A global clinical measure of fitness and frailty in elderly people

BACKGROUND

There is no single generally accepted clinical definition of frailty. Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians. We aimed to develop a tool that would be both predictive and easy to use.

METHODS

We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging (CSHA). We followed this cohort prospectively; after 5 years, we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care, and correlated the results with those obtained from other established tools.

RESULTS

The CSHA Clinical Frailty Scale was highly correlated (r = 0.80) with the Frailty Index. Each 1-category increment of our scale significantly increased the medium-term risks of death (21.2% within about 70 mo, 95% confidence interval [CI] 12.5%-30.6%) and entry into an institution (23.9%, 95% CI 8.8%-41.2%) in multivariable models that adjusted for age, sex and education. Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition, function or comorbidity in assessing risk for death (area under the curve 0.77 for 18-month and 0.70 for 70-month mortality).

INTERPRETATION

Frailty is a valid and clinically important construct that is recognizable by physicians. Clinical judgments about frailty can yield useful predictive information.

A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer's disease. The Alzheimer's Disease Cooperative Study

BACKGROUND

There is evidence that medications or vitamins that increase the levels of brain catecholamines and protect against oxidative damage may reduce the neuronal damage and slow the progression of Alzheimer's disease.

METHODS

We conducted a double-blind, placebo-controlled, randomized, multicenter trial in patients with Alzheimer's disease of moderate severity. A total of 341 patients received the selective monoamine oxidase inhibitor selegiline (10 mg a day), alpha-tocopherol (vitamin E, 2000 IU a day), both selegiline and alpha-tocopherol, or placebo for two years. The primary outcome was the time to the occurrence of any of the following: death, institutionalization, loss of the ability to perform basic activities of daily living, or severe dementia (defined as a Clinical Dementia Rating of 3).

RESULTS

Despite random assignment, the baseline score on the Mini-Mental State Examination was higher in the placebo group than in the other three groups, and this variable was highly predictive of the primary outcome (P<0.001). In the unadjusted analyses, there was no statistically significant difference in the outcomes among the four groups. In analyses that included the base-line score on the Mini-Mental State Examination as a covariate, there were significant delays in the time to the primary outcome for the patients treated with selegiline (median time, 655 days; P=0.012), alpha-tocopherol (670 days, P=0.001) or combination therapy (585 days, P=0.049), as compared with the placebo group (440 days).

CONCLUSIONS

In patients with moderately severe impairment from Alzheimer's disease, treatment with selegiline or alpha-tocopherol slows the progression of disease.

Family perspectives on end-of-life care at the last place of care

CONTEXT

Over the past century, nursing homes and hospitals increasingly have become the site of death, yet no national studies have examined the adequacy or quality of end-of-life care in institutional settings compared with deaths at home.

OBJECTIVE

To evaluate the US dying experience at home and in institutional settings.

DESIGN, SETTING, AND PARTICIPANTS

Mortality follow-back survey of family members or other knowledgeable informants representing 1578 decedents, with a 2-stage probability sample used to estimate end-of-life care outcomes for 1.97 million deaths from chronic illness in the United States in 2000. Informants were asked via telephone about the patient's experience at the last place of care at which the patient spent more than 48 hours.

MAIN OUTCOME MEASURES

Patient- and family-centered end-of-life care outcomes, including whether health care workers (1) provided the desired physical comfort and emotional support to the dying person, (2) supported shared decision making, (3) treated the dying person with respect, (4) attended to the emotional needs of the family, and (5) provided coordinated care.

RESULTS

For 1059 of 1578 decedents (67.1%), the last place of care was an institution. Of 519 (32.9%) patients dying at home represented by this sample, 198 (38.2%) did not receive nursing services; 65 (12.5%) had home nursing services, and 256 (49.3%) had home hospice services. About one quarter of all patients with pain or dyspnea did not receive adequate treatment, and one quarter reported concerns with physician communication. More than one third of respondents cared for by a home health agency, nursing home, or hospital reported insufficient emotional support for the patient and/or 1 or more concerns with family emotional support, compared with about one fifth of those receiving home hospice services. Nursing home residents were less likely than those cared for in a hospital or by home hospice services to always have been treated with respect at the end of life (68.2% vs 79.6% and 96.2%, respectively). Family members of patients receiving hospice services were more satisfied with overall quality of care: 70.7% rated care as "excellent" compared with less than 50% of those dying in an institutional setting or with home health services (P<.001).

CONCLUSIONS

Many people dying in institutions have unmet needs for symptom amelioration, physician communication, emotional support, and being treated with respect. Family members of decedents who received care at home with hospice services were more likely to report a favorable dying experience.

Fall risk index for elderly patients based on number of chronic disabilities

The present study was designed to identify prospectively the individual chronic characteristics associated with falling among elderly persons and to test the hypothesis that risk of falling increases as the number of chronic disabilities increases. Seventy-nine consecutive admissions to three intermediate care facilities were evaluated. Twenty-five of the subjects became recurrent fallers. The nine risk factors included in the fall risk index were mobility score, morale score, mental status score, distant vision, hearing, postural blood pressure, results of back examination, postadmission medications, and admission activities of daily living score. A subject's fall risk score was the number of index factors present. The proportions of recurrent fallers increased from 0 percent (0 of 30) in those with 0 to three risk factors, to 31 percent (11 of 35) in those with four to six factors, to 100 percent (14 of 14) in those with seven or more factors. Falling, at least among some elderly persons, appears to result from the accumulated effect of multiple specific disabilities. Some of these disabilities may be remediable. The mobility test, the best single predictor of recurrent falling, may be useful clinically because it is simple, recreates fall situations, and provides a dynamic, integrated assessment of mobility.

A comparison of two approaches to measuring frailty in elderly people

BACKGROUND

Many definitions of frailty exist, but few have been directly compared. We compared the relationship between a definition of frailty based on a specific phenotype with one based on an index of deficit accumulation.

METHODS

The data come from all 2305 people 70 years old and older who composed the clinical examination cohort of the second wave of the Canadian Study of Health and Aging. We tested convergent validity by correlating the measures with each other and with other health status measures, and analyzed cumulative index distributions in relation to phenotype. To test criterion validity, we evaluated survival (institutionalization and all-cause mortality) by frailty index (FI) score, stratified by the phenotypic definitions as "robust," "pre-frail," and "frail."

RESULTS

The measures correlated moderately well with each other (R=0.65) and with measures of function (phenotypic definition R=0.66; FI R=0.73) but less well with cognition (phenotypic definition R=-0.35; FI R=-0.58). The median FI scores increased from 0.12 for the robust to 0.30 for the pre-frail and 0.44 for the frail. Survival was also lower with increasing frailty, and institutionalization was more common, but within each phenotypic class, there were marked differences in outcomes based on the FI values-e.g., among robust people, the median 5-year survival for those with lower FI values was 85%, compared with 55% for those with higher FI values.

CONCLUSION

The phenotypic definition of frailty, which offers ready clinical operationalization, discriminates broad levels of risk. The FI requires additional clinical translation, but allows the risk of adverse outcomes to be defined more precisely.

Patient and caregiver characteristics and nursing home placement in patients with dementia

CONTEXT

The decision to institutionalize a patient with dementia is complex and is based on patient and caregiver characteristics and the sociocultural context of patients and caregivers. Most studies have determined predictors of nursing home placement primarily according to patient or caregiver characteristics alone.

OBJECTIVE

To develop and validate a prognostic model to determine the comprehensive predictors of placement among an ethnically diverse population of patients with dementia.

DESIGN, SETTING, AND PARTICIPANTS

The Medicare Alzheimer's Disease Demonstration and Evaluation study, a prospective study at 8 sites in the United States, with enrollment between December 1989 and December 1994 of 5788 community-living persons with advanced dementia.

MAIN OUTCOME MEASURES

Time to nursing home placement throughout a 36-month follow-up period, assessed by interview and review of Medicare records, and its association with patient and caregiver characteristics, obtained by interview at enrollment.

RESULTS

Patients were divided into a development (n = 3859) and validation (n = 1929) cohort. In the development cohort, the Kaplan-Meier estimates of nursing home placement throughout 1, 2, and 3 years were 22%, 40%, and 52%, respectively. After multivariate adjustment, patient characteristics that were associated with nursing home placement were as follows: black ethnicity (hazard ratio, 0.60; 95% confidence interval [CI], 0.48-0.74), Hispanic ethnicity (HR, 0.40; 95% CI, 0.28-0.56) (both ethnicities were inversely associated with placement), living alone (HR, 1.74; 95% CI, 1.49-2.02), 1 or more dependencies in activities of daily living (HR, 1.38; 95% CI, 1.20-1.60), high cognitive impairment (for Mini-Mental Status Examination score < or =20: HR, 1.52; 95% CI, 1.33-1.73), and 1 or more difficult behaviors (HR, 1.30; 95% CI, 1.11-1.52). Caregiver characteristics associated with patient placement were age 65 to 74 years (HR, 1.17; 95% CI, 1.01-1.37), age 75 years or older (HR, 1.55; 95% CI, 1.31-1.84), and high Zarit Burden Scale score (for highest quartile: HR, 1.73; 95% CI, 1.49-2.00). Patients were assigned to quartiles of risk based on this model. In the development cohort, patients in the first, second, third, and fourth quartile had a 25%, 42%, 64%, and 91% rate of nursing home placement at 3 years, respectively. In the validation cohort, the respective rates were 21%, 50%, 64%, and 89%. The C statistic for 3-year nursing home placement was 0.66 in the development cohort and 0.63 in the validation cohort.

CONCLUSIONS

Patient and caregiver characteristics are both important determinants of long-term care placement for patients with dementia. Interventions directed at delaying placement, such as reduction of caregiver burden or difficult patient behaviors, need to take into account the patient and caregiver as a unit.

Development of a minimum data set-based depression rating scale for use in nursing homes

BACKGROUND

depression is common but under-diagnosed in nursing-home residents. There is a need for a standardized screening instrument which incorporates daily observations of nursing-home staff.

AIM

to develop and validate a screening instrument for depression using items from the Minimum Data Set of the Resident Assessment Instrument.

METHODS

we conducted semi-structured interviews with 108 residents from two nursing homes to obtain depression ratings using the 17-item Hamilton Depression Rating Scale and the Cornell Scale for Depression in Dementia. Nursing staff completed Minimum Data Set assessments. In a randomly assigned derivation sample (n = 81), we identified Minimum Data Set mood items that were correlated (P < 0.05) with Hamilton and Cornell ratings. These items were factored using an oblique rotation to yield five conceptually distinct factors. Using linear regression, each set of factored items was regressed against Hamilton and Cornell ratings to identify a core set of seven Minimum Data Set mood items which comprise the Minimum Data Set Depression Rating Scale. We then tested the performance of the Minimum Data Set Depression Rating Scale against accepted cut-offs and psychiatric diagnoses.

RESULTS

a cutpoint score of 3 on the Minimum Data Set Depression Rating Scale maximized sensitivity (94% for Hamilton, 78% for Cornell) with minimal loss of specificity (72% for Hamilton, 77% for Cornell) when tested against cut-offs for mild to moderate depression in the derivation sample. Results were similar in the validation sample. When tested against diagnoses of major or non-major depression in a subset of 82 subjects, sensitivity was 91% and specificity was 69%. Performance compared favourably with the 15-item Geriatric Depression Scale.

CONCLUSION

items from the Minimum Data Set can be organized to screen for depression in nursing-home residents. Further testing of the instrument is now needed.

Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial

BACKGROUND

Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and psychological symptoms, carers' psychological wellbeing, or delay in institutionalisation. If so, which patients benefit, from what dose, and for how long?

METHODS

565 community-resident patients with mild to moderate Alzheimer's disease entered a 12-week run-in period in which they were randomly allocated donepezil (5 mg/day) or placebo. 486 who completed this period were rerandomised to either donepezil (5 or 10 mg/day) or placebo, with double-blind treatment continuing as long as judged appropriate. Primary endpoints were entry to institutional care and progression of disability, defined by loss of either two of four basic, or six of 11 instrumental, activities on the Bristol activities of daily living scale (BADLS). Outcome assessments were sought for all patients and analysed by logrank and multilevel models.

FINDINGS

Cognition averaged 0.8 MMSE (mini-mental state examination) points better (95% CI 0.5-1.2; p<0.0001) and functionality 1.0 BADLS points better (0.5-1.6; p<0.0001) with donepezil over the first 2 years. No significant benefits were seen with donepezil compared with placebo in institutionalisation (42% vs 44% at 3 years; p=0.4) or progression of disability (58% vs 59% at 3 years; p=0.4). The relative risk of entering institutional care in the donepezil group compared with placebo was 0.97 (95% CI 0.72-1.30; p=0.8); the relative risk of progression of disability or entering institutional care was 0.96 (95% CI 0.74-1.24; p=0.7). Similarly, no significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg and 10 mg donepezil.

INTERPRETATION

Donepezil is not cost effective, with benefits below minimally relevant thresholds. More effective treatments than cholinesterase inhibitors are needed for Alzheimer's disease.

The Confusion Assessment Method: a systematic review of current usage

OBJECTIVES

To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium.

DESIGN

Systematic literature review.

SETTING

Not applicable.

MEASUREMENTS

Electronic searches of PubMED, EMBASE, PsychINFO, CINAHL, Ageline, and Google Scholar, augmented by reviews of reference listings, were conducted to identify original English-language articles using the CAM from January 1, 1991, to December 31, 2006. Two reviewers independently abstracted key information from each article.

PARTICIPANTS

Not applicable.

RESULTS

Of 239 original articles, 10 (4%) were categorized as validation studies, 16 (7%) as adaptations, 12 (5%) as translations, and 222 (93%) as applications. Validation studies evaluated performance of the CAM against a reference standard. Results were combined across seven high-quality studies (N=1,071), demonstrating an overall sensitivity of 94% (95% confidence interval (CI)=91-97%) and specificity of 89% (95% CI=85-94%). The CAM has been adapted for use in the intensive care unit, emergency, and institutional settings and for scoring severity and subsyndromal delirium. The CAM has been translated into 10 languages where published articles are available. In application studies, CAM-rated delirium is most commonly used as a risk factor or outcome but also as an intervention or reference standard.

CONCLUSION

The CAM has helped to improve identification of delirium in clinical and research settings. To optimize performance, the CAM should be scored based on observations made during formal cognitive testing, and training is recommended. Future action is needed to optimize use of the CAM and to improve the recognition and management of delirium.

Helping caregivers of persons with dementia: which interventions work and how large are their effects?

BACKGROUND

In recent years, many different forms of interventions for caregivers of people with dementia have been developed. However, their results have been, in part, inconclusive.

METHODS

Meta-analysis was used to integrate the results of 127 intervention studies with dementia caregivers published or presented between 1982 and 2005.

RESULTS

Interventions had, on average, significant but small effects on burden, depression, subjective well-being, ability/knowledge and symptoms of care recipient. Only multicomponent interventions reduced the risk for institutionalization. Psychoeducational interventions that require active participation of caregivers had the broadest effects. Effects of cognitive-behavioral therapy, support, counseling, daycare, training of care recipient, and multicomponent interventions were domain specific. The effect sizes varied by study characteristics, such as caregiver gender and year of publication.

CONCLUSIONS

Because most interventions have domain-specific outcomes, clinicians must tailor interventions according to the specific needs of the individual caregivers. Although more recent interventions showed stronger effects, there is room for further improvements in interventions.

Psychiatric symptoms and nursing home placement of patients with Alzheimer's disease

Two hundred ten community-dwelling patients with Alzheimer's disease were examined prospectively by psychiatrists as part of a longitudinal study. Twenty-five of these patients who were institutionalized during the next 3 years were then matched to 25 patients who were not institutionalized, and the groups were compared. The patients who had been institutionalized had higher scores on standardized psychiatric rating scales but not on formal neuropsychological tests of cognition. These results suggest that potentially treatable (noncognitive) behavioral and psychiatric symptoms are risk factors for institutionalization, and that treating these symptoms might delay or prevent institutionalization of some patients.

Complications and outcome after acute stroke. Does dysphagia matter?

BACKGROUND AND PURPOSE

The published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination.

METHODS

We prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, lengthy of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures.

RESULTS

Patients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P=.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability (P=.02), length of hospital stay (P<.001), and institutional care (P<.05). When other factors were taken into account, dysphagia remained as an independent predictor of outcome only with regard to mortality. The use of videofluoroscopy in detecting aspiration did not add to the value of bedside assessment.

CONCLUSIONS

Bedside assessment of swallowing is of use in identifying patients at risk of developing complications. The value of routine screening with videofluoroscopy to detect aspiration is questioned.

Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: a randomized, double-blind trial. Risperidone Study Group

BACKGROUND

We report the findings from the first large, double-blind, placebo-controlled study conducted to evaluate the efficacy and safety of risperidone in the treatment of psychotic and behavioral symptoms in institutionalized elderly patients with dementia.

METHOD

625 patients (67.8% women; mean age = 82.7 years) with DSM-IV diagnoses of Alzheimer's disease (73%), vascular dementia (15%), or mixed dementia (12%) and significant psychotic and behavioral symptoms were included. Each patient was randomly assigned to receive placebo or 0.5 mg/day, 1 mg/day, or 2 mg/day of risperidone for 12 weeks. The primary outcome measure was the Behavioral Pathology in Alzheimer's Disease rating scale (BEHAVE-AD).

RESULTS

The study was completed by 70% of the patients. Baseline Functional Assessment Staging scores were 6 or 7 in more than 95% of the patients, indicating severe dementia. At endpoint, significantly greater reductions in BEHAVE-AD total scores and psychosis and aggressiveness subscale scores were seen in patients receiving 1 and 2 mg/day of risperidone than in placebo patients (p = .005 and p < .001, respectively). At week 12, 0.5 mg/day of risperidone was superior to placebo in reducing BEHAVE-AD aggression scores (p = .02). More adverse events were reported by patients receiving 2 mg/day of risperidone than 1 mg/day. The most common dose-related adverse events were extrapyramidal symptoms, somnolence, and mild peripheral edema. The frequency of extrapyramidal symptoms in patients receiving 1 mg/day of risperidone was not significantly greater than in placebo patients.

CONCLUSION

Risperidone significantly improved symptoms of psychosis and aggressive behavior in patients with severe dementia. Results show that 1 mg/day of risperidone is an appropriate dose for most elderly patients with dementia.

Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis

CONTEXT

The effects of home visitation programs to prevent functional decline in elderly persons have been inconsistent, and the value of these programs is controversial.

OBJECTIVE

To evaluate the effect of preventive home visits on functional status, nursing home admission, and mortality.

DATA SOURCES

Studies published in English, French, German, Italian, or Spanish reporting randomized trials of the effects of preventive in-home visits in older people (mean age >70 years) living in the community were identified through searches of MEDLINE, PSYCHINFO, and EMBASE (January 1985--November 2001). We also searched the Cochrane Controlled Trials Register, checked reference lists of earlier reviews and book chapters, searched conference proceedings and specialty journals, and contacted experts.

STUDY SELECTION

We screened 1349 abstracts and excluded those that did not test in-home interventions or in which the mean age of the study population was younger than 70 years. After further exclusions, 17 articles describing 18 trials were analyzed.

DATA EXTRACTION

Two reviewers independently screened abstracts. Discrepancies were resolved by consensus with a third reviewer. For each included trial, we extracted data on the study population and the characteristics of the intervention. Two of us extracted information on 3 end points: nursing home admissions, mortality, and functional status. One of us assessed trial quality, including an examination of the method of randomization, blinding of caregivers and research staff ascertaining outcomes, and proportion of patients included in analyses of the 3 end points.

DATA SYNTHESIS

The 18 trials included 13 447 individuals aged 65 years and older. The effect on nursing home admissions depended on the number of visits performed during follow-up. The pooled relative risk (RR) was 0.66 (95% confidence interval [CI], 0.48-0.92) for trials in the upper tertile (>9 visits) but was 1.05 (95% CI, 0.85-1.30) in the lower tertile (0-4 visits). Functional decline was reduced in trials that used multidimensional assessment with follow-up (RR, 0.76; 95% CI, 0.64-0.91) but not in other trials (RR, 1.01; 95% CI, 0.92-1.11). Functional decline was reduced (RR, 0.78; 95% CI, 0.64-0.95) in trials with a control group mortality rate in the lower tertile (3.4%-5.8%) but not (RR, 0.98; 95% CI, 0.84-1.13) in those with a control-group mortality rate in the upper tertile (8.3%-10.7%). A beneficial effect on mortality was evident in younger study populations (RR, 0.76; 95% CI, 0.65-0.88 for ages 72.7-77.5 years) but not in older study populations (RR, 1.09; 95% CI, 0.92-1.28 for ages 80.2-81.6 years).

CONCLUSION

Preventive home visitation programs appear to be effective, provided the interventions are based on multidimensional geriatric assessment and include multiple follow-up home visits and target persons at lower risk for death. Benefits on survival were seen in young-old rather than old-old populations.

Differences in vitamin D status between countries in young adults and the elderly

PURPOSE

To compare vitamin D status between countries in young adults and in the elderly.

MATERIALS AND METHODS

Reports on vitamin D status (as assessed by serum 25-hydroxyvitamin D) from 1971 to 1990 were reviewed. Studies were grouped according to geographic regions: North America (including Canada and the United States); Scandinavia (including Denmark, Finland, Norway, and Sweden); and Central and Western Europe (including Belgium, France, Germany, Ireland, The Netherlands, Switzerland, and the United Kingdom).

RESULTS

Vitamin D status varies with the season in young adults and in the elderly, and is lower during the winter in Europe than in both North America and Scandinavia. Oral vitamin D intake is lower in Europe than in both North America and Scandinavia. Hypovitaminosis D and related abnormalities in bone chemistry are most common in elderly residents in Europe but are reported in all elderly populations.

CONCLUSIONS

The vitamin D status in young adults and the elderly varies widely with the country of residence. Adequate exposure to summer sunlight is the essential means to ample supply, but oral intake augmented by both fortification and supplementation is necessary to maintain baseline stores. All countries should adopt a fortification policy. It seems likely that the elderly would benefit additionally from a daily supplement of 10 micrograms of vitamin D.

Multicomponent exercises including muscle power training enhance muscle mass, power output, and functional outcomes in institutionalized frail nonagenarians

This randomized controlled trial examined the effects of multicomponent training on muscle power output, muscle mass, and muscle tissue attenuation; the risk of falls; and functional outcomes in frail nonagenarians. Twenty-four elderly (91.9 ± 4.1 years old) were randomized into intervention or control group. The intervention group performed a twice-weekly, 12-week multicomponent exercise program composed of muscle power training (8-10 repetitions, 40-60 % of the one-repetition maximum) combined with balance and gait retraining. Strength and power tests were performed on the upper and lower limbs. Gait velocity was assessed using the 5-m habitual gait and the time-up-and-go (TUG) tests with and without dual-task performance. Balance was assessed using the FICSIT-4 tests. The ability to rise from a chair test was assessed, and data on the incidence and risk of falls were assessed using questionnaires. Functional status was assessed before measurements with the Barthel Index. Midthigh lower extremity muscle mass and muscle fat infiltration were assessed using computed tomography. The intervention group showed significantly improved TUG with single and dual tasks, rise from a chair and balance performance (P < 0.01), and a reduced incidence of falls. In addition, the intervention group showed enhanced muscle power and strength (P < 0.01). Moreover, there were significant increases in the total and high-density muscle cross-sectional area in the intervention group. The control group significantly reduced strength and functional outcomes. Routine multicomponent exercise intervention should be prescribed to nonagenarians because overall physical outcomes are improved in this population.

Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study

Vitamin D insufficiency and low calcium intake contribute to increase parathyroid function and bone fragility in elderly people. Calcium and vitamin D supplements can reverse secondary hyperparathyroidism thus preventing hip fractures, as proved by Decalyos I. Decalyos II is a 2-year, multicenter, randomized, double-masked, placebo-controlled confirmatory study. The intention-to-treat population consisted of 583 ambulatory institutionalized women (mean age 85.2 years, SD = 7.1) randomized to the calcium-vitamin D3 fixed combination group (n = 199); the calcium plus vitamin D3 separate combination group (n = 190) and the placebo group (n = 194). Fixed and separate combination groups received the same daily amount of calcium (1200 mg) and vitamin D3 (800 IU), which had similar pharmacodynamic effects. Both types of calcium-vitamin D3 regimens increased serum 25-hydroxyvitamin D and decreased serum intact parathyroid hormone to a similar extent, with levels returning within the normal range after 6 months. In a subgroup of 114 patients, femoral neck bone mineral density (BMD) decreased in the placebo group (mean = -2.36% per year, SD = 4.92), while remaining unchanged in women treated with calcium-vitamin D3 (mean = 0.29% per year, SD = 8.63). The difference between the two groups was 2.65% (95% CI = -0.44, 5.75%) with a trend in favor of the active treatment group. No significant difference between groups was found for changes in distal radius BMD and quantitative ultrasonic parameters at the os calcis. The relative risk (RR) of HF in the placebo group compared with the active treatment group was 1.69 (95% CI = 0.96, 3.0), which is similar to that found in Decalyos I (RR = 1.7; 95% CI = 1.0, 2.8). Thus, these data are in agreement with those of Decalyos I and indicate that calcium and vitamin D3 in combination reverse senile secondary hyperparathyroidism and reduce both hip bone loss and the risk of hip fracture in elderly institutionalized women.

The MDS-CHESS scale: a new measure to predict mortality in institutionalized older people

OBJECTIVES

To develop a scale predicting mortality and other adverse outcomes associated with frailty.

DESIGN

Observational study based on Minimum Data Set (MDS) 2.0 and mortality data.

SETTING

Ontario chronic hospitals.

PARTICIPANTS

All chronic hospital patients (N = 28,495) assessed with the MDS 2.0 after mandatory implementation in July 1996 followed until May 1999.

MEASUREMENTS

MDS 2.0 assessments done as part of normal practice mainly by registered nurses or multidisciplinary teams in a chronic hospital. Mortality data are available from the accompanying discharge tracking form.

RESULTS

The MDS-Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score is a composite measure addressing changes in health, end-stage disease, and symptoms and signs of medical problems. It is a strong predictor of mortality (P <.0001) independent of the effects of age, sex, activities of daily living impairment, cognition, and do-not-resuscitate orders. It is also strongly associated with physician activity, complex medical procedures, and pain (P <.001 for each dependent variable).

CONCLUSIONS

The CHESS score provides a useful new MDS-based test to predict mortality and to measure instability in health as a clinical outcome.

Epidemiology of gait disorders in community-residing older adults

OBJECTIVES

To study the epidemiology of gait disorders in community-residing older adults and their association with death and institutionalization.

DESIGN

Community-based cohort study.

SETTING

Bronx County and the research center at Albert Einstein College of Medicine.

PARTICIPANTS

The Einstein Aging study recruited 488 adults aged 70 to 99 between 1999 and 2001. At entry and during annual visits over 5 years, subjects received clinical evaluations to determine presence of neurological or nonneurological gait abnormalities.

MEASUREMENTS

Prevalence and incidence of gait disorders based on clinical evaluations and time to institutionalization and death.

RESULTS

Of 468 subjects (95.9%) with baseline gait evaluations, 168 had abnormal gaits: 70 neurological, 81 nonneurological, and 17 both. Prevalence of abnormal gait was 35.0% (95% confidence interval (CI) = 28.6-42.1). Incidence of abnormal gait was 168.6 per 1,000 person-years (95% CI = 117.4-242.0) and increased with age. Men had a higher incidence of neurological gait abnormalities, whereas women had a higher incidence of nonneurological gaits. Abnormal gaits were associated with greater risk of institutionalization and death (hazard ratio (HR) = 2.2, 95% CI =1.5-3.2). The risk was strongly related to severity of impairment; subjects with moderate to severe gait abnormalities (HR = 3.2, 95% CI = 1.9-5.2) were at higher risk than those with mild gait abnormalities (HR = 1.8, 95% CI = 1.0-2.8).

CONCLUSION

The incidence and prevalence of gait disorders are high in community-residing older adults and are associated with greater risk of institutionalization and death.

The prognostic significance of delirium in older hospital patients

OBJECTIVES

To determine whether delirium is an independent predictor of adverse outcomes of hospitalization in older patients.

DESIGN

Cohort study.

PATIENTS

A total of 225 people admitted as an emergency to an acute geriatric unit in a university teaching hospital.

METHODS

Subjects were screened for delirium, defined by Diagnostic and Statistical Manual, 3rd Edition criteria, every 48 hours. Outcome measures included mortality, duration of hospital stay, hospital-acquired complications, and institutional placement. The influence of delirium on these outcomes was calculated after adjusting for age, illness severity on admission, burden of comorbidity, prior cognitive impairment, and level of disability.

RESULTS

Delirium was present on admission in 41 patients (18%) and developed after admission in a further 53 patients (24%). Patients with delirium were more likely than non-delirious patients to have chronic cognitive impairment, severe acute illness, multiple comorbid conditions, and functional disability. Nevertheless, in multivariate analyses adjusting for these factors, delirium was independently associated with prolonged hospital stay, functional decline during hospitalization, increased risk of developing a hospital-acquired complication, and with increased admission to long-term care.

CONCLUSION

Delirium is an independent predictor of adverse outcomes in older hospital patients.

Salivary cortisol levels in children adopted from romanian orphanages

Six and a half years after adoption. 6- to 12-year-old children reared in Romanian orphanages for more than 8 months in their first years of life (RO. n = 18) had higher cortisol levels over the daytime hours than did early adopted (EA, < or = 4 months of age, n = 15) and Canadian born (CB, n = 27) children. The effect was marked, with 22% of the RO children exhibiting cortisol levels averaged over the day that exceeded the mean plus 2 SD of the EA and CB levels. Furthermore, the longer beyond 8 months that the RO children remained institutionalized the higher their cortisol levels. Cortisol levels for EA children did not differ in any respect from those of CB comparison children. This latter finding reduces but does not eliminate concerns that the results could be due to prenatal effects or birth family characteristics associated with orphanage placement. Neither age at cortisol sampling nor low IQ measured earlier appeared to explain the findings. Because the conditions in Romanian orphanages at the time these children were adopted were characterized by multiple risk factors, including gross privation of basic needs and exposure to infectious agents, the factor(s) that produced the increase in cortisol production cannot be determined. Nor could we determine whether these results reflected effects on the limbic-hypothalamic-pituitary-adrenal axis directly or were mediated by differences in parent-child interactions or family stress occasion by behavioral problems associated with prolonged orphanage care in this sample.

Lateral cerebral ventricular enlargement in chronic schizophrenia

To investigate if cerebral ventricular enlargement is associated with chronic schizophrenia, computerized tomography scans from 73 psychiatric patients were compared with 56 asymptomatic volunteers all less than 50 years old. Ventricular size was significantly greater in the subgroup of 58 chronic schizophrenic patients than in the controls. Of the chronic schizophrenic patients, 40% were outside the control range; 53% exceeded 2 SDs of the control mean. Neither duration of illness nor length of hospitalization correlated with ventricular size. The 44 chronic schizophrenic patients who had never been treated with electroshock therapy (EST) had larger ventricles than controls. A group of seven nonchronic schizophrenic patients also had enlarged ventricles; the eight patients who were either schizoaffective or nonschizophrenic did not differ from controls. This study shows that lateral cerebral ventricular enlargement is associated with chronic schizophrenia; it suggests that this is not a result of treatment.

Risk factors for nursing home placement in advanced Parkinson's disease

We evaluated the risk factors for nursing home placement of patients with Parkinson's disease (PD) by matching 11 PD patients permanently admitted to nursing homes with two control PD patients remaining at home. Risk factors assessed were motor severity, presence of hallucinations/delusions, and presence of memory of problems. The only statistically significant risk factor was the presence of hallucinations/delusions. Motor severity and the presence of memory problems did not have an impact on nursing home placement. There was no risk factor synergy for hallucinations, motor disability, and mental impairment. Since all patients in this series who entered nursing homes remained there permanently, these data suggest that vigorous efforts to control hallucinations may be warranted to prevent nursing home placement.