Journal of American Geriatrics Society

French, L. Ronald; Goetz, Frederick C.; Martinez, Anita M.; Boen, James R.; Bushhouse, Sally A.; Sprafka, J. Michael

doi: 10.1111/j.1532-5415.1992.tb02127.xpmid: 1556356

Objective To assess age‐related changes in stimulated plasma C‐peptide in a population‐based sample of adults. Design Cross‐sectional study. Setting Wadena, Minnesota, a city of 4,699 residents (1980 census) in west central Minnesota, approximately 150 miles from Minneapolis/St. Paul. Study Subjects 344 non‐diabetic subjects (NDDG standards) from a stratified random sample of the total adult population of Wadena, MN. The six‐study strata were men and women from three age groups: young, 20–39 years of age; middle‐aged, 40–59; and older, >60 years of age. Measurements During a liquid meal of Ensure‐Plus (Ensure‐Plus® challenge test; EPCT; Ross Laboratories), blood samples were taken for glucose, free fatty acids, creatinine, and C‐peptide. Plasma C‐peptide taken 90 minutes after the EPCT was used as a surrogate measure for insulin. Clinical tests included one‐time samples for hemoglobin, glycosylated hemoglobin, plasma cholesterol, triglycerides, and lipoproteins. Physical measurements included height, weight, and blood pressure. Urine was assayed for C‐peptide and creatinine. Assays of urine and plasma C‐peptide used antibody M1221 (from Novo; Copenhagen, Denmark). Main Results No differences were observed for the relationship between age and C‐peptide within each of the three age groups for men and the three age groups for women. However, the levels of plasma C‐peptide for older men or women were statistically significantly higher than levels for the young age groups of the same sex; fasting plasma glucose also was higher for older groups of both sexes, and postmeal glucose was significantly higher for older women. There were decreases with age in urine C‐peptide clearance for women and men; the decline for women was statistically significant. In multiple regression models for men alone and women alone, that controlled for age, post‐meal plasma glucose best explained plasma C‐peptide levels. For young men, plasma glucose alone provided the best prediction of plasma C‐peptide levels; body mass index (BMI) and plasma glucose provided the best prediction for young women. For older men and both middle‐aged and older women, a combination of urine C‐peptide clearance and plasma glucose best predicted plasma C‐peptide levels; for middle‐aged men, BMI also contributed to the prediction. Conclusions Secretion of insulin in response to an orally administered mixed meal is undiminished with age in non‐diabetic adults.

Johnson, J. C.; Kerse, N. M.; Gottlieb, G.; Wanich, C.; Sullivan, E.; Chen, K.

doi: 10.1111/j.1532-5415.1992.tb02128.xpmid: 1556357

Objective To determine if DSM‐III criteria or clinical or discharge diagnoses, reviewed retrospectively, are as accurate an indicator of the presence of delirium as prospective evaluation by a psychiatrist. Design Selection of delirious patients prospectively by a psychiatrist, followed by retrospective record review of the same patients. Setting A referral‐basesd university hospital. Patients From a sample of 235 consecutive medical patients over age 70, 47 delirious patients were identified prospectively by a research psychiatrist using DSM‐III criteria. The medical record of these delirious patients was reviewed after discharge for evidence of delirium. Results Four patients were assigned ICD‐9 codes suggestive of delirium (sensitivity 0.09). Review of physicians' diagnoses correctly identified 8 of 47 (sensitivity 0.17) patients as being delirious or acutely confused. The specific diagnostic criteria necessary to meet a DSM‐III diagnosis of delirium could be ascertained from 10 of 47 records (sensitivity 0.21). Conclusion The retrospective medical record review is very imprecise in establishing the diagnosis of delirium. As research in this field moves from descriptive epidemiology to studies of pathogenesis and treatment, prospective designs will be needed.

Lyness, Jeffrey M.; Conwell, Yeates; Nelson, J. Craig

doi: 10.1111/j.1532-5415.1992.tb02129.xpmid: 1556358

Objective To describe the psychopathological characteristics of elderly suicide attempters admitted to an inpatient psychiatric unit. Design Retrospective chart review. Patients All 168 patients age 60 years and over treated on the adult psychiatric inpatient unit of Yale‐New Haven Hospital from 1979 to 1984. Twenty‐five made a suicide attempt. Main Outcome Measures Presence and severity of suicide attempts were rated and compared with demographic, clinical, and functional data. Results (1) Eighty percent of the attempters had a major depressive syndrome; (2) among patients with affective disorders, presence of an attempt was significantly associated with a later age of onset; (3) patients who had made more severe attempts were more likely to be diagnosed as psychotic depression, although this trend was not significant; (4) substance abuse and dementia were uncommon diagnoses; (5) symptomatic and functional outcome of hospitalization was as favorable for the attempters as for the entire elderly cohort. Conclusions Affective illness, especially late‐onset major depression, was the major association with suicide attempts.

Osterweil, Dan; Syndulko, Karl; Cohen, Stanley N.; Pettier‐Jennings, Penny D.; Hershman, Jerome M.; Cummings, Jeffrey L.; Tourtellotte, Wallace W.; Solomon, David H.

doi: 10.1111/j.1532-5415.1992.tb02130.xpmid: 1556359

Purpose (1) to evaluate objectively changes in cognitive function and electrophysiologic characteristics associated with hypothyroidism of varying severity and duration in primarily older persons; (2) to determine whether these changes are reversible when a euthyroid state has been attained after treatment with thyroid hormone. Subjects and Methods We enrolled 54 non‐demented hypothyroid patients (31–99, mean 68.6 ± 16.4 years) with biochemical evidence of hypothyroidism (38 had overt and 14 had minimal hypothyroidism) and 30 euthyroid controls (31–96, mean 63.7 ± 18.4 years) screened for good general health. We evaluated attention, orientation, memory, learning, visual‐spatial abilities, calculation, language, visual scanning, and motor speed using standardized neuropsychological tests. Electrophysiological measures of neurocognitive function included the P300 latency component of the auditory Event‐Related Potentials (ERP) and conduction speed from eye to cortex, the P100 latency component of the Patterned Visual‐Evoked Potential (PVEP). All patients were studied when hypothyroid. A subset of patients with minimal initial test abnormalities were available to be retested when euthyroid, 5 and 9 months after onset of thyroid replacement therapy. Results Hypothyroid patients showed significantly lower scores on the Mini‐Mental Status Test (MMS) and on five of 14 neuropsychological tests as compared to controls. The neuropsychological tests affected were copying a cube (visual‐spatial function), the Inglis Paired Associates Learning Test‐Low and Medium association items (memory and learning), Animal Naming (word fluency/production), and the Trail Making A test (attention, visual scanning and psychomotor function. Hypothyroidism also was associated with longer P100 latencies of PVEPs to 20‘ checks, but showed no significant differences in PVEP P100 latency to 50‘ checks, nor in the latency of the auditory ERP component P300. There was a statistically significant correlation between a laboratory index of the severity of hypothyroidism (serum T4) and the Inglis Medium Association items and Animal Naming. There was a statistically significant improvement after 5 months of treatment on three of the timed performance tests that previous studies have shown to be most sensitive to brain dysfunction. Conclusion Hypothyroidism in non‐demented older adults is associated with impairments in learning, word fluency, visual‐spatial abilities, and some aspect of attention, visual scanning, and motor speed. The MMS by itself was sensitive in differentiating hypothyroid patients with cognitive deficits from controls, while electrophysiological measures did not generally differentiate the hypothyroid patients from normal controls. The MMS was not sensitive to treatment effects, but treatment was associated with significant improvements in three of the most sensitive measures of cognitive dysfunction.

Mayer‐Oakes, S. Allison; Hoenig, Helen; Atchison, Kathryn A.; Lubben, James E.; De Jong, Fred; Schweitzer, Stuart O.

doi: 10.1111/j.1532-5415.1992.tb02131.xpmid: 1556360

Objective To determine patient factors that predict use of physical or occupational therapy (PT/OT) services by elderly people. Design Time‐series study of the relationship of PT/OT use to a variety of characteristics present at baseline. Participants Eight‐hundred nine community‐dwelling men and women aged 65 and older. Setting The Medicare Screening and Health Promotion Trial at UCLA. Main Outcome Measures Use of PT/OT services, as reported in a telephone survey 1 year after initial information was obtained on the same subjects by the baseline telephonic survey. Results Fifteen percent of the sample used PT/OT within 12 months of baseline. In multiple logistic regression analysis, PT/OT use was significantly less frequent among racial minorities, less well educated groups, and the oldest age group. PT/OT use was higher among those who had both functional disability and the presence of arthritis, heart or lung disease, or a prior history of stroke. However, neither functional disability alone nor the presence of arthritis, cardiovascular or lung disease, in the absence of limited functioning, was associated with PT/OT use. Patients who had obtained a pneumococcal vaccination or used transportation services were also more likely to receive PT/OT. Conclusions Our findings suggest that there may be important sociodemographic inequalities in the use of rehabilitation services and raise the possibility of inappropriate underuse in certain subgroups. Additional studies are needed to determine whether similar inequalities of PT/OT use are found in other populations and whether rehabilitation is effective in various subgroups.

McMurtry, Cynthia T.; Young, Shari E.; Downs, Robert W.; Adler, Robert A.

doi: 10.1111/j.1532-5415.1992.tb02132.xpmid: 1556361

Objective To compare the vitamin D metabolite and nutritional status of institutionalized elderly males with a non‐institutionalized control group. Design Case‐control study. Setting Veterans Administration Medical Center Nursing Home (NH) in Richmond, Virginia. Patients Fifty‐seven consecutive nursing home subjects were screened. After excluding blacks, those receiving anticonvulsants, glucocorticoids, or vitamin supplements, and those with liver or renal failure (creatinine > 1.5 mg/dL), 35 subjects were enrolled, and 22 completed the study. The noninstitutionalized control group (n = 18) consisted of consecutive volunteers, meeting the above criteria, from either a senior citizen group or a geriatric clinic. Measurements and Main Results The serum 25‐hydroxyvitamin D level in the NH residents was significantly lower than in community dwellers (17.4 ± 5.2 ng/mL vs 31.2 pg/mL ± 8.0 ng/mL, P < 0.0001). No significant difference was demonstrated in 1,25‐dihydroxyvitamin D levels (36.5 pg/mL ± 10.5 in NH residents vs 42.0 pg/mL ± 11.1 in controls). In the NH group PTH levels were inversely correlated with 25 OHD levels (P < 0.008) and positively correlated with length of stay in the NH (P < 0.016). There was no significant seasonal variation in vitamin D metabolite levels in the NH group. In the NH patients, the mean dietary intake of vitamin D was 232 ± 378 mg/day and of calories was 1811 ± 447 kcal/day. Conclusion Despite apparently adequate calories, calcium, and vitamin D intake, hypovitaminosis D with compensatory PTH elevations occurs, regardless of season, in the nursing home population.

Guzik, Howard J.; Ooi, Wee Lock; Frishman, William H.; Greenberg, Steven; Aronson, Miriam K.

doi: 10.1111/j.1532-5415.1992.tb02133.xpmid: 1556362

Objective To examine the prevalence and cardiovascular implications of hypertension in advanced age. Design Prospective non‐interventional study of a fixed cohort of very elderly subjects. Participants and Setting The subjects were 488 community‐dwelling volunteers. Mean age at entry was 79 years (range 75–85). All subjects were ambulatory, non‐demented, and free of terminal illness at baseline. Participants were evaluated at the gerontology department of an urban medical school. Main Outcome Measures Cardiovascular morbid and mortal events that were followed included fatal and non‐fatal myocardial infarction, fatal and non‐fatal stroke, and death. Prevalence of unrecognized myocardial infarction defined by electrocardiographic changes was also assessed. Results When hypertension was defined by history, current use of medications, or measured elevations in blood pressure, 78% of the subjects could be considered hypertensive. Univariate analysis showed an increased incidence of strokes in subjects with measured hypertension (P = 0.04). Subjects with elevated blood pressure (untreated) were more likely to develop clinically unrecognized myocardial infarction (P = 0.017). Multivariate survival analysis showed hypertension to be a modest predictor of overall cardiovascular disease (P = 0.067) but not of all‐cause mortality. Left ventricular hypertrophy was a predictor of cardiovascular disease (P = 0.013) and all‐cause mortality (P = 0.008). Age remained a significant risk factor for these endpoints, even in the very old. Isolated systolic hypertension was analyzed separately and in univariate analysis was a risk factor for stroke but not other cardiovascular morbidity. Conclusions Hypertension at advanced age remains a modestly important risk factor in the development of cardiovascular disease.

LaPalio, Lawrence; Schork, Anthony; Glasser, Stephen; Tifft, Charles

doi: 10.1111/j.1532-5415.1992.tb02134.xpmid: 1556363

Objective To assess the short‐term efficacy and safety of metoprolol in the treatment of hypertension in a large population of older patients. Design Prospective, open‐label surveillance study. Setting Multicenter outpatient offices. Participants 21,692 patients with mild‐to‐moderate hypertension between the ages of 50 to 75 years. Patients were excluded if they had a contraindication to beta‐blocker therapy. Intervention Patients were treated with 100 mg of metoprolol once daily for 4 weeks. If the blood pressure was controlled, therapy was continued for an additional 4 weeks. If adequate blood pressure was not achieved after 4 weeks, 25 mg of hydrochlorothiazide was added. At the end of 8 weeks, final therapy decisions were recorded. If the blood pressure was controlled, therapy was continued for an additional 4 weeks. Main Outcome Measures Blood pressure, heart rate and side‐effects. Results After 4 weeks of therapy, mean systolic and diastolic blood pressures decreased significantly from 162/95 to 148/87 mm Hg (P < 0.001). Fifty‐eight percent of the patients had satisfactory blood pressure control. At the end of 8 weeks, mean systolic and diastolic blood pressure decreased to 143/84 mm Hg. Blood pressure response was similar in all age groups. At the termination of the study, 50% of the patients were continued on monotherapy, and 27% were continued on combined therapy. Overall, there was less than a 5% incidence of medical problems, and excellent or good tolerability was noted for 94% of the patients. Conclusions Metoprolol administered as monotherapy or in combination with hydrochlorothiazide was effective in normalizing blood pressure in a majority of elderly hypertensive patients. Both drug regimens were well tolerated.

Gurwitz, Jerry H.; Noonan, James P.; Soumerai, Stephen B.

doi: 10.1111/j.1532-5415.1992.tb02135.xpmid: 1348256

Objectives To examine the patterns of H2 blocker use in the long‐term‐care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns. Design Time‐series quasi‐experimental study and retrospective chart review. Setting A large academically‐oriented long‐term‐care facility. Patients Institutionalized elderly patients with a mean age of 88 years receiving H2 blocker therapy. Interventions Two interventions involving group discussions with the medical staff, supporting educational materials, and physician‐specific listings of patients receiving H2 blockers were employed sequentially over a 32‐month period. Results Each intervention resulted in substantial reductions in medication use (59.6% and 32.1%, respectively). Indications for H2 blocker use were determined retrospectively for patients identified as receiving therapy prior to the interventions (n = 110). Forty‐one percent were found to be receiving therapy for reasons unsubstantiated by the medical literature. These patients were more likely to be discontinued from therapy than those receiving therapy for substantiated indications (P < 0.01), consistent with the primary focus of the educational interventions. Conclusions These results suggest that the excessive use of H2 blocker therapy in the long‐term care setting responds to educational interventions with therapeutically appropriate reductions in utilization. Repeated interventions are necessary to maintain such reductions over time although there may be some reduction in the effectiveness of the intervention with repetition.

Berthélemy, Philippe; Bouisson, Michèle; Vellas, Bruno; Moreau, Jacques; Nicole‐Vaysse, Jacques; Albarede, Jean Louis; Ribet, André

doi: 10.1111/j.1532-5415.1992.tb02136.xpmid: 1372922

Objective Malnutrition is currently observed in aged people, and cholecystokinin is an important peripheral satiety signal. The aim of this study was to examine the effect of aging and protein‐energy malnutrition on postprandial cholecystokinin (CCK) release. Design Non‐randomized, cross‐sectional comparison by age group. Setting Gastroenterology section of a teaching hospital. Participants Twenty‐one human volunteers divided into three groups: young healthy subjects (Group 1: mean 29 years, n = 7), aged healthy subjects (Group 2, mean 80 years, n = 7), and aged subjects with an important degree of malnutrition (Group 3, mean 84.6 years, n = 7). Intervention Each subject ingested a standardized liquid meal after an overnight fast. Main Outcome Measures Plasma cholecystokinin was measured using a sensitive bioassay before and after the ingestion of the liquid meal. Results Basal cholecystokinin levels were similar (0.9 to 1 pm equivalent CCK‐8) in the three groups. Postprandial levels were significantly increased over basal (P < 0.05). The maximal cholecystokinin value was lower in Group 1 (3.5 ± 0.8 pm equivalent CCK‐8) and Group 2 (3.3 ± 0.77 pm equivalent CCK‐8) than in Group 3 (8.3 ± 2 pm equivalent CCK‐8) (P < 0.05). Integrated plasma cholecystokinin was also similar in Group 1 (171 ± 38 pm · 60 min), (P < 0.05). Conclusion The increase of postprandial maximal levels of cholecystokinin is more related to malnutrition than to aging.