Journal of American Geriatrics Society

doi: 10.1111/j.1532-5415.1991.tb02725.xpmid: N/A

doi: 10.1111/j.1532-5415.1991.tb02723.xpmid: N/A

Harris, Tamara B.; Makuc, Diane M.; Kleinman, Joel C.; Gillum, Richard F.; Curb, J. David; Schatzkin, Arthur; Feldman, Jacob J.

doi: 10.1111/j.1532-5415.1991.tb02695.xpmid: 2071804

Although coronary heart disease remains a leading cause of death and disability in old age, the relationship of serum cholesterol level to risk of coronary heart disease in old age is controversial. Data for 2,388 white persons aged 65–74 who participated in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow‐up Study (NHEFS) were examined to determine the relationship of serum cholesterol level to coronary heart disease incidence and whether activity level would modify this relationship. While there was no overall relationship between serum cholesterol level and coronary heart disease risk in either men or women, the relationship between serum cholesterol level and coronary heart disease differed within activity groups. For persons who were more active, serum cholesterol level was associated with a graded increase in risk of coronary heart disease, from 1.3 (95% CI 0.7,2.3) in those with serum cholesterol level of 4.7–5.1 to 1.7 in those with serum cholesterol level of 6.2 mmol/L or more (95% CI 1.0,2.7), when compared with those with serum cholesterol level below 4.7. For the least active persons, all levels of cholesterol were associated with a significant inverse relative risk, including cholesterol of 6.2 mmol/L or more (Relative risk = 0.4 (95% CI 0.2,0.7)). These data suggest that factors such as activity level may modify the serum cholesterol‐coronary heart disease association in old age. The serum cholesterol‐coronary heart disease association in more active older persons resembles that seen in younger populations, whereas the association in less active persons is that of serum cholesterol level and risk of cancer or death. The modification of the serum cholesterol‐coronary heart disease association by activity level may have implications for appropriate clinical management as well as appropriate design of research studies of this association.

Heeren, Thea J.; Lagaay, Anne M.; Hijmans, Willy; Rooymans, Harry G. M.

doi: 10.1111/j.1532-5415.1991.tb02696.xpmid: 2071805

Objective To estimate the prevalence rate of dementia in subjects 85 years of age and over. Design A two‐phase design with the Mini‐Mental State Examination (MMSE) in the screening phase and the Geriatric Mental State Schedule (GMS) in the diagnostic phase. Setting Community survey including subjects in residential care. Subjects All (n = 1,259) inhabitants of Leiden, The Netherlands, aged 85 years and over on December 1, 1986. First phase participation rate was 71% (17% drop‐out due to death); second phase participation rate was 82%. Main Outcome Measure DSM‐III diagnosis of dementia without further specification of the etiology of the dementia. Results An overall prevalence rate of 23% (95% C.I.: 19%–26%) was found. This included 12% mild dementia, 7% moderate and 4% severe dementia. The prevalence rate was higher among women (24%) than among men (18%). It increased with age from 19% (95% C.I.: 16%–22%) in the group of 85–89 years to 32% (95% C.I.: 26%–39%) in the group of 90–94 years to 41% (95% C.I.: 25%–58%) in the 95+ group. Conclusion A fifth of the 85+ and a third of the 90+ population suffer from dementia with an indication that half of the 95+ population is affected. With the expected steep rise in the number of the oldest old, dementia will stay a major health problem in the near future.

Gustafson, Yngve; Brännström, Benny; Norberg, Astrid; Bucht, Gustav; Winblad, Bengt

doi: 10.1111/j.1532-5415.1991.tb02697.xpmid: 2071806

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

Stanley, Holly L.; Schmitt, Brian P.; Poses, Roy M.; Deiss, William P.

doi: 10.1111/j.1532-5415.1991.tb02698.xpmid: 2071807

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

Hanson, Laura C.; Danis, Marion

doi: 10.1111/j.1532-5415.1991.tb02699.xpmid: 2071808

Advanced age has been proposed as one criterion for limiting the use of life‐sustaining medical treatment, but very little is known about current practices. We retrospectively studied utilization rates of intensive care (IC) and cardiopulmonary resuscitation (CPR) in admissions to a university hospital over 1 year (n = 9,998), to test whether these treatments are used more selectively for elderly patients. Overall utilization rates did not vary by age. However, among 524 terminal admissions, IC was used for 63% of patients age 35–74 but for only 50% of patients 75 and older (P < 0.01). Among elderly patients, nursing home residence, diagnosis of advanced malignancy, severe chronic illness, and older age were independent predictors of withholding IC prior to death. Despite more selective use, survival rates were lower for elderly than for younger patients receiving IC (88% vs 78%, P < 0.001). CPR showed similar but non‐significant trends. Intensive care is being used less frequently prior to death for elderly patients, based on diagnosis and functional status as well as chronologic age.

Winograd, Carol Hutner; Gerety, Meghan B.; Chung, Maria; Goldstein, Mary K.; Dominguez, Frank; Vallone, Robert

doi: 10.1111/j.1532-5415.1991.tb02700.xpmid: 1906492

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