摘要:

OBJECTIVES:To determine whether diabetes is rare in Alzheimer disease (AD) relative to other types of dementia and whether diabetics with dementia have a low frequency of the Apolipoprotein‐E E4 genotype.DESIGN:Observational survey study.SETTING:An Irvine, California, outpatient dementia assessment center.PARTICIPANTS:A total of 123 patients with AD, 51 with vascular dementia, 57 with “mixed” vascular dementia and AD, and 34 with “other” dementias (non‐vascular non‐AD).MEASUREMENTS:Demographic data; histories and evidence of diabetes, hypertension, heart disease, stroke; and Apolipoprotein‐E genotype for 95 cases distributed across the groups.RESULTS:There were 15 diabetics in the sample (5.7%), all of whom had extensive vascular disease. Diabetes was rare in AD patients (0.8%) relative to vascular dementia (11.8%), mixed vascular/AD dementia (8.8%), and “other” dementia patients (8.8%). In addition, the E4 allele of apolipoprotein‐E, associated with high risk for AD, was frequent in the AD group (71.4%), but in the diabetic group it was only as frequent as in the general population (38.5%). In the diabetics with E4, 60% (3/5) had mixed dementia.CONCLUSIONS:Diabetics with dementia rarely have AD except as a component of mixed dementia. Apo‐E genotyping showed only average E4 allele frequency in diabetics compared with the high E4 frequency found in AD patients. However, mixed dementia in diabetics may be associated with the E4 allele, suggesting that close control of diabetes may be particularly important for those with E4 since they may be more likely than others to develop both diseases. J Am Geria

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01857.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To test the hypothesis that there is an inverse relationship between smoking and cognitive impairment by examining the prevalence and incidence of such impairment in a representative cohort of older urban residents.DESIGN:Survey follow‐up with three interviews over a 4‐year period.SETTING:City of Cleveland, Ohio.PARTICIPANTS:Six hundred forty‐seven survivors of a population‐based, multi‐stage probability sample of urban residents, aged 74 years and older in 1984.MEASUREMENTS:Past and present cigarette smoking was measured in 1984 by direct questioning. Cognitive impairment was measured in 1984, 1987, and 1988 by the 10‐item Short Portable Mental Status Questionnaire. Mortality was determined at each interview date, and death certificates were obtained. Data were analyzed by univariate analysis, stratified analysis, and multivariate logistic regression.RESULTS:There were 99 cases of cognitive impairment at baseline among 628 individuals for whom complete data were available. Crude data suggest that the prevalence of cognitive impairment was lower among smokers than among non‐smokers, but logistic regression, adjusted for age, income, and gender, showed this difference to be nonsignificant, OR 0.73; 95% CI (0.42,1.29).Fifty‐one new cases of cognitive impairment occurred during the 4‐year observation period. Neither the crude data nor logistic regression showed any significant relationship between smoking and the incidence of cognitive impairment, OR 1.03; 95% CI (0.54, 1.99).Four‐year mortality did not differ significantly between these older smokers and non‐smokers, but smokers died at a relatively younger age and were more likely to die of diseases associated with smoking.CONCLUSION:This study does not confirm the hypothesis that there is a negative relationship between smoking and cognitive impairment. The mortality data suggest that case‐control prevalence studies of the hypothesized relationship may be distorted by complex life‐long trends in behavior, morbidity, and mortality which could result in a misleading appearance of low prevalence of cognitive impairment among smokers. Additional large, prospective, population‐based studies of the incidence of cognitive impairment and related disorders and possible protective or risk factors other than smoking are needed. J Am G

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01858.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To determine factors that might account for a significantly lower attack rate in a newly constructed nursing building during an epidemic of type A influenza.SETTING:A four‐building, long‐term care facility for veterans and their spouses, with an average daily census of 690.DESIGN:Prospective surveillance with retrospective analysis.PARTICIPANTS:Symptomatic residents submitting to viral culture.MEASUREMENTS:Number of respiratory illnesses and influenza cultures in consenting symptomatic residents. Building characteristicsRESULTS:An influenza A (H3N2) outbreak was culture‐confirmed in 68 nursing home residents. Influenza A was isolated in 3/184 (2%) residents in Building A, 31/196 (16%) in Building B, 18/194 (9%) in Building C, and 16/116 (14%) in Building D. Denominators are average daily census during the outbreak. Building A had significantly fewer culture‐confirmed cases than the other buildings (P<.001). Fewer residents in Building A, 47% compared with 61% in Buildings B, C, and D, were participants in a formal study of influenza. Eight of 15 respiratory illnesses identified during the outbreak that were not cultured occurred in Building A. These factors could not account for the difference in attack rates. Building A has a unique ventilation system, more square feet of public space per resident, and does not contain office space that serves the entire four‐building facility.CONCLUSION:Our retrospective observation suggests that architectural design may influence the attack rate of influenza A in nursing homes.J Am Geriatr Soc 44:910

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01859.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To assess the utility of geriatric targeting criteria in predicting survival and health care utilization in a cohort of hospitalized older veterans.DESIGN:A prospective cohort study assessing geriatric targeting criteria, e.g., polypharmacy, falls, or confusion, with respect to adverse outcomes at 12 months.SETTINGA Tertiary Care VA Medical Center.PATIENTS:507 acutely hospitalized male veterans aged 65 years or more.MAIN OUTCOME MEASURES:Survival status, nursing home placement, and total hospital days during 12 months following hospital admission.RESULTS:Patients who had a higher number of targeting criteria at admission showed a significantly increasing trend toward death (P≤ .001), nursing home placement (P≤ .01), and longer hospital stays (P≤ .01) at 12 months. In univariate analyses, weight loss (relative hazard 3.8, 95% CI 2.4, 5.9), appetite loss (relative hazard 3.3, 95% CI 1.9, 5.8), depression (relative hazard 2.5, 95% CI 1.4, 4.5), falls (relative hazard 2.2, 95% CI 1.2, 4.1), confusion (relative hazard 2.2, 95% CI 1.2, 4.0), and socioeconomic problems (relative hazard 1.6, 95% CI 1.0, 2.5) predicted death. Polypharmacy (OR 3.4, 95% CI 1.3, 8.8), confusion (OR 4.4, 95% CI 1.5, 13.0), and prolonged bedrest (OR 7.6, 95% CI 1.5, 39.3) predicted nursing home placement. Confusion (Beta 12.0, 95% CI 2.9, 21.3), falls (Beta 14.2, 95% CI 4.2, 24.3), and prolonged bedrest (Beta 22.4, 95% CI 3.9, 41.0) predicted total hospital days. In multivariate analyses, weight loss, depression, and socioeconomic problems predicted death; confusion and polypharmacy predicted nursing home placements; and falls predicted total hospital days.CONCLUSION:This prospective cohort study of hospitalized older veterans demonstrated geriatric targeting criteria as predictors of adverse hospital outcomes. Our findings suggest screening acutely hospitalized patients using chart abstracted geriatric targeting criteria is useful in identifying patients at risk for adverse outcomes of hospitalization. J Am Geriatr Soc 44:914–92

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01860.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To determine rates of and explore factors associated with mammography use among older women.DESIGN:Retrospective review of part B (physician) bills submitted to Medicare during 1990.SETTING:Health Care Financing Administration (HCFA) data, including sociodemographic information and part B physician bills for all services delivered to Medicare‐eligible women in 1990.PATIENTS/PARTICIPANTS:Women age 65 or older as of January 1, 1990, residing in one of 10 states with part B coverage through December 31, 1990.MEASUREMENTS AND MAIN RESULTS:The outcome was receipt of a mammogram (yes/no). We explored factors associated with mammography use within three age groups: 65 to 74, 75 to 84, and 85 +. The factors considered were race, state, median income of ZIP Code of residence (from the 1990 US Census, and used to divide the population into quintiles within each state), and number of primary care visits (0, 1, 2, and 3+). Overall, 15% of women had a mammogram: 20% of women age 65 to 74, 12% of women age 75 to 84, and 4% of women age 85 and older. Mammography use was lowest in Oklahoma and highest in Washington. However, in each state the older the age category, the less the mammography use (e.g., 9% vs 5% vs 2% in Oklahoma and 25% vs 16% vs 5% in Washington for women 65–74, 75–84, and 85+, respectively). Mammography use was lower for black than for white women age 65 to 74 (14% vs 21%,P<.001) and 75 to 84 (9% vs 12%,P<.001). Women in each of these two age groups had lower mammography use if they resided in the lowest income quintile and highest if they resided in the highest income quintile (17% vs 23% 65–74, and 10% vs 13% 75–84,Pvalues<.001). Among the oldest women (those 85+), mammography use was low (4%) and varied minimally by race and income (P= .907 and .003, respectively). In all age groups, mammography use was lowest among women who did not have a primary care visit, was greater among women who had at least one visit, and continued to rise with increasing numbers of visits (allPvalues<.001). For example, among women age 75 to 84, mammography use increased from 5% to 10%, 14%, and 17% for those with 0, 1, 2, and 3+ visits.CONCLUSIONS:We found that mammography use was less for women who were older, of black race, who did not visit a primary care provider, and who lived in areas with lower median income and certain geographic locations (states). Similar factors influenced mammography use in women age 65 to 74, where there is greater consensus as to who should receive a mammogram, and women age 75 to 84, where there is neither consensus nor data. Surprisingly, neither race nor income had much influence on mammography use among women age 85 or older. J Am Geriatr Soc 44:922

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01861.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVES:To describe patients with bacteremic urinary tract infections, compare characteristics of young and older patients, and suggest appropriate empiric antibiotic therapy for this clinical condition.DESIGN:Case series, with an observation period of 3 years.SETTING:A large southeastern community hospital.PARTICIPANTS:One hundred eighty patients more than 18 years old (101 older than age 65) with urine and blood cultures simultaneously positive for bacterial organisms.MEASUREMENTS:Chart review‐determined demographic characteristics, clinical data, bacterial organism and antibiotic susceptibility, number of medical diagnoses, use of a urinary catheter, admission source, and mortality.RESULTS:The 180 patients experienced bacteremias caused by 183 bacterial organisms. Sixty‐one patients were aged 65 to 79 years, and 40 were 80 years of age or older; 63.9% of patients were female; 62.2% were black. Gram‐negative organisms accounted for 80.3% of bacterial isolates, withEscherichia coliaccounting for 54.1% of cases. Gram‐positive organisms accounted for 19.7% of isolates, includingStaphylococcus aureus(13.1%) andEnterococcus(5.5%). Older patients had a distribution of Gram‐positive and Gram‐negative organisms similar to that of younger patients. Men and patients with chronic urinary catheters had higher proportions of Gram‐positive organisms and non‐E. coliGram‐negative rods. Organisms showed excellent susceptibilities to commonly used antibiotics. In‐hospital mortality was 16.1%, with higher mortality in patients with chronic urinary catheters, in patients who were admitted from nursing homes, and when a Gram‐positive organism was identified. Advanced age was not associated with higher mortality.CONCLUSIONS:Concomitant illness and especially the use of urethral catheters, but not advanced age itself, are associated with a higher mortality from bacteremic urinary tract infection. Single agent empiric antimicrobial therapy such as ceftriaxone may be appropriate in older patients with presumed urosepsis, except in catheterized patients or those with other risk factors for Gram‐positive or resistant Gram‐negative infections. J Am Ger

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01862.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVES:There is an ongoing debate about the proper management of localized prostate cancer in older men. We assessed whether older patients differ in their willingness to accept surgery versus expectant management for a hypothetical early stage, low grade, clinically localized prostate carcinoma, and whether patients' current levels or past history of urologic dysfunction (difficulties initiating urination, failing to empty the bladder, urinary dribbling, getting up at night to urinate, and frequency of sexual activity) influence their decisions. We assessed patients' willingness to choose surgery over expectant management by varying the expected survival benefit in years (ESBs‐em) of surgery over expectant management.DESIGN:Structured interviews with a consecutive series of male patients.SETTING:A university‐based Department of Veterans Affairs Medical Center.PATIENTS:One hundred forty‐eight patients seen consecutively in General Medicine Clinic at the Department of Veterans Affairs Medical Center in Portland, Oregon, were enrolled in the study. Mean age of the patients was 66.3 years (SD = 10.3, range = 30–85); mean level of formal education was 12.6 years (SD = 2.7, range = 6–22).MEASUREMENTS:Patients were asked whether they would accept surgery or expectant management in one of 11 treatment comparisons. We varied the ESBs‐emin 1‐year increments from 0 years to 10 years. As described to patients, surgery carried a mortality risk at the time of treatment of 1 to 2%. Once any patient indicated a willingness to accept surgery at any of the treatment comparisons or if any patient reported preferring expectant management across all treatment comparisons, the elicitation procedure was stopped. All patients were asked to complete a urological and sexual functioning questionnaire to determine the presence of coexisting urological dysfunction and level of sexual activity both at present and in the past.RESULTS:Of the 148 patients enrolled in the study, 43.2% (64/148) preferred surgery with a zero expected life benefit over expectant management (ESBs‐em= 0) and a 1 to 2% chance of dying within 1 month of surgery; 24.3% (36/148) rejected surgery as the expected life benefit of surgery was increased (0

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01863.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To assess the relationship between ethnicity and Health Care wishes, including Advance Directives, in a group of frail older persons in PACE (Program For All Inclusive Care Of The Elderly).DESIGN:Retrospective chart review of 1193 participants in the PACE program.SETTING:Program of All Inclusive Care Of The Elderly (PACE), a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation.PARTICIPANTS:A total of 1193 older adults, all of whom met state criteria for nursing home level of care. There were 385 non‐Hispanic whites, 364 blacks, 156 Hispanics, and 288 Asians.MEASUREMENTS:Presence or absence of advance directives, type of health care wishes selected including living will, durable power of attorney, and health care proxy.RESULTS:Frail older white, black, Hispanic and Asian Americans differ significantly in their health care wishes and how they choose to express them. Blacks were significantly more likely to select aggressive interventions and less likely than non‐Hispanic whites and Hispanics to utilize a written instrument for expressing health care wishes. Whites were significantly more likely to utilize written documents for advance directives, whereas Asians were more likely to select less aggressive interventions but were unlikely to use written advance directives.CONCLUSIONS:In this population, we found significant ethnic variations in choice of health care wishes. Although health care wishes are an individual decision, an awareness of cross cultural patterns can assist practitioners in addressing the concerns of their patients, as well as assisting Health Care Policy Development. J Am Geriatr Soc 44:938–943,

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01864.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE:To investigate the frequency, nature, and side effects of drug‐drug interactions (DDI) in a group of geriatric inpatients.DESIGN:Study of drugs administered at home in the 2 weeks preceding hospitalization.SETTING:Evaluation of patients admitted to a geriatric unit from the emergency unit.PATIENTS:One thousand inpatients more than 70 years of age (83.0 $pL 7.1 years), admitted consecutively to a hospital for acute illness.MEASUREMENTS:All possible two by two combinations of drugs administered at home were considered to determine whether these associations could lead to a DDI and whether side effects resulted from these interactions.RESULTS:Five hundred thirty‐eight patients were exposed to 1087 DDI. The most frequently involved drugs were cardiovascular and psychotropic medications. There were 189 side effects observed in 130 patients. The most frequent side effects were neuropsychological impairment, arterial hypotension, and acute renal failure. The number of side effects did not differ between the 66 contraindicated drug associations and the 1021 associations that only required precautionary use.CONCLUSIONS:DDI frequently lead to side effects in older adults. Classifications of DDI must be adapted to increased DDI sensitivity in this population. Nevertheless the frequency of side effects might be reduced by limiting the prescription of the most frequent and dangerous DDI. J Am Geriatr Soc 44:944–948,

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01865.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

OBJECTIVE: To study free‐ and protein‐bound cobalamin absorption and the correlation with atrophic gastritis in healthy middle‐aged and older subjects.DESIGN: A cross‐sectional study.PARTICIPANTS: Fifty‐two healthy subjects, aged 26 to 87 years, apparently free from conditions known to influence the cobalamin status. Middle‐aged subjects were defined as those younger than 65 years of age (median age 57 years) and older subjects as those 65 years and older (median age 75 years).MEASUREMENTS: Protein‐bound cobalamin absorption was assessed by 48‐hour urinary excretion method following oral administration of scrambled egg yolk, labeled in vivo with57Co‐cobalamin by injecting a hen with57Co‐cyanocobalamin. The percentage of57Co‐cobalamin bound to protein was 65%. Free cobalamin absorption was assessed by 48‐hour urinary excretion method following oral administration of crystalline57Co‐cyanocobalamin. Plasma cobalamin, folate and fasting plasma gastrin, and pepsinogen A and C concentrations were determined.RESULTS: The median urinary excretion of egg yolk57Co‐cobalamin in middle‐aged subjects was 12.3% (25th and 75th percentiles 10.5%‐14.5%) compared with 11.7% (25th and 75th percentiles 9.8%‐13.6%) in older subjects (P= .283). The median urinary excretion after administration of free57Co‐cobalamin in middle‐aged subjects was 25.7% (25th and 75th percentiles 20.6%‐30.7%) compared with 27.9% (25th and 75th percentiles 21.4%‐34.5%) in older subjects (P= .694). Neither egg yolk nor free57Co‐cobalamin excretion correlated with age.A ratio of pepsinogen A to pepsinogen C less than 1.6, indicating atrophic gastritis, was found in 13 subjects. Within the atrophic gastritis group, 11 subjects had a pepsinogen A concentration greater than or equal to 17 μg/L, indicating mild to moderate atrophic gastritis, and two subjects had a pepsinogen A concentration less than 17 μg/L, indicating severe atrophic gastritis or gastric atrophy. All subjects had normal fasting plasma gastrin concentrations. Free and egg yolk57Co‐cobalamin excretions were not reduced in the atrophic gastritis group when compared with the non‐atrophic gastritis group.Median plasma cobalamin concentration was not significantly lower in older subjects (P= .205). Nonetheless, plasma cobalamin concentration correlated negatively with age (r= ‐.36;P= .008).CONCLUSIONS: We demonstrated no significant difference in either free or protein‐bound cobalamin absorption between healthy middle‐aged and older adults. In addition, no alteration in cobalamin absorption was found in subjects identified as having mild to moderate atrophic gastritis. Therefore, based on our results, the high prevalence of low cobalamin levels in older people cannot be explained by either the aging process or mild to moderat

ISSN:0002-8614    

DOI:10.1111/j.1532-5415.1996.tb01866.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY