CI = 1.2–3.2) and Asian (OR = 3.4, 95% CI = 1.1–10.2), lower socioeconomic class (OR = 2.1, 95% CI = 1.3–3.3), left hemispheric lesion (OR = 1.6, 95% CI = 1.01–2.4), visual field defect (OR = 2.0, 95% CI = 1.2–3.2), and urinary incontinence (OR = 4.8, 95% CI = 3.1–7.3). Using multivariate analyses, cognitive impairment was associated with death or disability (BI <15) at 4 years after stroke (OR = 2.2, 95% CI = 1.1–4.5). In univariate analyses, it was also associated with higher institutionalization 4 years after stroke (P = .001). CONCLUSIONS: Cognitive impairment is common 3 months after stroke and is independently associated with older age, ethnicity, lower social class, left hemispheric stroke, visual field defect, and urinary incontinence. It is associated with poor long-term outcomes, including survival and disability, up to 4 years after stroke. Because physical and cognitive impairments after stroke have independent prognostic implications, measures that evaluate both functions should be used in future studies of stroke outcome and in care of stroke patients.

Recreational physical activity levels in healthy older women: the importance of fear of falling.

Abstract: OBJECTIVES: To examine whether fear of falling is a probable cause of reduced recreational physical activity levels in healthy older women. DESIGN: Cross-sectional analysis of baseline data from a longitudinal study. PARTICIPANTS: One thousand five hundred older, ambulatory women (aged 70–85), selected at random from the electoral roll. MEASUREMENTS: Self-reported recreational physical activity levels and fear of falling, demographic variables, anthropometric variables and measures of disability, and physical and cognitive function. RESULTS: The study subjects had low levels of physical and cognitive impairments; 24.1% of the group was obese (body mass index> 30). Twenty-six percent of the women did not participate in recreational physical activity; 39% participated in sufficient activity to gain probable health benefits. Although the women who did not participate in recreational activities were most likely to report fear of falling (45.2%), it was common in the group as a whole (33.9%), including the most active women (27.0%). Independent risk factors for nonparticipation in physical activity were fear of falling (odds ratio (OR) = 0.70, 95% confidence interval (CI) = 0.54–0.90, P = .006), obesity (OR = 0.50, 95% CI = 0.38–0.66, P = .001), and slower times on the timed up-and-go test (OR = 0.88, 95% CI = 0.84–0.92, P = .001). Fear of falling was also independently associated with lower recreational physical activity levels in women who were active (β = −0.09, P = .003). Subgroup analysis suggested that fear of falls affected activity levels at a predisability stage in women with mildly impaired mobility. CONCLUSIONS: Fear of falling is common in healthy, high-functioning older women and is independently associated with reduced levels of participation in recreational physical activity. Fear of falling is an important psychological barrier that may need to be overcome in programs attempting to improve activity levels in older women.

Xerostomia and the geriatric patient

Abstract: Saliva is essential for the preservation of oral-pharyngeal health, and disorders of salivary physiology are associated with numerous oral and pharyngeal problems, particularly in older people. Although salivary function is remarkably intact in healthy aging, medical problems, medications, and head and neck radiotherapy can cause salivary dysfunction and complaints of xerostomia among older people. Sjogren's syndrome, an autoimmune exocrinopathy, is the most common medical disease associated with salivary dysfunction. Medications with anticholinergic side effects will impair salivary output, and head and neck radiotherapy for cancer will cause permanent destruction of salivary glands. Treatments for salivary problems are based upon establishing a diagnosis, protecting oral and pharyngeal health, stimulating remaining glands, and replacing lost salivary fluids.

Serum Interleukin‐6 and Hemoglobin as Physiological Correlates in the Geriatric Syndrome of Frailty: A Pilot Study

Abstract: OBJECTIVES: To determine specific physiological correlates of the geriatric syndrome of frailty that warrant further investigation. DESIGN: Population-based case-control study. SETTING: General Clinical Research Center at Johns Hopkins Bayview Medical Center. PARTICIPANTS: Community-dwelling adults aged 74 and older from Baltimore, Maryland. MEASUREMENTS: Frailty status was determined using a recently validated screening tool that consists of weight loss, fatigue, low levels of physical activity, and measurements of grip strength and walking speed. Serum interleukin-6 (IL-6) was measured using enzyme-linked immunosorbent assay, and standard complete blood count was performed using a Coulter counter. RESULTS: Eleven frail and 19 nonfrail subjects with mean age ± standard deviation of 84.9 ± 6.7 vs 81.3 ± 4.1 years, respectively, completed the study. The frail subjects had significantly higher serum IL-6 levels and significantly lower hemoglobin and hematocrit than the nonfrail subjects (4.4 ± 2.9 vs 2.8 ± 1.6 pg/mL, 12.1 ± 1.1 vs 13.9 ± 1.0 g/dL, and 35.8%± 3.1% vs 40.6%± 2.8%, respectively). No significant difference was observed in mean corpuscular volume, red blood cell distribution width, or white blood cell and platelet counts between the frail and nonfrail groups. Furthermore, there was an inverse correlation between serum IL-6 level and hemoglobin (Pearson's correlation coefficient: −0.46) and hematocrit (−0.48) in the frail group but not in the nonfrail group. CONCLUSION: These results suggest that frail subjects have evidence of inflammation and lower hemoglobin and hematocrit levels. This subclinical anemia is normocytic and is hence unlikely due to myelosuppression or iron deficiency and is potentially related to the increased chronic inflammatory state marked by serum IL-6 elevation. Further studies are indicated to better characterize the immune and hematological changes that underlie frailty.

Nutritional Status Using Mini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients

Abstract: OBJECTIVES: To evaluate the clinical assessment of nutritional status and mortality in geriatric patients. DESIGN: Prospective follow-up study. SETTING: Acute geriatric inpatient ward. PARTICIPANTS: Eighty-three consecutive acute geriatric patients (mean age ± standard deviation = 83 ± 7; 68% women). MEASUREMENTS: Patients were classified as (1) having protein-energy malnutrition (PEM), (2) having moderate PEM or being at risk for PEM, or (3) being well nourished according to Subjective Global Assessment (SGA) and Mini Nutritional Assessment (MNA). Body mass index ((BMI) kg/m2), arm anthropometry, and handgrip strength were determined. In a subgroup of patients (n = 39), body composition was analyzed using dual energy x-ray absorption and bioelectrical impedance. Three-year mortality data were obtained from the Swedish population records. RESULTS: Twenty percent and 26% of the patients were classified as having PEM based on SGA and MNA, respectively, whereas 43% and 56%, respectively, were classified as having moderate PEM or being at risk for PEM. Objective measures, such as BMI, arm anthropometry, handgrip, and body fat were 20% to 50% lower in the malnourished group than in the well-nourished subjects (P < .05). Moreover, mortality was higher in those classified as being malnourished, ranging from 40% after 1 year to 80% after 3 years, compared with 20% after 1 year (P = .03–0.17) and 50% after 3 years (P < .01) in patients classified as being well nourished. CONCLUSION: Fewer than one-third of newly admitted geriatric patients had a normal nutritional status according to SGA and MNA. BMI, arm anthropometry, body fat mass, and handgrip strength were reduced, and 1-, 2-, and 3-year mortality was higher in patients classified as malnourished. The present data justify the use of SGA and MNA for the assessment of nutritional status in geriatric patients.

Predictors of Functional Change: A Longitudinal Study of Nondemented People Aged 65 and Older

Abstract: OBJECTIVES: To identify factors associated with functional change in an older population and investigate interactions among selected potential risk factors. DESIGN: A population-based prospective cohort study. SETTING: A random sample was selected from the Group Health Cooperative members in the Seattle area from 1994 to 1996 and followed biennially. PARTICIPANTS: Two thousand five hundred eighty-one people aged 65 and older, cognitively intact at baseline. MEASUREMENTS: Functional status was measured by activities of daily living, instrumental activities of daily living, and performance-based physical function testing. RESULTS: The cohort status at the time of these analyses was: deceased, 391; withdrawn, 179; dementia, 152; and on study, 1,873. The mean follow-up time was 3.4 years. Using linear regressions with Generalized Estimating Equation, selected medical conditions (diabetes mellitus, hypertension, coronary heart disease, cerebrovascular disease (CVD), osteoporosis, arthritis, and cancer), low cognitive function, depression, and smoking were associated with worse functional outcomes. Exercise and moderate alcohol use were associated with better functional outcomes. Over the follow-up period, coronary heart disease, CVD, and depression were associated with increased rates of functional decline. Exercise and moderate alcohol consumption were associated with decreased rates of functional decline. Significant interactions were observed between exercise and coronary heart disease, moderate alcohol use and CVD, and cognition and CVD. CONCLUSIONS: Our study has identified not only risk factors associated with functional decline but also the interactions among these factors. These observations, along with other published research, add to the growing understanding of the underlying process of functional change and could provide a basis to design effective strategies to delay functional decline.

Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair.

Abstract: OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity in a cohort of patients aged 65 and older; to examine the association between severity of delirium and patient outcomes; and to examine the association between psychomotor variants of delirium and each of those outcomes. DESIGN: Prospective assessment of sample. SETTING: Hospital. PARTICIPANTS: One hundred twenty-two older patients (mean age ± standard deviation = 79 ± 8) who had undergone acute hip fracture surgery. MEASUREMENTS: We used standardized instruments to assess prefracture activities of daily living (ADLs), ambulatory status, cognition, and living situation. Postoperatively, each patient was interviewed daily. Delirium was diagnosed using the Confusion Assessment Method (CAM), and delirium severity was measured using the MDAS. The MDAS was also used to categorize the psychomotor types of delirium into “purely hypoactive” or “any hyperactivity.” Telephone or face-to-face interviews were conducted at 1 and 6 months to assess survival, ADL function, ambulatory status, and living situation. RESULTS: Of 122 patients, 40% developed CAM-defined delirium. Delirious patients had higher average MDAS scores than nondelirious patients (11.7 vs 2.4, P <.0001). We used the median of the average MDAS score to classify patients into mild or severe delirium. Severe delirium was generally associated with worse outcomes than was mild delirium, and the associations reached statistical significance for nursing home placement or death at 6 months (52% vs 17%, P = .009). Additionally, patients who did not meet full CAM criteria for delirium experienced worse outcomes if they had some symptoms of delirium than if they had no or few symptoms (nursing home placement or death at 6 months: 27% vs 0%, P = .001). Surprisingly, these patients with subsyndromal delirium who did not fulfill CAM criteria for delirium but demonstrated significant delirium symptoms, had outcomes similar to or worse than those with mild CAM-defined delirium. Pure hypoactive delirium accounted for 71% (34/48) of cases and was less severe than was delirium with any hyperactivity (average MDAS score 10.6 vs 14.8, P = .007). In our cohort, patients with pure hypoactive delirium had better outcomes than did those with any hyperactivity (nursing home placement or death at 1 month: 32% vs 79%, P = .003); this difference persisted after adjusting for severity. CONCLUSION: In this study of delirium in older hip fracture patients, the MDAS, a continuous severity measure, was a useful adjunct to the CAM, a dichotomous diagnostic measure. In patients with CAM-defined delirium, severe delirium was generally associated with worse outcomes than was mild delirium. In patients who did not fulfill CAM criteria, subsyndromal delirium was associated with worse outcomes than having few or no symptoms of delirium. Patients with subsyndromal delirium had outcomes similar to patients with mild delirium, suggesting that a dichotomous approach to diagnosis and management may be inappropriate. Pure hypoactive delirium was more common than delirium with any hyperactive features, tended to be milder, and was associated with better outcomes even after adjusting for severity. Future studies should confirm our preliminary associations and examine whether treatment to reduce the severity of delirium symptoms can improve outcomes after hip fracture repair.

Peripheral blood markers of inflammation predict mortality and functional decline in high-functioning community-dwelling older persons.

Abstract: OBJECTIVES: Several peripheral blood markers of inflammation have demonstrated prognostic ability, but the value of combining multiple markers as a measure of inflammatory burden remains unknown. The objective of this study was to determine the prognostic value of combining four peripheral blood measures of inflammation in healthy older persons. DESIGN: Inception cohort study with 7 years of follow-up. SETTING: Three communities. PARTICIPANTS: Eight hundred seventy high-functioning subjects aged 70 to 79 who had serum albumin, cholesterol, interleukin (IL)-6, and C-reactive protein (CRP) levels measured at baseline. MEASUREMENTS: Three- and 7-year mortality and Rosow- Breslau functional decline. RESULTS: A summary score was created that assigned one point each for the following blood levels: albumin 3.8 pg/mL (top tertile), and CRP>2.65 mg/L (top tertile). By 3 years, 6% of subjects had died, and, by 7 years, 23% had died. In subjects with three or four markers of inflammation, the adjusted odds ratios (AORs) for 3- and 7-year mortality were 6.6 and 3.2, respectively, compared with those who had no abnormal markers. Subjects with one or two markers were at more moderate and statistically insignificant increased risk of 3- and 7-year mortality with AORs of 1.5 and 1.3, respectively. The risks for functional decline at 3- and 7-years were generally small (AOR = 1.1–1.9) and not statistically significant. CONCLUSIONS: In high-functioning older persons, a measure of inflammation can identify those at a much higher risk of mortality and a possibly higher risk of functional decline. Whether therapies directed at reducing inflammation can attenuate such risk remains to be determined.

Resistance exercise and physical performance in adults aged 60 to 83.

Abstract: .050). The in-creases in total strength (sum of all eight 1RMs) were17.2% and 17.8% for the LEX and HEX groups, respec-tively. Muscular endurance improved by 79.2% and105.0% for the leg press, and 75.5% and 68.0% for thechest press for the LEX and HEX groups, respectively.The time to ascend one flight of stairs significantly de-creased for both the LEX and HEX groups (

Evaluation of the effectiveness of Tai Chi for improving balance and preventing falls in the older population--a review.

Abstract: One of the challenges faced by people with advancing age is decreased postural stability and increased risks for falls. There has been an increased interest over the last decade in using Tai Chi as an intervention exercise for improving postural balance and preventing falls in older people. Despite the increased number of studies in recent years relating Tai Chi to balance and fall prevention, results are scattered and inconsistent. There is wide variation in the use of balance measures, subject population, type and duration of Tai Chi exercise, and type of study. This paper provides a systematic review/analysis of currently available study reports. The goal of the review is to address the following concerns: how the effect of Tai Chi on balance or fall prevention has been evaluated to date, what level of evidence exists supporting Tai Chi as an effective exercise for improving balance or preventing falls, and what factors could possibly affect the benefit of Tai Chi on balance or falls. This review also helps identify directions for future research.