Exercise training in the debilitated aged: strength and functional outcomes

OBJECTIVE

Resistance and endurance training result in gains in fitness in the aged. It is unclear whether the debilitated elderly can perform moderate-intensity training and whether such training results in short-term improvements in strength, endurance, and function in this population.

DESIGN

Randomized, controlled trial.

SETTINGS AND PATIENTS

Subjects were from a Veterans Affairs nursing home and rehabilitation unit and a community nursing home. They were older than 60 yrs with impairment in at least one physical activity of daily living. Seventy-eight subjects volunteered and 58 (mean age, 75 yrs; 9 women, 49 men) completed the intervention and initial posttest. Only one subject withdrew because of injury or disinterest.

INTERVENTION

Thrice-weekly resistance training (using an isokinetic dynamometer) and twice-weekly endurance training for 4 to 8 weeks.

MAIN OUTCOMES

Isometric strength in dominant arm and leg, heart rate response to timed endurance test, and activities of daily living score.

RESULTS

The mean change in isometric strength across the muscle movements tested was 32.8% in the training group and 10.2% in the control group (difference, 22.6%; 95% confidence interval, 6.2% to 39.0%). No change in heart rate during exercise was seen in the training group. Trained subjects tended to have a greater improvement in functional activity than control subjects, which was statistically significant (p = .04) for those subjects who at enrollment were most dysfunctional (i.e., activities of daily living score less than 13 [maximum score 26]).

CONCLUSION

This group of debilitated elderly patients effectively performed resistance training and increased their strength, with the most impaired gaining the most function. Few in the group could effectively perform endurance training.

Influenza vaccination and warfarin anticoagulation: a comparison of subcutaneous and intramuscular routes of administration in elderly men

STUDY OBJECTIVES

To determine if subcutaneous administration of influenza vaccine is as immunogenic as the intramuscular route, and to evaluate the frequency of local adverse events associated with both routes in elderly anticoagulated men.

DESIGN

Single-blind, prospective study of consecutively enrolled subjects.

SETTING

Ambulatory clinic at a university-affiliated Veterans Affairs medical center.

PATIENTS

Twenty-six men age 60 years or older, receiving therapeutic dosages of warfarin.

INTERVENTIONS

Subjects were randomized to receive either intramuscular or subcutaneous injection of a standard trivalent influenza vaccine.

MEASUREMENTS AND MAIN RESULTS

Serum antibody titers to the vaccine's components were measured at baseline, and 6 weeks and 4 months after vaccination. Both routes of administration induced comparable serum antibody titers. There were no differences in adverse events at administration sites between routes of administration.

CONCLUSIONS

Elderly individuals are able to mount an immune response to influenza vaccine and produce antibody concentrations deemed protective. The routes of administration are similarly effective at inducing an immune response. The intramuscular route in anticoagulated elderly men does not commonly result in local bleeding complications.

Appropriateness of iron prescribing: a retrospective study

We retrospectively reviewed the charts of 120 patients who received an initial prescription of iron from a resident physician in internal medicine to determine how accurately house officers diagnose iron-deficiency anemia before initiating iron therapy. Each patient's laboratory records were reviewed for the 3-month period before the prescription. Of the 120 patients, 77 (64%) did not have any iron tests performed to aid in the diagnosis of iron-deficiency anemia. Forty-three percent of those who had iron tests did not have the disorder by our criteria. Ferritin levels and iron profiles are often not measured in patients prescribed iron, and when they are, they are frequently misinterpreted by medical house officers. This can lead to inappropriate gastrointestinal procedures as well as inappropriate prescribing of iron.

Assessing medical interview performance. Effect of interns' gender and month of training

Observation of history taking is commonly used to assess interviewing skills in medical internships, yet specific interviewing problems are infrequently documented. We evaluated videotaped recordings of 83 complete medical histories of new patients for content and questioning technique. Frequent deficiencies were found in history of medication compliance, gynecologic and psychiatric history, use of open questions, and mental status examination. The initial segments of 48 interviews were evaluated, and in 44% the patient was not allowed to complete their opening statement of concerns. Female physicians allowed fewer patients to finish their opening statement, and physicians at the end of the internship permitted the patients less time to express their concerns. Structured evaluation of complete histories reveals frequent interviewing problems as well as possible important effects of physician gender and length of training.

Health status of the aged: medical profile of a group of functional elderly

By studying a group of very elderly but generally functional people, we have compiled a medical profile that helps describe health-related characteristics of effective aging. We obtained functional, nutritional, and biochemical information regarding 61 men and women (mean age 86.8 years) attending a veterans' convention. Twenty-three out of 60 (38%) reported a fall in the previous year, with those who were less physically active falling more than the most active. Many of the men were thin or had lost weight, but at most 3 of the 25 male subjects were clinically malnourished. Many of the women were heavy but were otherwise healthy. Of the 36 women, 6 (17%) had an elevated level of thyroid-stimulating hormone (TSH). Five of 58 (9%) had low vitamin B12 levels. Even in the older old who seem to be aging well, falling is relatively common, and screening for certain laboratory abnormalities has a reasonably high yield.

Drug use among functionally active, aged, ambulatory people

BACKGROUND AND METHODS

Only a few pharmacoepidemiology studies have included very old subjects and most studies included both healthy and very ill people. Interpretation of data from these investigations is limited because of the mix of health status in the populations studied. We examined drug use in a group of active, relatively healthy, older people. Sixty-one attendees at a national convention, aged 76-96 years, volunteered to participate in a study on health status in a very old, ambulatory population. Medication histories, selected blood biochemistry analyses, a mental status examination, and other data were collected.

RESULTS

The mean number of prescription and nonprescription drugs used per person was 2.02 and 1.85, respectively. More than a quarter of the sample population took no prescription medications and two-thirds used two or fewer prescription drugs. Sixteen percent of those taking prescription medications experienced adverse effects from their current drug regimens. Although falling was prevalent among our study subjects, there were similar drug-use patterns in those who did and who did not fall.

CONCLUSIONS

In a group of relatively healthy and functional very old people, we found that drug use was not excessive, although adverse effects were still prevalent. In addition, most subjects were knowledgeable about their medications. These studies demonstrate that extreme age alone does not always result in sickness, frailty, and overuse of medications.

Anergy testing in nursing home residents

Delayed cutaneous hypersensitivity (DCH) testing is commonly used to determine exposure to Mycobacterium tuberculosis and in the evaluation of cellular-mediated immunity. Many reports indicate that anergy to ubiquitous antigens is common in the elderly. Recent studies suggest that anergy in the aged is not common when five or more antigens are used. Because it is often difficult to purchase singularly or apply a larger number of quality DCH antigens, we investigated the usefulness of the Multitest CMI in 29 nursing home residents with chronic diseases. This device simultaneously applies seven skin test antigens and a negative control. Ten young healthy subjects served as controls. DCH reactions were scored based on the sum of induration and total number of positive responses. Although elderly subjects had significantly lower scores than the young subjects, only 7% of elderly subjects were anergic. Our data indicate that the Multitest CMI is a highly effective device to test for DCH in geriatric subjects with chronic diseases. Although skin test responses in these subjects were blunted, in most residents cellular-mediated immunity remained intact.

Evaluation of temazepam and diphenhydramine as hypnotics in a nursing-home population

Seventeen nursing home residents with sleeping problems were enrolled in a randomized, double-blind, crossover trial of temazepam 15 mg, diphenhydramine (DPH) 50 mg, and placebo. Each drug was given for five consecutive nights with a 72-hour washout period between drugs. Subjects were assessed three times weekly with tests of psychomotor and cognitive function and four times weekly with observer sleep diaries and morning sleep questionnaires. Three subjects failed to complete the study. By report of the subjects, DPH resulted in shorter sleep latency than did placebo (t = 2.77, p less than 0.05). On the fifth night, use of DPH was associated with longer duration of sleep than temazepam (t = 2.88, p less than 0.05). No significant difference in tests of neurologic function was noted although, compared with placebo, subjects performed more poorly on seven of eight tests while taking temazepam and five of eight tests while taking DPH. Several instances of daytime hypersomnolence were noted in subjects taking temazepam and DPH, but none in subjects given placebo.

Initial treatment of hypertension: a questionnaire survey

The "stepped care" (SC) approach to the management of hypertension has been the standard of care for many years. Recently, concerns about safety of diuretics, coupled with the development of a variety of new antihypertensive agents, have led to questions about the continued use of SC. It is unclear what effect this continuing debate has had on the initial selection of drugs to treat mild to moderate hypertension. We developed four vignettes intended to represent typical patients with mild to moderate hypertension and asked three groups of physicians (house staff, faculty physicians, and private practitioners) how they would initially treat the patients represented by the vignettes. Ninety-five physicians responded. Among the physicians who chose a drug therapy for a vignette (85.9% of total responses), 81.2% selected either a diuretic or a beta-blocking agent, the standard SC regimen. Differences among the groups of physicians dealt with decisions to treat rather than choice of drugs, although house officers tended to use slightly more beta blockers and non-SC drugs. In spite of recent criticism of the SC approach, many physicians are comfortable with the use of diuretics or beta-blocking agents as the initial treatment of mild to moderate hypertension.