Factors associated with geriatric syndromes in older homeless adults

Although older homeless adults have high rates of geriatric syndromes, risk factors for these syndromes are not known. We used multivariable regression models to estimate the association of subject characteristics with the total number of geriatric syndromes in 250 homeless adults aged 50 years and older. Geriatric syndromes included falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence. A higher total number of geriatric syndromes was associated with having less than a high school education, medical comorbidities (diabetes and arthritis), alcohol and drug use problems, and difficulty performing one or more activities of daily living. Clinicians who care for older homeless patients with these characteristics should consider screening them for geriatric syndromes. Moreover, this study identifies potentially modifiable risk factors associated with the total number of geriatric syndromes in older homeless adults. This knowledge may provide targets for clinical interventions to improve the health of older homeless patients.

Characteristics of emergency department visits by older versus younger homeless adults in the United States

OBJECTIVES

We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.

METHODS

We analyzed 2005-2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.

RESULTS

The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003). Conclusions. Older homeless adults' patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.

Meeting the Housing and Care Needs of Older Homeless Adults: A Permanent Supportive Housing Program Targeting Homeless Elders

The homeless population is aging faster than the general population in the United States. As this vulnerable population continues to age, addressing complex care and housing needs will become increasingly important. This article reviews the often-overlooked issue of homelessness among older adults, including their poor health status and unique care needs, the factors that contribute to homelessness in this population, and the costs of homelessness to the U.S. health care system. Permanent supportive housing programs are presented as a potential solution to elder homelessness, and Hearth, an outreach and permanent supportive housing model in Boston, is described. Finally, specific policy changes are presented that could promote access to housing among the growing older homeless population.

Dementia medications and risk of falls, syncope, and related adverse events: meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the effect of cholinesterase inhibitors (ChEIs) and memantine on the risk of falls, syncope, and related events, defined as fracture and accidental injury.

DESIGN

Meta-analysis of randomized controlled trials that were identified from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (no language restriction, through July 2009), and manual search.

SETTING

Community and nursing homes.

PARTICIPANTS

Participants in fifty-four placebo-controlled randomized trials and extension studies of ChEIs and memantine that reported falls, syncope, and related events in cognitively impaired older adults.

MEASUREMENTS

Falls, syncope, fracture, and accidental injury.

RESULTS

ChEI use was associated with greater risk of syncope (odds ratio (OR)=1.53, 95% confidence interval (CI)=1.02-2.30) than placebo but not with other events (falls: OR=0.88, 95% CI=0.74-1.04; fracture: OR=1.39, 95% CI=0.75-2.56; accidental injury: OR=1.13, 95% CI=0.87-1.45). Memantine use was associated with fewer fractures (OR=0.21, 95% CI=0.05-0.85) but not with other events (falls: OR=0.92, 95% CI=0.72-1.18; syncope: OR=1.04, 95% CI=0.35-3.04; accidental injury: OR=0.80, 95% CI=0.56-1.12). There was no differential effect according to type and severity of cognitive impairment, residential status, or length of follow-up, although because of underreporting and small number of events, a potential benefit or risk cannot be excluded.

CONCLUSION

ChEIs may increase the risk of syncope, with no effects on falls, fracture, or accidental injury in cognitively impaired older adults. Memantine may have a favorable effect on fracture, with no effects on other events. More research is needed to confirm the reduction in fractures observed for memantine.

Dementia medications and risk of falls, syncope, and related adverse events: meta-analysis of randomized controlled trials

OBJECTIVES

To evaluate the effect of cholinesterase inhibitors (ChEIs) and memantine on the risk of falls, syncope, and related events, defined as fracture and accidental injury.

DESIGN

Meta-analysis of randomized controlled trials that were identified from MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (no language restriction, through July 2009), and manual search.

SETTING

Community and nursing homes.

PARTICIPANTS

Participants in fifty-four placebo-controlled randomized trials and extension studies of ChEIs and memantine that reported falls, syncope, and related events in cognitively impaired older adults.

MEASUREMENTS

Falls, syncope, fracture, and accidental injury.

RESULTS

ChEI use was associated with greater risk of syncope (odds ratio (OR)=1.53, 95% confidence interval (CI)=1.02-2.30) than placebo but not with other events (falls: OR=0.88, 95% CI=0.74-1.04; fracture: OR=1.39, 95% CI=0.75-2.56; accidental injury: OR=1.13, 95% CI=0.87-1.45). Memantine use was associated with fewer fractures (OR=0.21, 95% CI=0.05-0.85) but not with other events (falls: OR=0.92, 95% CI=0.72-1.18; syncope: OR=1.04, 95% CI=0.35-3.04; accidental injury: OR=0.80, 95% CI=0.56-1.12). There was no differential effect according to type and severity of cognitive impairment, residential status, or length of follow-up, although because of underreporting and small number of events, a potential benefit or risk cannot be excluded.

CONCLUSION

ChEIs may increase the risk of syncope, with no effects on falls, fracture, or accidental injury in cognitively impaired older adults. Memantine may have a favorable effect on fracture, with no effects on other events. More research is needed to confirm the reduction in fractures observed for memantine.

Health care access and utilization in older versus younger homeless adults

OBJECTIVES

To examine whether demographic characteristics, health care access, and acute health care utilization differ by age among homeless adults.

METHODS

We interviewed all 2,175 adult attendees of a citywide homeless outreach event.

RESULTS

Older participants were more likely than younger participants to have a regular place for health care (59.8% vs. 44.3%, p<.01), a regular health care provider (53.6% vs. 35.6%, p<.01), and health insurance (45.5% vs. 32.1%, p<.01). Older participants were less likely to be unable to obtain needed health care (15.6% vs. 20.9%, p=.05). In a multivariate analysis, only lack of health insurance predicted inability to obtain needed care (AOR 2.9, CI 1.76-4.8).

CONCLUSIONS

Older and younger homeless adults have similarly high rates of acute health care utilization. The better access to care among older homeless adults speaks to the importance of insurance in determining access to care among homeless adults.

The Unexpected Preference for the fac-Isomer with the Tris(5-ester-substituted-2,2‘-bipyridine) Complexes of Ruthenium(II)

The synthesis of a number of new 2,2'-bipyridine ligands, functionalized with bulky ester side groups, is reported (L2-L8). Their reaction with [Ru(DMSO)(4)Cl(2)] gives rise to tris-chelate ruthenium(II) metal complexes which show an unusually high proportion of the fac-isomer, as judged by (1)H NMR following conversion to the ruthenium(II) complex of 2,2'-bipyridine-5-carboxylic acid methyl ester (L1). The initial reaction appears to have thermodynamic control with the steric bulk of the ligands causing the third ligand to be labile under the reaction conditions used, giving rise to disappointing yields and allowing rearrangement to the more stable facial form. DFT studies indicate that this does not appear to be as a consequence of a metal centered electronic effect. The two isomers of [Ru(L1)(3)](PF(6))(2) were separated into the two individual forms using silica preparative plate chromatographic procedures, and the photophysical characteristics of the two forms compared. The results appear to indicate that there is no significant difference in both their room temperature electronic absorption and emission spectra or their excited state lifetimes at 77 K.

Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study

OBJECTIVE

To test the feasibility, acceptability, and potential efficacy of after-school dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, among African-American girls.

DESIGN

Twelve-week, 2-arm parallel group, randomized controlled trial.

SETTING

Low-income neighborhoods.

PARTICIPANTS

Sixty-one 8-10-year-old African-American girls and their parents/guardians.

INTERVENTIONS

The treatment intervention consisted of after-school dance classes at 3 community centers, and a 5-lesson intervention, delivered in participants' homes, and designed to reduce television, videotape, and video game use. The active control intervention consisted of disseminating newsletters and delivering health education lectures.

MAIN OUTCOME MEASURES

Implementation and process measures, body mass index, waist circumference, physical activity measured by accelerometry, self-reported media use, and meals eaten with TV.

RESULTS

Recruitment and retention goals were exceeded. High rates of participation were achieved for assessments and intervention activities, except where transportation was lacking. All interventions received high satisfaction ratings. At follow up, girls in the treatment group, as compared to the control group, exhibited trends toward lower body mass index (adjusted difference = -.32 kg/m2, 95% confidence interval [CI] -.77, .12; Cohen's d = .38 standard deviation units) and waist circumference (adjusted difference = -.63 cm, 95% CI -1.92, .67; d = .25); increased after-school physical activity (adjusted difference = 55.1 counts/minute, 95% CI -115.6, 225.8; d = .21); and reduced television, videotape, and video game use (adjusted difference = -4.96 hours/week, 95% CI -11.41, 1.49; d = .40). The treatment group reported significantly reduced household television viewing (d = .73, P = .007) and fewer dinners eaten while watching TV (adjusted difference = -1.60 meals/week, 95% CI -2.99, -.21; d = .59; P = .03). Treatment group girls also reported less concern about weight (d = .60; P = .03), and a trend toward improved school grades (d = .51; P = .07).

CONCLUSIONS

This study confirmed the feasibility, acceptability, and potential efficacy of using dance classes and a family-based intervention to reduce television viewing, thereby reducing weight gain, in African-American girls.

Psychosocial adjustment and peer competence of siblings of children with Attention-Deficit/Hyperactivity Disorder

Preliminary data examined the relationships between mothers, their sons with Attention-Deficit/Hyperactivity Disorder (ADHD), and younger siblings. We hypothesized that the conflict between the mother and the son with ADHD would also occur in the relationship between the child with ADHD and the younger sibling. Significant associations were found among ADHD behaviors, family conflict variables, conflict in the relationship between mother and child with ADHD, conflict in the relationship between mother and younger sibling, and conflict in the relationship between the child with ADHD and the younger sibling. Further, significant associations were found between behavior symptoms associated with ADHD and more problematic family relationships. Of particular interest was the finding of an unexpected inverse association between siblings' peer competence and mother-ADHD conflict; specifically, that conflict occurring at home from ADHD accounted for a greater percentage of the variance in peer competence as rated by teachers. Recommendations are made for future research with larger samples, alternative designs, older siblings, and fathers.

Neuropsychological aspects of pediatric sickle cell disease

Sickle cell disease (SCD), a class of genetic disorders characterized by abnormal, sickled red blood cells, is a chronic illness that results in progressive cerebrovascular disease. Neurocognitive sequelae of clinically apparent cerebrovascular accidents in children with SCD are characterized by pervasive impairments, including decrements in general intellectual functioning, language and verbal abilities, visual-motor and visual-spatial processing, memory, academic achievement, and processing of subtle prosodic information. In contrast, subtle neurocognitive deficits in the areas of attention and concentration, executive function, and visual-motor speed and coordination appear to be associated with silent infarcts that are not necessarily detected on physical examination. Investigation of the disease course and associated neurocognitive sequelae suggest a disease-specific model of neuropsychological impairment. Recommendations are made for clinical and research efforts in the field of pediatric neuropsychology.

Unilateral diaphragmatic palsy in association with a subclavian vein thrombus in a very-low- birth-weight infant

Phrenic nerve paralysis due to iatrogenic injury is not uncommon in neonates. We report an unusual case of acquired unilateral paralysis of the diaphragm in a very-low-birth-weight infant, associated with a thrombus secondary to percutaneous subclavian vein catheterization. Conservative management resulted in complete resolution of the paralyzed diaphragm.

Association of parental psychological and behavioral factors and children's syncope

The authors examined the associations between parental variables and child syncope (fainting). Children ages 7 to 18 years undergoing tilt-table testing for neurocardiogenic syncope (NCS) at a pediatric cardiac center served as participants (N = 56). Results revealed that fathers' shortness of breath and overall psychological distress were significantly related to syncope frequency and emergency room (ER) visits for girls. Mothers' overall psychological distress, depressive symptoms, and shortness of breath were associated with boys' frequency of syncope and ER visits. Fathers' psychological factors were highly correlated with syncope for the children diagnosed negative for NCS. The frequency of children's syncope was higher in stepfamilies than in homes with both biological parents, and the correlations between children's syncope and the stepfathers' psychological symptoms were greater than for the children and their biological fathers in intact families. The role of parental psychological factors on child syncope is supported.

Predictors of affective responses of mothers and fathers of children with cancer

We investigated predictors of affective responses for 125 parents (77 mothers, 48 fathers) of children with various types of cancer who varied in time of diagnosis from newly diagnosed to 13 years following cancer treatment. The primary rationale of the investigation was to determine whether cognitive appraisals, perceived social supports, and caregivers' perceptions of children's behavior would predict affective responses differentially for mothers and fathers. We defined affectivity as self-reported depressive symptoms, and state and trait anxiety symptoms. Parents did not differ on any of the variables, including affective responses, although differential predictors of affective responses were revealed for mothers and fathers. Affiliation-related attributions were associated with affective responses for mothers, and achievement-related attributions and perceived social support were associated with affective responses for fathers.

Social information processing and magnetic resonance imaging in children with sickle cell disease

OBJECTIVE

To examine social information processing, social skills, and adjustment difficulties in children with sickle cell disease (SCD) as rated by caregivers, teachers, and the children themselves. Children were classified in two groups: cerebral vascular accidents (CVA) (n = 21) or without central nervous system (CNS) pathology (n = 20) on magnetic resonance imaging (MRI). Both groups had HbSS SCD. We compared these two groups and a third group of 11 children who had a milder type of SCD (HbSC).

METHODS

Participants referred for evaluation of learning and behavior problems were administered MRIs to ascertain the presence of pathology and a series of measures designed to assess nonverbal emotional decoding abilities and ratings of social emotional functioning.

RESULTS

Children with CVA displayed more errors on tasks of facial and vocal emotional decoding than did comparison controls without CVA.

CONCLUSIONS

Acquired neurological impairments in children with SCD seemed to be associated with difficulties in the decoding of emotions of other children and adults. We recommend that future research integrate neuropsychological and psychosocial research programs for pediatric chronic illness groups.

Situational analysis of parenting problems for caregivers of children with sickle cell syndromes

A situational analysis of problematic situations was conducted for 37 caregivers of children with sickle cell disease (SCD) who ranged in age from 5 to 13 years. Participants responded to a semistructured interview related to caring for a child with SCD. The interview included the domains of medication adherence, nutrition, minimizing and coping with pain episodes, social problems, academic difficulties, and children's expression of negative feelings related to having SCD. Caregivers described a total of 356 problems. Almost all caregivers reported experiencing problems with their children's nutrition (n = 35), minimizing pain episodes (n = 34), and their children expressing feelings about having SCD (n = 33). Moderately challenging and emotionally upsetting problems were reported for coping with pain episodes. The total number of problems was significantly higher for boys than for girls. Nutrition issues were more frequently reported for younger children. Findings have salient clinical implications for the care of children with SCD.

Behavioral teratology/toxicology: how do we know what we know?

Knowledge about human behavioral teratology/toxicology must necessarily be limited by the methods that can ethically be used. Research in the field is an enterprise calling for tolerance for uncertainty if not chaos. Among the main points of this paper are: (a) Kaufman's criticisms of research on low blood-lead level (BLL) and children's IQ are generally valid and apply to virtually all human natural-groups research; (b) Relative to some contexts, research on low BLL on children's IQ is exemplary; (c) Relative to other contexts, the conclusion that low BLL have linear effects is well supported; (d) Owing to necessary design limitations, all natural-groups studies have shortcomings; (e) Inference of causality is uncertain under any conditions; and (f) Some authors readily leap from molehills of data to mountains of causal conclusions.

Poor school and cognitive functioning with silent cerebral infarcts and sickle cell disease

The authors evaluated education attainment and neuropsychological deficits in children with sickle cell disease (SCD) and silent cerebral infarcts. Children with silent infarcts had twice the rate of school difficulties as children without infarcts. Eighty percent of silent infarct cases had clinically significant cognitive deficits, whereas 35% had deficits in academic skills. Children with silent cerebral infarcts show high rates of poor educational attainment, cognitive deficits, and frontal lobe injury. Poor school performance in SCD is one indicator of silent infarcts.

Self-assessment in clinical health psychology: a model for ethical expansion of practice

Society expects autonomous professions to ensure the competency of it practitioners, and professions should facilitate the continuing education and training of its members. Given the shift from psychology as a mental health profession to that of a health profession, the authors propose a self-assessment model for the individual practitioner to gauge his or her readiness to provide professional service in expanded areas of practice. This model could also be useful to the American Psychological Association, state psychological associations, and other purveyors of continuing education programs in systematically developing postgraduate experiences. A template for self-assessment that reflects well-accepted core domains of knowledge and skills is presented.

Prevalence and assessment of attention-deficit/hyperactivity disorder in primary care settings

Research literature relating to the prevalence of attention-deficit/hyperactivity disorder (ADHD) and co-occurring conditions in children from primary care settings and the general population is reviewed as the basis of the American Academy of Pediatrics clinical practice guideline for the assessment and diagnosis of ADHD. Epidemiologic studies revealed prevalence rates generally ranging from 4% to 12% in the general population of 6 to 12 year olds. Similar or slightly lower rates of ADHD were revealed in pediatric primary care settings. Other behavioral, emotional, and learning problems significantly co-occurred with ADHD. Also reviewed were rating scales and medical tests that could be employed in evaluating ADHD. The utility of using both parent- and teacher-completed rating scales that specifically assess symptoms of ADHD in the diagnostic process was supported. Recommendations were made regarding the assessment of children with suspected ADHD in the pediatric primary care setting.

Risk-resistance adaptation model for caregivers and their children with sickle cell syndromes

This investigation examined the risk-resistance adaptation model for children with sickle cell disease and their primary caregivers. Participants were 55 children, ranging in age from 5 to 16 years with a mean age of 9 years 2 months, diagnosed with sickle cell disease and their primary caregivers, recruited from a university medical center. Measures included adjustment (i.e. primary caregiver and child adjustment), risk factors (i.e. disease and disability, functional independence, and psychosocial stressors), resistance factors (i.e. intrapersonal health locus of control, social-ecological), and stress processing (coping). Primary caregivers' adjustment was associated with developmental coping, changeR2 = .08, and child adaptation was associated with an internal health locus of control, changeR2 = .22. An indirect effect of primary caregivers' coping on child adjustment was found through influence on primary caregivers' adjustment, changeR2 = .11. The findings support research among other chronically ill populations that suggests an association between coping and disease adjustment. The results were interpreted to support the use of theoretically driven models in predicting the adaptation of children with chronic illness and adjustment in their caregivers.

Constitutive activation of STAT3 is associated with the acquisition of an interleukin 6-independent phenotype by murine plasmacytomas and hybridomas

Interleukin 6 (IL-6), the major growth factor for myeloma cells, signals through the activation of signal transducers and activators of transcription (STAT) proteins. An important step in the malignant progression of murine plasmacytomas is the transition from dependence on IL-6 to a state of IL-6 independence. To elucidate the mechanism whereby IL-6 independence occurs, intracellular signaling events elicited by IL-6 in both IL-6-dependent and -independent plasmacytomas and hybridomas were compared. It was found that STAT3, a key molecule involved in IL-6 signaling, was constitutively activated and phosphorylated in IL-6-independent cell lines compared to the IL-6-dependent cells. Further comparison of upstream signaling pathways revealed that JAK-1 was constitutively present in anti-phosphotyrosine immunoprecipitates of IL-6-independent cells; gp130 was constitutively phosphorylated in a subset of IL-6-independent plasmacytomas, whereas other IL-6-independent lines showed no detectable gp130 phosphorylation in the absence of exogenous IL-6. Secretion of a factor capable of supporting the growth of IL-6-dependent cells was observed in one of the IL-6-independent plasmacytomas, but not in others, making an autocrine mechanism an unlikely explanation for IL-6 independence. These findings provide evidence that the constitutive activation of STAT3, either in the absence of detectable receptor-proximal events or associated with the concomitant activation of gp130, can contribute to the process of IL-6 independence.

Allergic gastroenteropathy in preterm infants

OBJECTIVES

To determine the clinical presentation, histopathologic features, and outcome of biopsy-proven allergic gastroenteropathy (AGE) in preterm infants. We hypothesized that AGE is a more frequent cause of gastrointestinal disease in this population than previously suspected.

STUDY DESIGN

The retrospective portion of the study, from 1992 to 1997, included preterm infants <37 weeks' gestation who underwent biopsy because of suspected AGE. The prospective portion, from January to December 1998, included 20 infants undergoing endoscopy and biopsy because of suspected AGE.

RESULTS

Twenty-five infants (12 retrospective/13 prospective) with mean gestational age of 29 weeks at birth and mean postnatal age at diagnosis of 78 days were diagnosed with AGE. Three clinical patterns of presentation were noted: group 1, gastroesophageal reflux disease (n = 5); group 2, non-specific feeding intolerance (n = 8); and group 3, lower gastrointestinal bleeding (n = 12). Ten patients had negative biopsy findings (3 retrospective/7 prospective) and had clinical features indistinguishable from those of groups 1 and 2. Patients in group 3 were most likely to have positive biopsy findings (12 of 12). Fifteen patients responded to a casein hydrolysate formula, and 10 patients required an amino acid-based formula. Patients with AGE who had eosinophilic infiltration and villous atrophy took longer to recover than those with eosinophilic infiltration alone (P <.03). Subsequently, most have tolerated formula challenges and are currently tolerating cow's milk.

CONCLUSIONS

AGE may be an under-recognized cause of gastrointestinal symptoms in preterm infants. Confirmation with endoscopy and biopsy can be done safely and provides the basis for appropriate dietary management.

Neurocognitive functioning and magnetic resonance imaging in children with sickle cell disease

OBJECTIVE

To examine neurocognitive functioning in children classified with overt cerebral vascular accidents (CVAs), silent infarcts, or without central nervous system (CNS) pathology on magnetic resonance imaging.

METHODS

Participants were 63 children and adolescents with sickle cell disease (SCD).

RESULTS

Children with overt CVAs and silent infarcts differed from their peers without CNS pathology on measures of attention and executive functioning.

CONCLUSIONS

We consider these deficits the result of the high frequency of frontal lobe deficits incurred by children with SCD. Recommendations include the use of tests designed to measure attention and executive functioning as a way of screening children with SCD for possible CNS pathology. We also suggest that future research examine the mechanism underlying frontal lobe involvement for individuals with SCD.