Cognitive impairment and the use of health services in an elderly rural population: the MoVIES project. Monongahela Valley Independent Elders Survey

CERAD (Consortium to Establish a Registry for Alzheimer's Disease) Neuropsychology Assessment Battery: 35 Years and Counting

BACKGROUND

In 1986, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) was mandated to develop a brief neuropsychological assessment battery (CERAD-NAB) for AD, for uniform neuropsychological assessment, and information aggregation. Initially used across the National Institutes of Aging-funded Alzheimer's Disease Research Centers, it has become widely adopted wherever information is desired on cognitive status and change therein, particularly in older populations.

OBJECTIVE

Our purpose is to provide information on the multiple uses of the CERAD-NAB since its inception, and possible further developments.

METHODS

Since searching on "CERAD neuropsychological assessment battery" or similar terms missed important information, "CERAD" alone was entered into PubMed and SCOPUS, and CERAD-NAB use identified from the resulting studies. Use was sorted into major categories, e.g., psychometric information, norms, dementia/differential dementia diagnosis, epidemiology, intervention evaluation, genetics, etc., also translations, country of use, and alternative data gathering approaches.

RESULTS

CERAD-NAB is available in ∼20 languages. In addition to its initial purpose assessing AD severity, CERAD-NAB can identify mild cognitive impairment, facilitate differential dementia diagnosis, determine cognitive effects of naturally occurring and experimental interventions (e.g., air pollution, selenium in soil, exercise), has helped to clarify cognition/brain physiology-neuroanatomy, and assess cognitive status in dementia-risk conditions. Surveys of primary and tertiary care patients, and of population-based samples in multiple countries have provided information on prevalent and incident dementia, and cross-sectional and longitudinal norms for ages 35-100 years.

CONCLUSION

CERAD-NAB has fulfilled its original mandate, while its uses have expanded, keeping up with advances in the area of dementia.

Association of 100% Fruit Juice Consumption with Cognitive Measures, Anxiety, and Depression in US Adults

Cognitive decline, anxiety, and depression are significant contributors to human ill health and decreased quality of life. Intake of fruits including 100% juice is associated with beneficial effects on several health outcomes. The current study explored the potential associations between consumption of 100% fruit juice and neurocognitive markers in adults. Twenty-four-hour dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 1988-1994, 1999-2018 for adults 20+ years (N = 62,606) were used to assess 100% fruit juice intake, and NHANES questionnaire data were used for the assessment of neurocognition. Association of usual intake of 100% fruit juice with neurocognitive outcomes were assessed by regression analysis after adjusting for demographic, lifestyle, dietary, and health-related covariates. About 21% of adults were fruit juice consumers and the intake was a little over 2 oz per day. Consumers of 100% fruit juice had 16.3% fewer days per month of feeling anxious compared to non-consumers. There were no significant associations of 100% fruit juice usual intake with other neurocognitive measures. A large number of potential confounding variables have been identified to be associated with one or more neurocognitive measures suggesting that these may be important parameters to include in future studies.

Cognitive function and its transitions in predicting all-cause mortality among urban community-dwelling older adults

BACKGROUND

Cognitive impairment is accompanied with high rates of comorbid conditions, leading ultimately to death. Few studies examine the relation between cognitive transition and mortality, especially in Asian population. This study evaluated baseline cognition and cognitive transition in relation to all-cause mortality among community-dwelling older adults.

METHODS

We conducted a community-based prospective cohort study among 921 participants of Taichung Community Health Study for Elders in 2009. Cognitive function was evaluated by the Mini-Mental State Examination. Cognitive impairment was considered if the total score is less than 27, 24, and 21 for a participant's educational level of more than 6 years, equal or less than 6 years, and illiteracy, respectively. One-year transition in cognitive function was obtained among 517 individuals who were assessed in both 2009 and 2010. Mortality was followed up until 2016. Cox proportional hazards models were applied to estimate the adjusted hazard ratios of mortality for baseline cognitive impairment and one-year transition in cognitive status.

RESULTS

After a follow-up of 6.62 years, 160 deaths were recorded. The multivariate adjusted hazard ratio (95% confidence interval) for baseline cognitive impairment was 2.08 (1.43, 3.01). Significantly increased mortality risk was observed for cognitively impaired-normal and impaired-impaired subgroups over 1 year as compared with those who remained normal [2.87 (1.25, 6.56) and 3.79 (1.64, 8.73), respectively]. The area under the receiver operating characteristic curves demonstrated that baseline cognition and one-year cognitive transition had no differential predictive ability for mortality. Besides, there was an interaction of cognitive impairment and frailty, with an additive mortality risk [5.41 (3.14, 9.35)] for the elders who presented with both.

CONCLUSION

Baseline cognitive impairment rather than one-year progression is associated with mortality in a six-year follow-up on older adults.

Risk factors and clinical outcomes of functional decline during hospitalisation in very old patients with acute decompensated heart failure: an observational study

OBJECTIVE

To investigate the prevalence and risk factors of functional decline during hospitalisation and its relationship with postdischarge outcomes in very old patients with acute decompensated heart failure (ADHF) hospitalisation.

DESIGN

Prospective cohort study between 1 October 2014 and 31 March 2016.

SETTING

A physician-initiated, multicentre study of consecutive patients admitted for ADHF in 19 hospitals throughout Japan.

PARTICIPANTS

Among 3555 patients hospitalised for ADHF (median age (IQR), 80 (71-86) years; 1572 (44%) women), functional decline during the index hospitalisation occurred in 528 patients (15%).

PRIMARY AND SECONDARY OUTCOMES

The primary outcome measure was a composite of all-cause death or heart failure (HF) hospitalisation after discharge. The secondary outcome measures were all-cause death, HF hospitalisation, and a composite of all-cause death or all-cause hospitalisation.

RESULTS

The independent risk factors for functional decline included age ≥80 years (OR 2.71; 95% CI 2.09 to 3.51), female (OR 1.32; 95% CI 1.05 to 1.67), prior stroke (OR 1.67; 95% CI 1.28 to 2.19), dementia (OR 2.26; 95% CI 1.74 to 2.95), ambulatory before admission (OR 1.74; 95% CI 1.29 to 2.35), elevated body temperature (OR 1.91; 95% CI 1.31 to 2.79), New York Heart Association class III or IV on admission (OR 1.54; 95% CI 1.07 to 2.22), decreased albumin levels (OR 1.76; 95% CI 1.32 to 2.34), hyponatraemia (OR 1.49; 95% CI 1.10 to 2.03) and renal dysfunction (OR 1.55; 95% CI 1.22 to 1.98), after multivariable adjustment. The cumulative 1-year incidence of the primary outcome in the functional decline group was significantly higher than that in the no functional decline group (50% vs 31%, log-rank p<0.001). After adjusting for baseline characteristics, the higher risk of the functional decline group relative to the no functional decline group remained significant (adjusted HR 1.46; 95% CI 1.24 to 1.71; p<0.001).

CONCLUSIONS

Independent risk factors of functional decline in very old patients with ADHF were related to both frailty and severity of HF. Functional decline during ADHF hospitalisation was associated with unfavourable postdischarge outcomes.

TRIAL REGISTRATION NUMBER

NCT02334891, UMIN000015238.

Synergistic effects of cognitive impairment on physical disability in all-cause mortality among men aged 80 years and over: Results from longitudinal older veterans study

Objective

We evaluated effects of the interrelationship between physical disability and cognitive impairment on long-term mortality of men aged 80 years and older living in a retirement community in Taiwan.

Methods

This prospective cohort study enrolled older men aged 80 and older living in a Veterans Care Home. Those with confirmed diagnosis of dementia were excluded. All participants received comprehensive geriatric assessment, including sociodemographic data, Charlson’s Comorbidity Index (CCI), geriatric syndromes, activities of daily living (ADL) using the Barthel index and cognitive function using the Mini-Mental State Examination (MMSE). Subjects were categorized into normal cognitive function, mild cognitive deterioration, and moderate-to-severe cognitive impairment and were further stratified by physical disability status. Kaplan-Meier log-rank test was used for survival analysis. After adjusting for sociodemographic characteristics and geriatric syndromes, Cox proportional hazards model was constructed to examine associations between cognitive function, disability and increased mortality risk.

Results

Among 305 male subjects aged 85.1 ± 4.1 years, 89 subjects died during follow-up (mean follow-up: 1.87 ± 0.90 years). Kaplan-Meier unadjusted analysis showed reduced survival probability associated with moderate-to-severe cognitive status and physical disability. Mortality risk increased significantly only for physically disabled subjects with simultaneous mild cognitive deterioration (adjusted HR 1.951, 95% CI 1.036–3.673, p = 0.038) or moderate-to-severe cognitive impairment (aHR 2.722, 95% CI 1.430–5.181, p = 0.002) after adjusting for age, BMI, education levels, smoking status, polypharmacy, visual and hearing impairment, urinary incontinence, fall history, depressive symptoms and CCI. Mortality risk was not increased among physically independent subjects with or without cognitive impairment, and physically disabled subjects with intact cognition.

Conclusions

Physical disability is a major risk factor for all-cause mortality among men aged 80 years and older, and risk increased synergistically when cognitive impairment was present. Cognitive impairment alone without physical disability did not increase mortality risk in this population.

Geographic Access and Service Use in a Community-Based Sample of Cognitively Impaired Elders

Objective: The purpose of this research was to determine whether geographic access influences service utilization in a community-based sample of older adults with cognitive impairment. Methods: A telephone screener for cognitive impairment was administered to 9,100 elderly Arkansans with caregivers, resulting in a sample with 317 elder/caregiver dyads. Self-reported service utilization was collected for three sectors: home health, physical health, and mental health. Geographic access was measured from (a) self-reported awareness of services in each sector and (b) the travel time to the closest provider in each sector calculated using a Geographic Information System. Results: Travel time significantly predicted home health service utilization while perceived awareness significantly predicted mental health service utilization. Neither measure of geographic access predicted use of physical health services. Discussion: Because rural elders with less geographic access receive fewer home/mental health services, they may be at greater risk for hospitalization or nursing home placement.

The impact of dementia on the use of general practitioners among the elderly in Norway

OBJECTIVE

To assess the use of general practitioners (GPs), in elderly home-dwelling persons in Norway and explore the impact of cognitive decline, age, and living situation.

DESIGN

Prospective longitudinal study.

SETTING

Data were collected from municipalities in four counties in Norway in the period from January 2009 to August 2012.

SUBJECTS

Home-dwelling persons 70 years of age or older, receiving in-home care.

MAIN OUTCOME MEASURES

Use of GPs over a period of 18 months related to cognitive state, functional status, neuropsychiatric symptoms, and demographics.

RESULTS

A total of 599 persons were included. The mean annual number of consultations per participant was 5.6 (SD = 5.4). People with moderate to severe dementia had fewer consultations per year compared with those with mild or no dementia (3.7 versus 5.8 per year, p = 0.004). In the multivariate model higher age predicted fewer consultations while affective neuropsychiatric symptoms were associated with an increase in frequency of consultations. The most frequent reason to consult a GP was cardiovascular diseases (36.8% of all consultations), followed by musculoskeletal complaints (12.1%) and psychiatric diagnoses (8.7%).

CONCLUSION

Our study shows that the home-dwelling elderly with moderate to severe dementia in Norway consult their GP less often than persons with mild or no dementia. This could indicate a need for better interaction between the municipal care and social services and the general practitioners.

Cognitive impairment in public housing residents living in Western New York

PURPOSE

Many older adults in the USA live in public housing facilities and have characteristics that may place them at risk for cognitive impairment. Cognitive impairment has been largely unexamined in this socioeconomically disadvantaged population, however. We therefore aim to characterize its prevalence and correlates, which may help determine which residents could benefit from additional assistance to optimize their ability to function independently.

METHODS

We interviewed 190 English-speaking public housing residents aged 60 years and older in Rochester, a city in Western New York, to assess socio-demographics, mental health, physical health and disability, coping strategies and social support, and service utilization. The Mini-Cog dementia screen evaluated cognitive status.

RESULTS

Twenty-seven percent of residents screened positive for cognitive impairment. In bivariate analyses, older age, less education, greater duration of residence, worse health, less reliance on adaptive coping strategies, and greater utilization of health services were associated with cognitive impairment; age and worse health remained correlated with cognitive impairment in multivariable analyses. Anxiety, depression, and history of substance misuse were not associated with cognitive impairment.

CONCLUSIONS

The high level of cognitive impairment in public housing could threaten residents' continued ability to live independently. Further examination is needed on how such threats to their independence are best accommodated so that public housing residents at risk for needing higher levels of care can successfully age in place.

DigiSwitch: a device to allow older adults to monitor and direct the collection and transmission of health information collected at home

Home monitoring represents an appealing alternative for older adults considering out-of-home long term care and an avenue for informal caregivers and health care providers to gain decision-critical information about an older adults' health and well-being. However, privacy concerns about having 24/7 monitoring, especially video monitoring, in the home environment have been cited as a major barrier in the design of home monitoring systems. In this paper we describe the design and evaluation of "DigiSwitch", a medical system designed to allow older adults to view information as it is collected about them and temporarily cease transmission of data for privacy reasons. Results from a series of iterative user studies suggest that control over the transmission of monitoring data from the home is helpful for maintaining user privacy. The studies demonstrate that older adults are able to use the DigiSwitch system to monitor and direct the collection and transmission of health information in their homes, providing these participants with a way to simultaneously maintain privacy and benefit from home monitoring technology.

Caregiving Networks in Later Life: Does Cognitive Status Make a Difference?

This study examines the caregiving networks of older adults, with particular emphasis on differences according to cognitive status (n = 303). Individuals with cognitive impairment were significantly more likely than those who were cognitively intact to receive assistance with personal care, linking with the outside world, and mobility. The types of network were generally similar for care receivers with cognitive impairment and those who were cognitively intact, although the percentage of networks comprised solely of the identified caregiver varied depending on the tasks. Coresidence of the caregiver and care receiver was more important than the care receiver's cognitive status for exclusive care by the identified caregiver. Having more ADL/IADL limitations was associated with a reliance on a network of the identified caregiver, in conjunction with other caregivers in several task areas. The findings highlight the complexity of sources of help in later life and the need for future research to consider the caregiving network as a whole.

Inhome Service Use by Caregivers and Their Elders: Does Cognitive Status Make a Difference?

The intent of this study was to examine the effect of cognitive status on the use of inhome services by caregivers and their elders. Data from the screening, clinical and community-caregiver phases of the Manitoba Study on Health and Aging (MSHA-1) were analysed utilizing a modified Andersen-Newman model. The findings indicated that those with dementia were more likely to use personal care services and use two or more inhome services than caregivers and their elders with no cognitive impairment and those with cognitive impairment but no dementia. Functional status of the elder and living arrangement of the caregiver and elder were strongly associated with the use of specific inhome services and with overall use. Policy and research implications of the findings including other significant factors such as caregiver employment, are presented.

Screening for undiagnosed cognitive impairment in homebound older adults

OBJECTIVE

To screen for undetected cognitive impairment in homebound elders receiving home health care services.

DESIGN

A cross-sectional study of adults 60 years of age and older receiving visiting nurse services. A pharmacist administered the Mini-Cog, a rapid screening test for cognitive impairment, during the enrollment home visit.

SETTING

Participants' homes.

PARTICIPANTS

A consecutive sample of 100 homebound adults, 60 years of age or older with no previous diagnosis of dementia, Alzheimer's disease, or other cognitive impairment.

MAIN OUTCOME MEASURE

Percentage of participants scoring in the likely impaired range (screen failure) on the Mini-Cog.

RESULTS

Seventeen percent of persons with no prior diagnosis of dementia or cognitive decline failed the Mini-Cog.

CONCLUSION

Rates of undetected cognitive impairment are substantial in homebound elders receiving care from a visiting nurse service. The home health setting represents an important point in the continuum of geriatric care for detection of cognitive impairment. Future work should define the types and trajectories of cognitive impairment detected in home care patients by simple screens such as the Mini-Cog and test ways to integrate this knowledge into longitudinal treatment plans across settings of care.

Rural residence and prescription medication use by community-dwelling older adults: a review of the literature

CONTEXT

Due to various barriers to health care access in the rural setting, there is concern that rural older adults might have lower access to prescribed medications than their urban counterparts.

PURPOSE

To review published research reports to determine prevalence and mean medication use in rural, noninstitutionalized older adults and assess whether rural-urban differences exist.

METHODS

PubMed, Ageline, Cinahl, PsycInfo, International Pharmaceutical Abstracts, Agricola, and Institute for Scientific Information Web of Science - Social Science Index were searched. English-language articles through May 2005 involving a sample of rural, noninstitutionalized older adults and analyses of overall medication prevalence and/or intensity were included. Review articles, conference abstracts, dissertations, books, and articles targeting nonprescription or specific therapeutic categories were excluded. A total of 206 citations were identified and 26 met the inclusion criteria.

FINDINGS

Reported prevalence of prescription medication use by rural older adults varied between 62% and 96%, with 2-6 prescriptions per person. Multivariate analyses results were equally inconsistent. Controlling for insurance, most US studies suggest there is no rural-urban difference in access to prescribed medications. However, this finding may not be generalizable across all regions in the United States or other countries.

CONCLUSIONS

Geographic location may not be as important a variable for medication usage as for other health services utilization.

Mental illness and use of home care nationally in the U.S. Department of Veterans Affairs

OBJECTIVE

To determine whether patients with mental health diagnoses are more likely to utilize home-based primary care (HBPC), and to identify characteristics associated with HBPC admission among elderly and nonelderly veterans, specifically.

METHODS

Patients receiving treatment during fiscal year (FY) 2003 and having no evidence of home care utilization during FY2002 were followed through FY2005 using administrative claims data of the Veterans Health Administration of the U.S. Department of Veterans Affairs (VA). Participants were 4,411,677 VA patients with no prior HBPC use. Cox proportional hazard models were developed to identify correlates of HBPC use.

RESULTS

Of VA patients with no prior use of HBPC, 24.2% received a mental health diagnosis, of whom 1.5% eventually used HBPC. Two in five new HBPC admissions were diagnosed with mental illness. Patients diagnosed with dementia were 66% more likely to be admitted. Patients diagnosed with nonschizophrenia psychoses (hazard ratio [HR]: 1.30), miscellaneous affective disorders (HR: 1.22), and schizophrenia (HR: 1.21) had the next highest probabilities. Risk of admission was highest for > or = 3 outpatient medical visits (HR: 2.61), followed by any inpatient medical/surgical days (HR: 1.79) or outpatient mental health visits (HR: 1.30). Elderly patients with any inpatient mental health days were less likely to be admitted; younger patients with nursing home use, community residential care, and mental health intensive care management were more likely to be admitted.

CONCLUSION

Given that mental illness is independently associated with the likelihood of admission, it is critical that providers develop the skills and resources necessary to meet the psychiatric needs of home care recipients.

Impairment of activities of daily living requiring memory or complex reasoning as part of the MCI syndrome

BACKGROUND

Mild Cognitive Impairment (MCI) is a borderline state between age-associated cognitive decline and mild dementia. MCI is separated from mild dementia by an absence of global intellectual deterioration and the preservation of activities of daily living (ADL). However, even mild degrees of cognitive deterioration are known to have negative effects on complex ADL.

OBJECTIVES

To examine whether patients with MCI have impaired ADL as compared to healthy controls, which areas of ADL are particularly involved, and whether limitations on ADL are associated with demographical or clinical data.

METHODS

Forty-eight patients with MCI diagnosed according to research criteria and 42 cognitively unimpaired controls were enrolled. Cognitive function was inter alia assessed by the MMSE, complex ADL by the ADCS-MCI-ADL scale. Frequency distributions were compared between patients and controls using chi-square tests. Mean values were examined for statistically significant differences using Kruskal-Wallis tests. A Bonferroni correction for multiple comparisons was applied to the comparison of the 18 areas of the ADCS-MCI-ADL scale. Associations between ADL and biographical or clinical data were analysed using non-parametric correlations.

RESULTS

The overall score on the ADCS-MCI-ADL scale was significantly lower in the MCI group. Patients performed significantly worse on 14 out of 18 activities. Activities involving memory or complex reasoning were particularly impaired, whereas more basic activities were unimpaired. There were no statistically significant associations of the ADCS-MCI-ADL overall score with age, years of formal education, gender, or number of cognitive domains affected in the group of MCI patients. However, there was a statistically significant association between the ADCS-MCI-ADL and the MMSE score.

CONCLUSION

MCI patients may be impaired in complex ADL.

The amount of informal and formal care among non-demented and demented elderly persons-results from a Swedish population-based study

BACKGROUND

Developed countries are experiencing a dramatic increase in the proportion of elderly persons, as well as a progressive aging of the elderly population itself. Knowledge regarding the amount of formal and informal care and its interaction at population-based level is limited.

OBJECTIVES

To describe the amount of formal and informal care for non-demented and demented persons living at home in a population-based sample.

METHODS

The population consisted of all inhabitants, 75 + years, living in a rural community (n = 740). They were clinically examined by physicians and interviewed by nurses. Dementia severity was measured according to Washington University Clinical Dementia Rating Scale (CDR). Informal and formal care was examined with the RUD (Resource Utilization in Dementia) instrument.

RESULTS

The amount of informal care was much greater than formal care and also greater among demented than non-demented. There was a relationship between the severity of the cognitive decline and the amount of informal care while this pattern was weaker regarding formal care. Tobit regression analyses showed a clear association between the number of hours of informal and formal care and cognitive decline although this pattern was much stronger for informal than formal care.

CONCLUSIONS

Informal care substitutes rather than compliments formal care and highlights the importance of future studies in order to truly estimate the amount of informal and formal care and the interaction between them. This knowledge will be of importance when planning the use of limited resources, and when supporting informal carers in their effort to care for their intimates.

Over-the-counter analgesics in older adults: a call for improved labelling and consumer education

The use of analgesics increases with age and on any given day 20-30% of older adults take an analgesic medication. Over-the-counter (OTC) analgesics are generally well tolerated and effective when taken for brief periods of time and at recommended dosages. However, their long-term use, use at inappropriately high doses, or use by persons with contraindications may result in adverse effects, including gastrointestinal haemorrhage, cardiovascular toxicity, renal toxicity and hepatotoxicity. Many OTC drugs are also available through a prescription, for a broader range of indications and for longer durations of use and wider dose ranges, under the assumption that healthcare providers will help patients make safe choices about analgesics. Safe and effective use of medications is one of the greatest challenges faced by healthcare providers in medicine. More than 60% of people cannot identify the active ingredient in their brand of pain reliever. Additionally, about 40% of Americans believe that OTC drugs are too weak to cause any real harm. As a result of a recent US FDA policy, the conversion of prescription to OTC medications will result in a 50% increase of OTC medications. To reduce the risks of potential adverse effects from OTC drug therapy in older adults, we propose that the use of analgesics will be enhanced through the use of patient and healthcare provider education, as well as improved labelling of OTC analgesics. Improved labelling of OTC analgesics may help consumers distinguish common analgesic ingredients in a wide variety of preparations and facilitate informed decisions concerning the use of OTC drugs.

Exercise level and cognitive decline: the MoVIES project

Growing evidence suggests that physical exercise may be protective against cognitive impairment and decline. A prospective study of a representative rural community sample (N = 1,146) aged 65+ years examined self-reported exercise habits and measured global cognitive function using the Mini-Mental State Examination (MMSE). A composite variable "exercise level" combining type, frequency, and duration of exercise was created with three levels: "high exercise" (aerobic exercise of > or = 30 minute duration > or = 3 times a week), "low exercise" (all other exercise groups), and "no exercise." Cognitive decline was defined as being in the 90 percentile of decline in this cohort, ie, declining by 3 or more MMSE points during the 2-year interval between two assessments. In a multiple regression model, high exercise level at the baseline assessment was negatively associated with, ie, was protective against, being in the group with the greatest amount of decline at the follow-up assessment, after adjusting for likely confounders (odds ratio = 0.39; 95% confidence interval, 0.19, 0.78). When high exercise was redefined using frequency as > or = 5 days per week as the threshold, as per the Surgeon General's guidelines, both low exercise and high exercise were negatively associated with cognitive decline. Exercise may have implications for prevention of cognitive decline.

Impact of diabetes on cognitive function among older Latinos: a population-based cohort study

BACKGROUND AND OBJECTIVES

Type 2 diabetes, which is highly prevalent in older Mexican Americans, may influence cognitive functioning. We examined the association of diabetes with decline in global cognitive function and memory function over a 2-year period.

METHODS

Study subjects were derived from an existing cohort of Latinos aged 60 and over in the SALSA project (n=1,789). Statistical analysis was conducted using logistic regression and a generalized estimating equation (GEE).

RESULTS

Logistic regression analysis indicated that baseline diabetes was a significant predictor of major cognitive impairment in Modified Mini Mental State Exam (3MSE) (OR=1.68, 95% CI=1.21, 2.34) and word-list test (OR=1.31, 95% CI=0.99, 1.75). GEE analysis showed that there was no significant difference between diabetic and nondiabetic subjects in change of cognitive scores over 2 years (3MSE, mean=-0.58, 95% CI=-1.48, 0.32; word-list test, mean=-0.10, 95% CI=-0.32, 0.11).

CONCLUSIONS

More diabetic complications were associated with major cognitive decline among diabetic subjects. Research on long-term impact of treatment for type 2 diabetes is warranted.

[Non-detected dementia and use of the health services: implications for primary care]

OBJECTIVES

To calculate the proportion of cases of dementia detected in people over 70 living in their homes and to describe the use made by people with dementia of the health and social services.

MATERIAL AND METHODS

Population survey of the survivors of the cohort "Growing old in Leganés", started in 1993. In the third monitoring (1999-2000), the clinical diagnosis of dementia on the basis of a neurological examination and an extensive neuro-psychological battery was included. Their use of health and social services and prior diagnoses were also asked.

RESULTS

In the sample of survivors (n=527), there was 12.1% prevalence of dementia. Only 30% of the demented had previously been diagnosed by the health services. The proportion of undetected dementia was significantly associated with its seriousness (light 95%, moderate 69%, severe 36%). Compared with older persons who were not demented, the demented used more often hospital services, medical and nursing consultations at home and consultations through third parties; and less often, preventive and rehabilitation services. This trend was accentuated in patients with grave dementia. The use of community social services was very low (below 8% in the most serious cases).

CONCLUSIONS

The detection of dementia in the elderly is very low and efforts to detect it in primary care need to be stepped up. Specific social-health resources for this population also need to be increased and the attendance guide-lines for primary care teams, and for health professionals in general, need to be changed.

The role of APOE-epsilon4 in longitudinal cognitive decline: MacArthur Studies of Successful Aging

BACKGROUND

While a genetic risk factor for late-onset AD, the effects of the epsilon4 allele of the APOE gene on cognitive functioning more generally remain unclear.

OBJECTIVE

To assess the role of the epsilon4 allele of the APOE gene in longitudinal cognitive decline.

METHODS

Multiple measures of cognitive function were assessed longitudinally in the MacArthur Successful Aging Study, a population-based cohort free of frank impairment at baseline. Subjects were 965 Caucasian and African American men and women from Durham NC, East Boston, MA, and New Haven, CT, aged 70 to 79 years, recruited in 1988 through 1989, who completed two follow-up evaluations, one at 3 years and another at 7 years.

RESULTS

At the first follow-up, modest but significant declines in naming and spatial ability were associated with the APOE-epsilon4 genotype. By the second follow-up, more pronounced and significant associations were noted between the APOE-epsilon4 genotype and cognitive decline from six of the eight cognitive outcomes. After 7 years, APOE-epsilon4 allele carriers were twice as likely to have declined on a global cognitive score (odds ratio = 2.0; 95% CI: 1.1, 3.6) as noncarriers.

CONCLUSIONS

APOE-epsilon4 is associated with cognitive decline among a high-functioning elderly cohort, with effects most pronounced after 7 years of follow-up. Hence, the epsilon4 allele either may function as a risk factor for cognitive impairment in normal aging across a broad spectrum of domains or may exert detectable effects early in a long prodromal AD trajectory.

Cognitive and functional decline in adults aged 75 and older

OBJECTIVES

To simultaneously examine the influence of functional disability on the development of cognitive impairment and the influence of cognitive status on the development of functional disability over time and compare findings across ethnic groups.

DESIGN

A population-based longitudinal study.

SETTING

Galveston County, Texas.

PARTICIPANTS

Three hundred sixty-five community-dwelling Hispanic Americans, African Americans, and non-Hispanic whites, aged 75 and older.

MEASUREMENTS

Baseline measures included demographics, self-reported chronic medical conditions, functional disability, and cognitive status. Longitudinal measures included functional decline and cognitive decline.

RESULTS

Substantial functional decline was associated with each additional error on the mental status measure; substantial cognitive decline was associated with each additional antecedent disability. These findings were evident across all three ethnic groups, even when taking into account the effects of demographic factors and chronic health conditions, although the specific chronic health conditions that influenced cognitive and functional decline were found to vary across the three ethnic groups.

CONCLUSION

Our findings suggest that, rather than simply being correlated markers of increasing frailty, cognitive and functional decline appear to influence the development of one another. Clinicians need to be aware of these associations, which may affect the direction of preventive care and rehabilitation in the oldest old. Appropriate intervention may result in the prevention or delay of functional disability and cognitive decline. Awareness of the specific chronic health conditions that increase the risk for cognitive or functional decline in various ethnic groups, and the effect of comorbid disease, may also help efforts to prevent decline in older adults.

Rural-urban differences in service use for memory-related problems in older adults

The reduced availability of providers and travel difficulties in rural areas may thwart older rural adults from getting the care they need for memory-related problems. The purpose of this study was to determine whether rural-urban differences exist in the probability of any service use of primary care physicians and mental health specialists in a full sample of older adults and in a subset of impaired respondents. In the full sample, rural respondents were 0.66 times as likely (p = .06) to have used primary care physicians for memory-related problems compared with urban respondents. In the subgroup, rural individuals were 0.26 times as likely (p = .02). In both groups, there were no rural-urban differences in the probability of mental health specialty use for memory-related problems. Further investigations are necessary to determine the causes.

Cognitive impairment, disruptive behaviors, and home care utilization

Disruptive behaviors by an elder with cognitive impairment, such as violence, abrupt mood swings, and overt inappropriate sexual behaviors have been known to create caregiver distress, but little is known about how these behaviors may influence the use of home care services by that elder or their informal caregiver. The purpose of this study is to explore the associations between type of cognitive impairment (cognitive impairment with no dementia, and dementia), selected disruptive behaviors, and the use of four home care services (homemaking/cleaning, personal care, in-home nursing, home-delivered meals). Secondary data analysis from the 1991-1992 Manitoba Study on Health and Aging data set was conducted, using a sample of 124 community-dwelling elders and their unpaid caregivers. Multivariate analysis revealed that disruptive behaviors were significantly associated with the use of two services: personal care and home-delivered meals. Being cognitively impaired with dementia was significant for only home-delivered meals. Overall functional status of the elder emerged as a consistent predictor.

Dementia in rural primary care practices in Lake County, Oregon

Procedures used in assessing patients with dementia in rural settings are little studied. Among all patients aged 65 years and older in the four primary care practices in Lake County, Oregon, dementia cases were identified from computerized office databases using preselected International Classification of Diseases, Ninth Edition, codes. A semi-structured chart review determined (1) a dementia diagnosis, (2) cognitive and functional domains assessed, and (3) diagnostic studies performed. Of 1540 available records, 30 had dementia. Nineteen of them met National Institute of Neurological and Communicative Diseases and Stroke-Alzheimer's Disease and Related Disorders Association criteria for Alzheimer's disease (AD). Cognitive impairment was documented in 73% of the 51 identified charts and all with AD. Laboratory studies were recorded in 33% overall and in 42% with AD. Neuroimaging was documented in 18% overall and in 16% with AD. The prevalence of documented dementia in these rural practices may be low, possibly because cases of mild dementia may not be labeled as such. Laboratory studies were performed in a minority of cases of dementia.

Medicare expenditures associated with Alzheimer disease

This study uses 4 years of data from the Medicare Current Beneficiary Survey to compare the use of Medicare covered services for persons who report having a diagnosis of dementia or Alzheimer disease with those who do not, adjusting for the prevalence of comorbidities and functional limitations. Although overall rates of Medicare spending are higher for demented persons, when other factors such as functional status are included in the predictive model, there is no consistent relation between the presence of dementia and higher Medicare spending. In some years, dementia was associated with higher adjusted expenditures for community living persons, whereas nursing home residents with Alzheimer disease have lower Medicare expenditures.

Medical services utilization and charge comparisons between elderly patients with and without Alzheimer's disease in a managed care organization

OBJECTIVES

The purposes of this study were to describe the health service utilization patterns and the associated charges for elderly patients (aged > or = 65 years) diagnosed with Alzheimer's disease (AD) enrolled in a managed care organization (MCO), and to compare these patterns and charges with those of elderly enrollees not diagnosed with AD (non-AD).

METHODS

We analyzed medical claims data over a 12-month period for the population of elderly patients with a diagnosis of AD or AD-related dementia, and for all other elderly patients enrolled in an integrated MCO. Comparisons were made at the level of service location (eg, inpatient hospital, outpatient hospital, physician's office).

RESULTS

For a total of 250 patients diagnosed with AD (66.0% female, 34.0% male; mean age. 80.5 years), health care charges were 1.6 times higher per patient per year than the corresponding charges for 13,553 non-AD patients (58.6% female, 41.4% male; mean age, 73.3 years). AD patients received 1.7 times more health care services per patient per year than their non-AD counterparts.

CONCLUSIONS

Despite the lack of nursing home and prescription drug data, our results show that AD patients in this MCO used more health care services and had higher annual medical care charges than non-AD patients. If MCOs conduct similar analyses of elderly AD patients' patterns of care and compare these with the patterns of elderly non-AD patients, they may be able to pinpoint areas of disparity in medical care and improve service delivery for AD patients.

Factors associated with admission to a geriatric hospital in semisuburban southern Japan

A case-control study was conducted to evaluate the factors associated with admission to a geriatric hospital. Case studied were 13 Japanese elderly who were admitted to a geriatric hospital because their female caregivers had found it impossible to look after them at home. We used 35 pairs of elderly and female caregivers, who were receiving domiciliary visits by nurses, in the catchment area of the hospital. The present study revealed that elderly with dementia (vs without; Odds ratio = 6.69) and with moderately limited activities of daily living (Barthel Index 61 +) (vs severely limited activities of daily living: Barthel Index 0-60; Odds ratio = 6.62), caregivers being a daughter-in-law (vs other kinship; Odds ratio = 6.30), were risk factors.

Association between bone mineral density and cognitive decline in older women

OBJECTIVE

To test the hypothesis that bone mineral density (BMD), a marker of cumulative estrogen exposure, is associated with cognitive function in nondemented older women.

DESIGN

A prospective cohort study.

SETTING

Clinical centers in Baltimore, Maryland, Minneapolis, Minnesota, the Monongahela Valley near Pittsburgh, Pennsylvania, and Portland, Oregon.

PARTICIPANTS

We evaluated 8333 older community-dwelling women enrolled in the Study of Osteoporotic Fractures who were not taking estrogen replacement.

MEASUREMENTS

Calcaneal and hip BMD were measured at baseline and at follow-up (4-6 years later); vertebral fractures were ascertained radiologically at year 6. Women were administered a modified Mini-Mental State Exam, Trails B, and Digit Symbol at baseline and at follow-up.

RESULTS

Compared with women with higher bone mineral density, women with low baseline BMD had up to 8% worse baseline cognitive scores (P = .001) and up to 6% worse repeat cognitive scores (P = .001), even after multivariate adjustments. For 1 SD decrease in baseline hip BMD or calcaneal BMD, women had a 32% (95% CI, 19-47%) or a 33% (95% CI, 20-48%) greater odds of cognitive deterioration (worst 10th percentile of change). Women with vertebral fractures had lower cognitive test scores and a greater odds of cognitive deterioration than those without fractures (OR = 1.29; 95% CI, 1.03-1.60).

CONCLUSIONS

Women with osteoporosis, whether measured by baseline BMD, reductions in BMD, or vertebral fractures, have poorer cognitive function and greater risk of cognitive deterioration. Our findings suggest a link between two of the most common conditions affecting older women. Further understanding of this association may be important for new treatment and prevention directions.

Functional significance of mild cognitive impairment in elderly patients without a dementia diagnosis

The authors investigated differences in functional ability among three groups of subjects who were not diagnosed with dementia: normal control (NC) subjects (n=35); Clinical Dementia Rating Scale (CDRS) score of 0 (minimal impairment; n=26); and CDRS 0. 5 (questionable dementia; n=42). CDRS 0 and 0. 5 patients reported significantly poorer functioning than NCs in household and other activities, but CDRS 0 and CDRS 0. 5 groups did not differ in self-reported functioning. It is likely that CDRS 0. 5 patients overestimated their functional abilities. Correlations between self- and informant reports of functional status were significantly lower in the CDRS 0. 5 group than in the CDRS 0 group, an important finding for clinical management because patients with questionable dementia may actually be more impaired than they admit. Informants' reports or standardized performance-based assessment should be considered in the clinical evaluation of such patients.

Dementing illnesses in rural populations: the need for research and challenges confronting investigators

Expansion of the world's elderly populations has increased concerns about aging-related medical disorders like Alzheimer's disease and other dementias. In the United States, one fourth of those older than age 65 and at greatest risk for developing dementia live in rural environments that may influence its manifestation. The objectives of this study were to determine the need for and potential benefits of further epidemiological research concerning dementia and similar disorders in rural U.S. populations and to identify pertinent methodological issues related to rural dementia research. This study employed a National Library of Medicine (MEDLINE) document search based on the key words "cognitive disorders," "dementia," "Alzheimer's disease," and "rural," followed by recovery of literature resources references in the bibliographies of selected articles. Nineteen studies focusing on dementia or related disorders in rural settings have been reported from around the world. While four of these were conducted in the United States, only one rural dementia prevalence study has been undertaken in this country. Because of methodological variability, comparisons of prevalence estimates between these rural studies, as well as with those from urban investigations, is difficult. Nonetheless, there is reason to believe that certain potentially dementing illnesses are more common in rural populations. There is also evidence to suggest that the screening instruments commonly used in such studies tend to misclassify rural elders as "false positive" dementia cases. Information regarding dementing disorders, particularly Alzheimer's disease, in rural populations is scarce. Preliminary observations that dementia may be more common in rural settings and that rural families are more likely to maintain their dementing elders in the community imply that further rural dementia research could yield important insights into the risk factors for these illnesses, the variables influencing their course, and the methods by which they can be more effectively managed. A determination of the reliability and validity of commonly used dementia screening instruments in rural populations would represent an important advancement in this area of research.

Aging and cognition

A substantial portion of elderly people experience declines in mental capacities. While these changes are often attributable to serious dementing illnesses such as Alzheimer's disease, a surprising number result from apparently normal aging processes. The effects of senescence on cognition may be indirect (i.e., gait instability leading to falling and subsequent head trauma); however, they may have a more direct and subtle impact on the brain. The evidence available to date suggests that only a limited range of cognitive domains are susceptible to these aging effects. Perhaps the most important are short-term memory functions. The specific character of these and other age-related cognitive deficits are reviewed.

Depression and disability associated with impaired vision: the MoVies Project

OBJECTIVE

To assess how depression and impaired vision relate to disability in older people.

DESIGN

An epidemiological survey of an age-stratified random community sample.

SETTING

The rural mid-Monongahela Valley in South-western Pennsylvania.

PARTICIPANTS

A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education.

MEASUREMENTS

Demographics, self-reported vision impairment, OARS Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies-Depression scale to assess depression.

RESULTS

Compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2). The number of depressive symptoms (1-4: OR = 2.4, CI = 1.8, 3.4) and (5+: OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender.

CONCLUSIONS

Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment. Treating depression may reduce excess disability associated with impaired vision.

Antidepressant use over time in a rural older adult population: the MoVIES Project

OBJECTIVE

To examine the use of antidepressant drugs over time among community-based older persons.

DESIGN

A longitudinal community study with four approximately biennial data collection waves (1987-1996).

SETTING

A low-socioeconomic status rural older community-based population in Southwestern Pennsylvania.

PARTICIPANTS

A total of 1681 individuals with a mean age of 72.9 years at study entry,

MEASUREMENTS

Antidepressant drug use, demographics, and health services utilization by self-report.

RESULTS

Antidepressant use was reported by less than 5% of the population during all four waves. It was associated with female gender, use of mental health services, presence of five or more depressive symptoms, and use of five or more prescription drugs, but not with age. During the four waves, tricyclics accounted for 84.6%, 85.3%, 78.4%, and 45.5% of total antidepressants used, whereas selective serotonin reuptake inhibitors (SSRIs) accounted for 2.6%, 11.8%, 8.1%, and 36.4%.

CONCLUSIONS

Overall, our data on antidepressant use in this rural older population mirror national trends away from tricyclics and towards SSRIs. Our findings also suggest underutilization of mental health services and antidepressant drugs in this population.

Care services for dementia patients: predictors for service utilization

AIM

The objective of this study was to examine service utilization figures among a representative sample of demented patients and to determine whether sociodemographic and health-related variables are associated with care utilization.

METHOD

The study population was derived from a population-based, two-stage cross-sectional study in The Netherlands and consisted of 102 demented subjects. Four levels of care intensity were used: level 1, no use of professional care; level 2, use of one or more types of professional care by community-dwelling subjects; level 3, residential living in homes for the aged; level 4, long-term care in specialized nursing homes. Sociodemographic variables and variables related to mental and physical health, functional dependency and severity of dementia were studied as determinants of levels of care.

RESULTS

Eighty-two per cent of the study subjects used one or more types of formal care and 55% were institutionalized. Multivariate analysis yielded age, severity of dementia, somatic disorders, dependency in terms of ADL and martial status as predictors of higher levels of care. Sets of predictors differed across different care levels.

CONCLUSIONS

The findings point to the importance of the social network and the relevance of general medical treatment and an active approach towards decreasing the impact of ADL dependency in demented subjects.

The relationship between self-rated health and depressive symptoms in an epidemiological sample of community-dwelling older adults

OBJECTIVE

To confirm the association between depression and self-rated general health, independent of demographics, functional disability, physical illness burden, and health services utilization.

DESIGN

Logistic regression analyses of data obtained in a cross-sectional epidemiological survey.

SETTING

The mid-Monongahela Valley, a rural, nonfarm, low SES community.

PARTICIPANTS

Random sample of 880 subjects aged 65 and older.

MEASUREMENTS

The dependent variable was self-rated overall health, categorized as excellent, good, fair, or poor. The independent variables were demographics (age, gender, education), number of depressive symptoms, number of impaired instrumental activities of daily living (IADLs), measures of physical illness burden (individual medical conditions, number of affected organ systems or disease processes, and number of prescription medications), and measures of health services utilization (number of visits to physicians, and acute hospitalization).

RESULTS

Univariate analyses indicated that poorer self-rated health was associated with lesser education, higher numbers of depressive symptoms, impaired IADLs, prescription medications, physician visits, hospitalizations, and affected organ systems, and with the presence of several specific conditions. However, multiple logistic regression analyses revealed that only the following variables were associated independently with poorer self-rated health: age less than 75 years, education less than high school graduation, greater numbers of depressive symptoms, impaired IADLs, prescription medications, and physician visits.

CONCLUSIONS

Even when controlling for physical illness and functional disability, subjective rating of overall health remains strongly and independently associated with depressive symptoms.

Nutrition and health for older persons in rural America: a managed care model

Health care services and resources for older persons living in rural areas may be highly variable, and integrated service-delivery models are often lacking. This article presents a managed-care model of nutrition risk screening and intervention for older persons in rural areas. Nutrition risk screening was implemented by the Geisinger Health Care System, Danville, Pa, to target all eligible enrollees in a regional Medicare risk program. A single remote clinic site participating in the managed health care system was chosen for further study of a linked screening and case-management effort for undernourished persons. Screening and intervention at the clinic site selected for this study were guided by centralized expertise and resources. Individualized evaluation and intervention plans were developed with the aid of a dietitian and implemented by the clinic case manager. Of the 417 subjects who completed screening at the remote site, 68 met the risk criteria for undernutrition and were selected for case management. Many of the targeted persons received interventions that included evaluations by a physician or physician extender (eg, physician assistant, nurse practitioner) at the clinic and consultations with nutrition, mental health, or social services professionals. Twenty-six of the subjects who took part in the intervention completed a follow-up screening 6 months later. Ten of those persons no longer exhibited risk criteria. This demonstrates the feasibility of a linked screening and case management program for nutrition risk in the managed-care setting.

Over-the-counter medication use in an older rural community: the MoVIES Project

OBJECTIVE

To examine the self-reported use of over-the-counter (OTC) medications and the factors associated with OTC use in a rural older population.

DESIGN

A cross-sectional study of an age-stratified random community sample.

SETTING

The mid-Monongahela Valley, a rural area of Southwestern Pennsylvania.

PARTICIPANTS

A total of 1059 older individuals with a mean age of 74.5 (+/- 5.5) years, 96.9% of whom were white and 57.3% of whom were women.

MEASUREMENTS

Self-reported over-the-counter drug use and demographic information, and information about prescription drug use and recent use of health services.

RESULTS

The majority (87.0%) of the sample were taking at least one OTC medication; 5.7% reported taking five or more OTCs. Women took significantly more OTCs than did men (P < .001). Individuals with more education took significantly more OTCs than those who had less (P = .018). The OTC category used most commonly was analgesics (66.3% overall), followed by vitamin and mineral supplements (38.1%), antacids (27.9%), and laxatives (9.7%). The use of analgesics decreased significantly (P = .018) with increasing age, whereas the use of laxatives increased significantly (P < .001). Women were more likely than men to be using each of these four major OTC groups. Unlike the associations with prescription drug use we reported previously in the same population, there were no significant associations for overall OTC use with age or with the use of health services. However, although vitamin use (as an example of an OTC drug taken for "preventive" purposes) was not associated with health services use, the use of laxatives (as an example of a "curative" OTC) was significantly associated (P < or = .002) with a greater number of physician visits, emergency room visits, hospitalizations during the past 6 months, home health care service utilization, and number of prescription medications.

CONCLUSIONS

A substantial proportion of our older sample reported using a variety of over-the-counter drugs. Analgesics and vitamin/mineral supplements were the most frequently used categories. Women and those with more education were taking more OTC drugs. OTC use was not related to age, but the use of analgesics decreased with age while laxative use increased with age. Unlike prescription drug use, overall OTC drug use was not associated with health services utilization.

Association between dementia and elevated TSH: a community-based study

We report on 194 individuals (96 men and 98 women), aged 65 and over, who had dementia assessments and basal TSH measurements as part of an ongoing epidemiological study of dementing disorders in a larger population. Dementia was diagnosed according to DSM-III-R and measured by the Clinical Dementia Rating scale; CDR scores of 0, 0.5, and > or = 1, represent individuals with no dementia (n = 122), possible dementia (n = 29), and definite dementia (n = 43), respectively. The odds ratio for the association of elevated TSH with definite dementia (CDR > or = 1) was 3.8 (95% confidence interval = 1.6, 9.1) and with possible and/or definite dementia (CDR > or = 0.5) was 3.8 (95% confidence interval = 1.6, 9.2), after adjusting for the effects of age, gender, and level of education. This is the first community-based study to report an association between TSH elevation and dementia. Our findings are consistent with recent evidence that subclinical hypothyroidism is associated with cognitive impairment, and that thyroidal state may influence cerebral metabolism.

Prevalence and persistence of sleep complaints in a rural older community sample: the MoVIES project

OBJECTIVES

To determine the prevalence and 2-year persistence of subjective sleep complaints in a rural older population.

DESIGN

A prospective epidemiological study of an age-stratified random community sample.

SETTING

The mid-Monongahela Valley, a rural area of Southwestern Pennsylvania.

PARTICIPANTS

A total of 1050 individuals with a mean age of 74.4 years (range, 66-97; SD = 5.5); 57.2% were women.

MEASUREMENTS

Subjective responses to questions about sleep complaints, classified as "never" experienced versus "sometimes" or "usually"; these questions reflected difficulty falling asleep (DFA), sleep continuity disturbance (SCD), early morning awakening (EMA), and uncontrollable daytime somnolence (DaSom). Subjects were also asked about snoring. Frequencies of these complaints were used to calculate their prevalence; those who remained in the study 2 years later were asked the same questions again to determine the persistence of sleep complaints. On the first occasions, subjects were also asked for "usual" estimates of how long they took to fall asleep, how many times they wakened during the night, and how many hours of sleep they obtained per night.

RESULTS

With regard to prevalence, 385 (36.7%) subjects reported DFA, 301 (28.7%) reported SCD, 201 (19.1%) reported EMA, and 198 individuals (18.9%) reported DaSom. Of those who knew whether they snored, 334 (40.0%) reported snoring loudly during sleep. Within the age range of this group, age was not associated with complaints of insomnia or somnolence; however, older age was associated with a significantly lower prevalence of snoring (P < .001). All three insomnia complaints were significantly more common among women (P < .001). Snoring was significantly more common among men (P < .005), but there was no gender difference in DaSom. With regard to subjective estimates, of those reporting DFA, 49.2% reported that sleep latency exceeded an hour; of those reporting SCD, 26.2% reported waking three or more times per night; and of the entire sample, 11.8% reported 5 hours or less, whereas 12.7% reported 9 to 12 hours, of sleep per night. Approximately 2 years later, among those who had reported insomnia previously and participated in the follow-up wave, the persistence of DFA was 74.9%, that of SCD 68.9%, that of EMA 47.3%, and that of known snoring was 59.6%. The persistence of DaSom, however, was only 5.7%; only DaSom was significantly (P = .049) associated with mortality.

CONCLUSIONS

Sleep complaints were common among these older individuals. Because these data were collected prospectively, they also provide objective evidence that insomnia is relatively persistent or chronic among older adults. This finding has implications for the diagnosis and long-term management of sleep disorders in older people. Derivation from a random community-based sample rather than from samples of patients or volunteers makes these data more generalizable to the general older population. Finally, these data describe a rural older populations, a group which, in general, is medically underserved and understudied.

Use of prescription medications in an elderly rural population: the MoVIES Project

OBJECTIVE

To determine the pharmacoepidemiology of prescription drug use in a rural elderly community sample, specifically the numbers and categories of medications taken and the factors associated with them.

DESIGN

Cross-sectional community survey.

SETTING

The mid-Monongahela Valley of southwestern Pennsylvania.

PARTICIPANTS

An age-stratified random sample of 1360 community-dwelling individuals, aged 65 years and older.

MEASURES

Self-reported use of prescription drugs demographic characteristics, and use of health services.

RESULTS

Nine hundred sixty-seven participants (71%) reported regularly taking at least one prescription medication and 157 (10%) reported taking five or more medications (median 2.0, range 0-13). Women took significantly more medications than men (median 2.0, range 0-13 and median 1.0, range 0-9, respectively; p = 0.01). The use of a greater number of medications was independently and statistically significantly associated with older age, hospitalization within the previous 6 months, home health care in previous year, visit to a physician within the previous year, and insurance coverage for prescription medication. Individuals older than 85 years were significantly more likely to be taking cardiovascular agents, anticoagulants, vasodilating agents, diuretics, and potassium supplements. Significantly more women than men were taking nonsteroidal antiinflammatory drugs, antidepressants, potassium supplements, and thyroid replacement medications.

CONCLUSIONS

Both the number and the types of prescription medications vary with age and gender. The demographic and health service use variables associated with greater medication use in the community may help define high-risk groups for polypharmacy and adverse drug reactions. Longitudinal studies are needed.

Characteristics of rural homebound older adults: a community-based study

OBJECTIVE

To determine the frequency and characteristics of homebound older adults in a rural community.

DESIGN

An epidemiological survey of an age-stratified random community sample.

SETTING

The rural mid-Monongahela Valley in Southwestern Pennsylvania.

PARTICIPANTS

A total of 878 noninstitutionalized persons aged 68 years and older, fluent in English, and with at least grade 6 education.

MEASUREMENTS

The frequency with which subjects left their homes, the Mini-Mental State Examination (MMSE) score, and additional information on demographics, self-reported health problems, health services utilization, IADLs, depression, and social support were measured.

RESULTS

10.3% of the sample was classified as homebound. In univariate analyses, being homebound was found to be associated significantly (P < .001) with being older, female, and widowed and with MMSE and IADL impairment, with more depressive symptoms and worse social supports, fair to poor self-rated general health, weight loss, and histories of stroke, angina, arthritis of the spine, and falls. In a multiple regression model, variables associated independently with homebound status were gender (odds ratio = 9.4, 95% confidence interval = 3.6 - 24.9), weight loss (OR = 3.7, CI = 1.7 - 8.2), IADL impairment (OR = 2.6, CI = 2.1 - 3.1), and depressive symptoms (OR = 2.1, CI = 1.3 - 3.2). Being homebound was also associated with recent acute hospitalization and use of home health and social services.

CONCLUSIONS

These data provide evidence that homebound older adults have a disproportionate share of morbidity and disability and suggest a sociodemographic and clinical profile to help identify those older people at risk of being or becoming homebound. They also point to the need for home-based health services for the older adults, particularly in medically underserved communities such as rural areas.

The loss of independence in activities of daily living: the role of low normal cognitive function in elderly nuns

OBJECTIVES

This study investigated the role of low normal cognitive function in the subsequent loss of independence in activities of daily living.

METHODS

Of the 678 elderly nuns who-completed cognitive and physical function assessments in 1992/93, 575 were reassessed in 1993/94. Mini-Mental State Examination scores were divided into three categories and related to loss of independence in six activities of daily living.

RESULTS

Participants with low normal cognitive function at first assessment had twice the risk of losing independence in three activities of daily living by second assessment relative to those with high normal cognitive function. This relationship was largely due to a progression from low normal cognitive function at first assessment to impaired cognitive function at second assessment and was associated with an elevated risk of losing independence in the six activities.

CONCLUSIONS

Progression from low normal to impaired cognitive function was associated with loss of independence in activities of daily living. Thus low normal cognitive function could be viewed as an early warning of impending cognitive impairment and loss of physical function.

The neuropsychological differentiation of patients with very mild Alzheimer's disease and/or major depression

OBJECTIVE

To evaluate the usefulness of standardized neuropsychological tests in the psychometric differentiation of patients with very mild or mild Alzheimer's Disease (AD) and/or major depression presenting in a tertiary clinic with memory/attention complaints.

DESIGN

Controlled prospective clinicoexperimental design.

SETTING

Multidisciplinary Memory Clinic at Addenbroke's Hospital, Cambridge, England.

PARTICIPANTS

Twenty-four patients with a clinical diagnosis of Alzheimer's disease (12 with major depression and 12 without), 12 patients with major depressive illness but without AD, and 12 healthy control subjects, all matched for age, sex, education levels, and estimates of premorbid intellectual potential.

MEASUREMENTS

Mini-Mental State Examination (MMSE), Wechsler's Logical Memory (WLM) and Visual Reproduction (WVR), immediate and delayed reproduction, Wechsler's paired Associate Learning (WPAL), including the Easy and Hard subsets. Warrington's Recognition Memory for Faces (WRMF), Kendrick's Object Learning (KOLT) and Digit Copying (KDCT) Tests.

OUTCOME MEASURES

Minimum 2-year follow-up diagnosis.

RESULTS

Statistically, patients with very mild AD were distinguished clearly from those without AD on most tests of memory functions. Psychometrically, only KOLT and an index of retention on WLM and WVR were specific enough to avoid false positives, a requirement for second-stage tools. They also proved sensitive enough to suggest their role as first-stage instruments when screening for primary dementia in high-functioning patients scoring above the cut-point on MMSE.

CONCLUSIONS

As efforts intensify to develop more powerful means to identify patients with Alzheimer's disease in its earliest stages, inclusion of specialist tests posing greater cognitive challenge than standard mental status scales has been one strategy. Our study explored how some of these neuropsychological tools behave psychometrically when analyzed on a single-case basis, and the results suggest a few are sensitive enough to boost detection above base rates alone while also being specific enough to reduce false alarms. Retention on Wechsler's Logical Memory and Visual Reproduction tasks and scores on Kendrick's Object Learning Test helped decrease the degree of ambiguity when cognitive profiles were used to distinguish depressed patients with Alzheimer disease from those without.

Depressive Symptoms and Associated Factors in a Rural Elderly Population: The MoVIES Project

In a random population sample of 1,040 elderly persons participating in a community survey, subjects were screened for depressive symptoms using a modified Center for Epidemiological Studies-Depression Scale. About 10% reported five or more possible symptoms of depression present during 3 or more days of the previous week. Approximately 1% of the sample had a sufficient number of symptoms for a diagnosis of major depression, although severity, disability, and 2-week duration were not assessed. More depressive symptoms were found to be independently associated with the following: age, widowhood, and less education; general health and appetite self-rated as fair-to-poor; and a greater number of sleep problems, social support problems, and stressful life events in the previous year. Further, subjects with more depressive symptoms were significantly more likely to have been recently hospitalized and to have used home health and social services. These findings have implications for the public health importance of depressive symptomatology, even when subsyndromal, in older groups.