摘要:

OBJECTIVE:To determine if basal metabolic rate (BMR) could be elevated in older women undertaking a program of progressive resistance exercise of up to 52‐weeks duration.DESIGN:Randomized controlled trial with subjects assigned to either a control (CO), high‐intensity (HI), or low‐intensity (LO) training group for 15 weeks. BMR, body composition, energy intake and expenditure, and muscle strength were assessed at baseline and after 15 weeks. Subjects were encouraged to continue in their assigned exercise group for an additional 37 weeks, after which time they were reevaluated.SETTING:An exercise facility at a medical center.SUBJECTS:Thirty‐six community‐dwelling healthy women aged 65 to 79 years.INTERVENTION:Exercise groups performed three sets of 10 exercises, 3 days/week, at either 80% of one‐repetition maximum (1‐RM) for seven repetitions (HI) or 40% of 1‐RM for 14 repetitions (LO).MEASURES:BMR by indirect calorimetry, body composition by dual energy X‐ray absorptiometry, energy intake and expenditure from 4‐day dietary and activity records, and dynamic muscle strength by 1‐RM.RESULTS:Muscle strength increased, on average (±SEM), by 40 ± 6% and 36 ± 7% in the HI and LO groups after 15 weeks, respectively, compared with 4 ± 1% in the nonexercising subjects (P= .0001). Fat mass decreased after 15 weeks in LO exercisers by 1.0 kg (P<.05), whereas there was a trend for fat‐free mass (FFM) to increase in the HI group by 0.7 kg (P= .08). No change occurred in any group for BMR. From weeks 15 to 52, muscle strength increased a further 9 ± 2% and 11 ± 2% in HI and LO groups, respectively, compared with 3 ± 1% in nonexercisers (P<.005). There was no change in BMR or any body composition parameter during this time period.CONCLUSIONS:Neither training program significantly altered BMR and both produced only minimal changes in body composition. However, both the HI and LO exercise regimens resulted in similar and substantial gains in upper and lower body muscle strength that persisted over the course of the year. This suggests that either exercise regimen may prove an effective strategy for preventing frailty and maintaining functiona

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06090.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To evaluate the reliability of the DSM‐IV approach and five other schemes for counting symptoms toward the diagnosis of depression in hospitalized medically ill older patients and to examine whether mental health professionals can reliably make judgments about the etiology (medical or psychological) of depressive symptoms.METHOD:A sample of 38 patients aged 60 years or older admitted to the general medicine, cardiology, or neurology services at Duke University Medical Center were evaluated for depression using a structured psychiatric interview and the Hamilton Depression Scale. Interrater reliability for the diagnostic schemes, for unstructured clinical diagnoses, and for determinations of the causes of individual depressive symptoms was assessed by three pairs of mental health professionals.RESULTS:Agreement between raters for structured diagnoses was high regardless of diagnostic strategy, with the DSM‐IV approach being only slightly less reliable than the strict inclusive approach (Kappa 0.88 vs Kappa 1.0, respectively). For all diagnostic approaches, there was perfect agreement between raters for eight cases of major depression. Agreement for unstructured clinical diagnoses of depression (K = 0.50) was much lower than for the structured diagnoses. Agreement between raters on the etiology of individual depression criterion symptoms assessed by structured interview was greater than 80% for 14 of 19 symptoms. Correlation between raters' depression severity ratings on the Hamilton Scale using the DSM‐IV etiologic approach was equivalent to that using the strict inclusive approach (0.98 vs 0.95, respectively).CONCLUSIONS:Mental health professionals can be trained to make judgments reliably about the cause (medical or psychological) of symptoms in hospitalized older medical patients. The “strict inclusive” and other diagnostic schemes for counting symptoms toward the diagnosis of depression have only marginal, if any, benefit compared with the the current DSM‐

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06091.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To investigate the prevalence of foot pain in older people and its association with pathological conditions of the feet and with disability in basic and instrumental activities of daily living.DESIGN:Cross‐sectional survey of a community‐dwelling older population.PARTICIPANTS:A total of 459 subjects, 73% of the population aged 65 years and older living in Dicomano, Florence, Italy.MEASUREMENTS:A standardized medical examination was performed by a geriatrician to collect information on the presence of pain, specific problems of the feet, gait, and several indicators of physical health status. Disability in basic and instrumental activities of daily living was evaluated by self‐report.RESULTS:The prevalence of foot pain was very high, especially in subjects affected by calluses or corns, hallux deformities, hammer toes, pes planus, and edema and among those who complained of difficulty in looking after the basic needs of the feet. Patients with foot pain needed a greater number of steps and longer time to walk the same distance. Foot pain was associated with a higher prevalence of disability in instrumental activities of daily living, particularly those related to standing and ambulation capacities, but it was not related to higher prevalence of disability in basic activities of daily living.CONCLUSIONS:Foot pain is associated with specific conditions of the feet and disability in instrumental activities of daily living. Adequate assessment and treatment of foot problems may prevent foot pain and potentially reduce risk of disability. This hypothesis needs to be tested in longitudinal studies and specific intervention t

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06092.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To study the relationship between social and leisure activities and risk of subsequent dementia in older community residents.SETTING:A cohort study of people aged 65 and older were followed‐up 1 and 3 years after a baseline screening (the Paquid study).PARTICIPANTS:2040 older subjects living at home in Gironde (France) were randomly selected and followed for at least 3 years.DATA COLLECTION:Information about social and leisure activities was collected during the baseline screening with an interview by a psychologist. Incident cases of dementia were detected during the first and third year follow‐up screenings according to the DSM‐III‐R criteria.MAIN RESULTS:All but one of the social and leisure activities noted were significantly associated with a lower risk of dementia. Only golden club participation was not significantly associated with this risk. After adjustment for age and cognitive performance measured by the Mini‐Mental State Exam, visual memory test, and verbal fluency test, only traveling (Relative risk (RR) = .48, 95% Confidence Interval (95%CI) = .24‐.94), odd jobs or knitting (RR = .46, 95%CI = .26‐.85), and gardening (RR = .53, 95%CI = .28‐.99) remained significant.CONCLUSIONS:Regular participation in social or leisure activities such as traveling, odds jobs, knitting, or gardening were associated with a lower risk of subs

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06093.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To evaluate the relationship between total serum anticholinergic activity (SAA) and the presence or absence of delirium in older hospitalized persons on general medical wards.DESIGN:Case‐control study and within‐subjects repeated‐measures in recovered delirious patients.SETTING:Minneapolis Veterans Affairs Medical Center medical wards.PARTICIPANTS:Eleven male delirious patients (DSM‐III‐Rcriteria) aged 60 or older and 11 comparably aged male nondelirious controls.MEASUREMENTS:Radioreceptor bioassay of total SAA using tritiated quinuclidinyl benzilate (QNB) binding to muscarinic receptors. Results are expressed in terms of atropine equivalents (nm).MAIN RESULTS:Mean SAA was significantly elevated in the delirious group (mean ± SD = 6.05 ± 2.97 nmatropine equivalents) compared with the controls (3.38 ± 2.49;t(20) = 2.28,P<.05). At study entry, mean SAA was significantly higher in delirious subjects whose symptoms eventually resolved completely (mean ± SD = 7.77 ± 2.37) compared with subjects whose delirious symptoms persisted (3.99 ± 2.30;t(9) = 2.68,P<.05). All six patients in whom delirium resolved completely had a decrease in serum anticholinergic activity when measured during delirium (7.77 ± 2.37) and after symptom resolution (3.92 ± 2.61;t(5) = 3.29,P<.05).CONCLUSIONS:Our findings suggest that serum anticholinergic activity may play a role in delirium in medical inpatients. The relationships between SAA and delirium in medical patients and between total SAA and medication use warr

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06094.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To describe the total cost of pressure ulcer prevention, component costs of each intervention, and the relationship of costs to subjects' risk level.DESIGN:3‐month cohort trial.SETTING:A 600‐bed, state‐supported, long‐term care facility.PATIENTS:A total of 539 war veterans, 83% of whom were male; mean age was 73 years.MAIN OUTCOME MEASURES:Cost to facility for using each of four preventive interventions: turning, pressure‐reducing mattresses, chair cushions, miscellaneous preventive devices.RESULTS:Sixty‐eight percent of subjects received a preventive intervention. Total 3‐month facility cost of prevention was $132,114, and 97% of the cost was consumed by 30% of the subjects. Turning was the most expensive component, accounting for $99,567. The daily cost of turning for subjects who received it was $8.83 ± 1.66. Cost increased with subject risk level. Low cost devices were instituted for lower risk subjects, whereas high cost interventions (turning) were reserved for the highest risk subjects.CONCLUSIONS:This long‐term care facility expended substantial resources on prevention, and most resources (97%) were expended on less than half (30%) of subjects. Turning was, by far, the most expensive intervention, and the nursing staff reserved it for highest risk subjects. Strategies that substitute moderately priced mattresses for frequent turning may decrease the cost of prevention, as long as mattress cost is less than the daily turning costs it replaces. Future research to define the optimum combinations of preventive interventions for patients of various risk

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06095.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To determine if patients with Paget's disease of bone involving the tibia, femur, and/or acetabular portion of the ilium had more impairments in function and mobility than age‐ and sex‐matched control subjects.PATIENTS AND METHODS:A case control study with Paget's disease patients selected from a center for bone disease at a tertiary medical center; control subjects were volunteers from the Duke University Aging Center subject registry. Demographic characteristics, physical examination and serum alkaline phosphatase levels were obtained. Radiographs of the pelvis and lower extremities were evaluated by a radiologist. All participants completed a Functional Status Questionnaire (FSQ). Mobility measures included mobility skills protocol, 10‐foot walk time, 360‐degree turn left (number of steps), and 6‐minute walk distance.RESULTSThe 12 Paget's disease patients were no different in age (70.7 ± 6.2 years) than the 12 control subjects (69.5 ± 6.2 years). Serum alkaline phosphatase levels were elevated in Paget's patients (539 ± 530 IU/L), and normal in control subjects (85 ± 17 IU/L). In addition to Paget's disease, radiographs showed joint space loss in joints proximate to the diseased bone. On the FSQ scales Paget's disease patients had significantly lower scores in basic activities of daily living (P<.05), instrumental activities of daily living (P<.001), and social activity than control subjects (P<.05). There was no difference between the groups on scales measuring mental health and quality of social interaction. On mobility measurements, Paget's disease patients showed significant impairments when compared with control subjects: mobility skills protocol score (22.5 ± 2.5 vs 25.6 ± 0.7,P<.001); 10‐foot walk (3.96 ± 1.3 vs 2.55 ± 0.5 seconds,P<.001); 360 degree turn left (8.0 ± 1.0 vs 5.9 ± 0.6 steps,P<.001); and 6‐minute walk (342.0 ± 108.5 vs 519.4 ± 100 meters,P<.001).CONCLUSION:When compared with control subjects, patients who have Paget's disease of bone involving the tibia, femur, or acetabular portion of the ilium have clinically and statistically significant functional and mobility impairments compared to age‐

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06096.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of 1‐year postdischarge mortality in a population of older rehabilitation patients.DESIGN:Prospective survey (cohort study)SETTING:The Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospitalPARTICIPANTS:Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.MEASUREMENTS:At admission and again at discharge, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. After discharge, each subject was tracked for 1 year.MAIN RESULTS:Within the 1‐year posthospital discharge follow‐up period, 64 study subjects (20%) died. This included 17% of the patients discharged home and 34% of the patients discharged to a nursing home (P<.01). Based on the Cox Proportional Hazards survival model, the variable most strongly associated with mortality was the discharge serum albumin, followed by discharge weight expressed as a percentage of ideal, self‐dressing ability, and a discharge diagnosis of cardiac arrhythmia (usually atrial fibrillation). When all four of these variables were included in the analysis, the model was able to differentiate the survivors from those who died by years end with a sensitivity of 69%, a specificity of 69%, and an overall predictive accuracy of 69%. When tested using the data from the previous study, the model differentiated the patients who died from those who had not at a sensitivity of 62%, a specificity of 68%, and an overall predictive accuracy of 64%.CONCLUSIONS:Protein‐energy undernutrition appears to be a strong independent risk factor for 1‐year postdischa

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06097.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVES:To determine the prevalence and patient‐specific predictors of the use of 10 presumptively inappropriate medications used to treat medical conditions among nursing home residents, and to use this information to examine alternative screening strategies using computerized assessment data to identify residents who are at high risk of receiving inappropriate medications.DESIGN:Retrospective, cross‐sectional study.PATIENTS:All persons residing in all 252 nursing homes in two states during the last 6 months of 1991 (N = 21,884).MEASUREMENTS:Data were from Minimum Data Set Plus (MDS+) assessments, gathered as part of the Health Care Financing Administration (HCFA) Multistate Nursing Home Casemix and Quality Demonstration Project. The MDS+ is an expanded version of the federally mandated Minimum Data Set (MDS) that includes additional information on medications and their doses and schedules (frequency, standing vs prn). The reliability of the MDS has been demonstrated previously. Medications were defined as inappropriate using explicit criteria from published literature.Outcome measures were the standing use of each or any of 10 presumptively inappropriate medications used to treat medical (rather than psychiatric or behavioral) conditions. Potential predictors of inappropriate medication use included patient demographic characteristics, payer, a proxy measure for length of stay and admission source, functional status, number of standing medications, and state.MAIN RESULTS:A total of 12% of residents were prescribed one or more of 10 presumptively inappropriate medications on a standing basis, a figure that differed substantially between states (14.0% vs 7.4% (P65 years, never having been married, severe functional limitations, being a long‐stay patient, and medical diagnosis) did not substantially improve the overall predictive ability of the model.CONCLUSIONS:A substantial proportion of nursing home residents receives presumptively inappropriate medications to treat medical conditions. Selecting persons prescribed large numbers of medications for further review may be the most efficient method for nursing home or pharmacy personnel to identify residents at high risk of receiving inappropriate medications. Extensive additional information on residents' characteristics, although widely available through the Minimum Data Set, does not significantly improve the ability to identify residents receiving inappropriate medications for medical conditions. State‐specific policies or provider practices also influence the likelihood of presumptively inappropriate medication use among nursing home residents and deserve further invest

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06098.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY

摘要:

OBJECTIVE:To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates.DESIGN:Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community‐residing older persons (n = 228) matched on age, gender, and year of cardiac arrest.SETTING:A large metropolitan city served by a tiered emergency medical service.MEASUREMENTS:Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge.RESULTS:The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community‐residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between‐group comparisons of these variables revealed no significant differences even though our sample size was adequate.CONCLUSIONS:We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community‐residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1995.tb06099.x

出版商:Blackwell Publishing Ltd    

年代:1995

数据来源: WILEY