Search

BACKGROUND AND AIMS: Pain is a common and unpleasant problem among elderly people and affects the possibility for them to remain living in their own homes. The aims of this study were therefore to report the prevalence of pain reporting and pain treatment, and their association with functional and cognitive status in a very old population. METHODS: Cross-sectional population-based study. Participants were 333, aged 84 years or older, living at home alone or with someone in Kungsholmen, in central Stockholm, Sweden. Information on pain was obtained from interviews. The Mini- Mental State Examination (MMSE) measured cognitive status and the index of basic Activities of Daily Living (ADL) functional status. Descriptive statistics were used to describe the population and logistic regression models to investigate factors associated with pain reporting and pain treatment. RESULTS: The prevalence of pain was 46%, and the prevalence of pain treatment 71%. Results from logistic regression analysis including all variables in the model showed that pain reporting was not associated with age, gender or living conditions. However, pain reporting was correlated with cognitive and functional status. There was no association between pain treatment and age, gender, living conditions, cognitive or functional status. CONCLUSIONS: Pain is common among the oldest old. Our results indicate that cognitive and functional status affect pain reporting. Poor cognitive status was associated with less pain reporting, whereas poor functional status was associated with more pain reporting. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIMS: To identify pre-operative risk factors for delirium in patients undergoing elective cardiac surgery, using clearly defined diagnostic criteria for delirium, and a thorough clinical assessment. METHODS: The incidence of post-operative delirium in 107 patients >/=60 years undergoing elective cardiac surgery was calculated. None of the patients included suffered from dementia. Pre-operative cognitive function in all patients was assessed using the Mini Mental State Examination (MMSE) and post-operative delirium was diagnosed using the Confusion Assessment Method (CAM). Post-operative clinical and cognitive assessments were carried out for all patients. RESULTS: Twenty-five patients (23.4%) developed delirium post-operatively. Clinical parameters, including age, gender, co-morbidities, medications, and peri-operative parameters, were similar in patients with and without post-operative delirium. Patients with pre-operative subjective memory complaints and lower MMSE scores, undergoing valve operation or valve + coronary artery bypass grafting (CABG), exhibited an increased risk of developing post-operative delirium. Additionally, delirious patients had a significant decline in post-operative MMSE score compared with the non-delirious ones. CONCLUSIONS: The main pre-operative risk factors for post-operative delirium after elective cardiac operations were subjective memory complaints, mild cognitive impairment, and type of cardiac surgery, such as valve procedures. This study suggests that cognitive evaluation should be included in pre-operative assessment. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIMS: Elderly people in Sweden live longer in their own homes, some of them with good health, and others with chronic conditions that require medical treatment. Thus, the aim of this study was to investigate factors influencing elderly people's handling of their medicines. METHODS: Cross-sectional population-based study. Participants were 333, aged 84+ years, living in their own homes. Information on regular drug use was obtained from interviews. Descriptive statistics were used to describe the population, and logistic regression models were used to investigate the factors associated with receiving help in handling medicines. The Mini-Mental State Examination (MMSE) measured cognitive status, and the basic Activities of Daily Living (ADL) assessed functional status. RESULTS: Most participants were women living alone. 88% of this population took medicines on a regular basis and 23% of them received help with medicine handling. Using logistic regression models controlling for sociodemographic variables, cognitive and functional status, female (OR=2.8, 95% CI=1.2-6.5) was the only variable associated with regular use of medicines. Older age and functional disability in ADL increased the risk of receiving help with medicines, while higher cognitive status decreased the odds of receiving help. The only factor related to receiving help from a family member was living alone (OR=0.05; 95% CI=0.01-0.40). CONCLUSIONS: This study indicates that cognitive and functional problems require increased help with handling medicines. These results stress the need for ongoing vigilance of, and support for, people with this high-risk profile. [ABSTRACT FROM AUTHOR]

Objective: To explore the hypothesis that older adults often are affected by more than one disease, making the differential diagnosis between Alzheimer's disease (AD) and vascular dementia (VaD) difficult. Methods: Incident dementia cases (n = 308) from a population-based longitudinal study of people 75+ years were investigated. The DSM-III-R criteria were used for the clinical diagnosis of dementia. Data on vascular disorders (hypertension, cerebrovascular and ischemic heart diseases, heart failure, atrial fibrillation, diabetes) as well as type of onset/course of dementia were used retrospectively to reclassify dementias. Results: Only 47% of the AD cases were reclassified as pure AD without any vascular disorder. Among subjects with AD and with a vascular component, cerebrovascular disease was the most common (41%). Only 25% of VaD were reclassified as pure VaD. Further, 26% of the pure AD subjects developed a vascular disorder in the following 3 years. Conclusions: Both vascular and degenerative mechanisms may often contribute to the expression of dementia among the elderly. Most of the AD cases have vascular involvements, and pure dementia types in very old subjects constitute only a minority of dementia cases. Copyright (c) 2006 S. Karger AG, Basel. [ABSTRACT FROM AUTHOR]

Dementia is a common and disabling disorder in the elderly. Because of the worldwide aging phenomenon, existing in both developed and developing countries, dementia has a growing public health relevance. This article reviews the prevalence and incidence data for dementia reported in the international literature in the last 10 years. Results from 36 prevalence and 15 incidence studies have been examined. Prevalence is equal to 0.3 to 1.0 per 100 people in individuals aged 60 to 64 years, and increases to 42.3 to 68.3 per 100 people in individuals 95 years and older. The incidence varies from 0.8 to 4.0 per 1000 person years in people aged 60 to 64 years, and increases to 49.8 to 135.7 per 1000 person years when the population was older than 95 years. The international comparison allows the following conclusions: both prevalence and incidence show little geographical variation, as differences between countries seem to reflect methodological rather than real differences [the low prevalence of dementia in Africa needs to be confirmed by incidence data]; both incidence and prevalence figures increase with age even in the advanced ages; regarding dementia types, most of the inconsistency in results from different studies is due to vascular dementia rather than to Alzheimer's disease (AD); it is still unclear if the reported higher frequency of vascular dementia in Asian populations is due to differential distribution of genetic and/or environmental factors, or due to methodological differences; different dementia types might have different age distributions. [ABSTRACT FROM AUTHOR]

We investigated the influence of individual-difference variables implicated as risk factors for Alzheimer's disease (AD) or known to be related to cognitive performance in normal aging (e.g., age, sex, years of education, previous and recent diseases, apolipoprotein E status, social network, and substance use) on rate of cognitive change from preclinical to clinical AD. With the use of data from a population-based study, 230 persons who were nondemented at baseline and diagnosed with AD at a 3-year follow-up were examined with the Mini-Mental State Examination (MMSE). Of all predictor variables examined, only number of diseases resulting in hospital admission during the follow-up period made an independent contribution to rate of MMSE change. These results suggest that many variables affecting the onset of the degenerative process as well as cognitive functioning in normal aging exert little influence on rate of cognitive change in preclinical AD. This may reflect the fact that the emerging dementia disease overshadows the role of these variables for cognitive functioning. A possible exception to this pattern is that an increasing number of concomitant health conditions may exacerbate the rate of cognitive decline during the final portion of the preclinical phase in AD. [ABSTRACT FROM AUTHOR]

QUESTION; In patients having major elective surgery, can a risk assessment system based on preoperative factors predict postoperative delirium risk?DesignA cohort study for validation of a previously developed Brigham and Women's Hospital Delirium [BWD] risk assessment system.SettingA clinic in Cleveland, Ohio, USA.Patients500 consecutive patients >/= 50 years of age (mean age 67 y, 61% women) having major elective surgery with an expected hospital stay > 2 days. Patients were excluded if they could not speak English, met the DSM-IV diagnostic criteria for delirium, or had an abnormal screening assessment for delirium.Description of prediction guidePatients were evaluated on preoperative medication use; medical history including chronic or acute illness, smoking habits, alcohol use, psychological or neurological disease, and history of delirium; laboratory tests; functional and cognitive status using the Specific Activity Scale and the Telephone Interview for Cognitive Status (TICS); and comorbid conditions. The expected delirium risk was calculated using the BWD scoring system (score range 0-8).Main outcome measureDelirium during postoperative days 1-4 was considered present if DSM-IV criteria were met and a >/=3 point reduction in the postoperative TICS score was seen relative to the preoperative TICS score. Postoperative measurements were made by clinical interviewers who were blinded to the preoperative results.Main results57 patients (11%) experienced delirium in the first 4 postoperative days. Postoperative delirium was seen in 6% of patients who had a BWD score of 0, 8% who had a BWD score of 1, 27%) who had a BWD score of 2, and 35% who had a BWD score of >/=3. The area under the receiver operating characteristics curve for the validation cohort (Cleveland Clinic population) (0.69, standard error [SE] 0.04) differed from that reported for the derivation cohort (Brigham and Women's Hospital population) (0.81, SE 0.02) (p=0.007). Using a BWD score >/=2, the sensitivity in predicting postoperative delirium risk was 47% in the validation cohort and 62% in the derivation cohort The table displays test characteristics for having a BWD score >/= 2.ConclusionIn patients having major elective surgery, a risk assessment system based on preoperative factors had fairly good specificity but variable sensitivity for predicting the risk of postoperative delirium. [ABSTRACT FROM AUTHOR]

Objectives: This study explored the effect of multimorbidity, cognitive and physical impairment, and sociodemographic factors on the choice of allocation of geriatric patients at hospital discharge., Design: Cross-sectional study, Setting and Participants: Eight hundred thirty patients 65 years or older admitted into an acute geriatric ward in Italy were evaluated (1998-2000)., Measurements: Social characteristics before hospitalization, multimorbidity, physical functioning, and cognitive status were related to allocation of living place after hospitalization (home, rehabilitation unit, or nursing home)., Results: Most patients were discharged to their homes (85%); 7% of the younger patients (65-74 years) and 11% of the very old (75+ years) were referred to a rehabilitation unit, while only among the very old 4% were discharged to a nursing home. Worse functional status, longer hospitalization, and being affected by dementia and cerebrovascular diseases (CVD) were associated with the admission to both rehabilitation and nursing home. Cognitive impairment and multimorbidity played a role in discharge destination, but only in functionally impaired patients. Living alone before hospitalization was correlated only with being discharged to a rehabilitation unit., Conclusion: In geriatric patients, both medical and sociodemographic characteristics are key factors for referral to rehabilitation or nursing home at discharge.

Cardiovascular diseases constitute the most common health problems in very old people. Consequently, cardiovascular drugs are the medicines that are most frequently used by elderly subjects. Although many studies have examined the physiological effect and adverse reactions of these drugs, knowledge on their effect on emotional well-being is missing. The present study aims to examine the association between cardiovascular diseases and their medical treatment on the emotional well-being of very old people. We investigated a representative group of elderly subjects gathered from a population-based study (n=235). Participants were 84 years or older and cognitively intact (mini-mental state examination (MMSE) > or =24 points). Well-being was assessed with the positive and negative affect schedule (PANAS), measuring different mood categories. Cardiovascular diseases were diagnosed following the International Classification of Diseases. In this population the prevalence of cardiovascular diseases was high (62%). Multivariate regression analysis showed that while being affected by a cardiovascular disease did not affect the emotional well-being of the subjects (PANAS-PA, p=0.171; PANAS-NA, p=0.209), the use of some cardiovascular drugs showed an association. Cardiac glycosides (p=0.006) and nitrates (p=0.008) were associated with increased negative feelings. Due to high prevalence of cardiovascular diseases and use of cardiovascular medicines, this finding has relevance on the quality of life of elderly people. However, due to the nature of this study we cannot assess cause-effect relationship of this positive association. Therefore, the present findings suggest that there is a need for clinical studies in this increasing and limited studied age group.

Objective: To evaluate the relationship between depressive symptoms, cognition and somatic diseases on functional status of geriatric patients at hospital discharge., Method: Patients 65+ years consecutively admitted to the acute care geriatric ward of the Internal Medicine Department I, Civil Hospital of Brescia, Italy, from February 1998 to December 2000 (n = 830) were examined. Functional disability was defined as need of physical assistance in at least one of the basic Activities of Daily Living (ADL). The Greenfield Index of Disease Severity (IDS) and the Geriatric Index of Comorbidity (GIC) were used to measure number and severity of diseases. The Mini-Mental State Examination (MMSE) assessed cognitive status and the Geriatric Depression Scale (GDS) measured depressive symptoms., Results: Prevalence of functional disability at discharge was 29.3% in the younger age group (65-74 years) and 55.2% in the older age group (75+ years). Using logistic regression models, older age, poorer cognitive status, and depressive symptoms were independently associated with functional disability in the younger and older age group, respectively. Additionally cognitive impairment and depressive symptoms showed an additive association with disability, especially in younger patients, while comorbidity was correlated with functional status only in the oldest old, in particular among those who were cognitively impaired., Conclusion: Functional disability after acute hospitalization is highly prevalent in geriatric patients. Depressive symptoms, comorbidity, and cognitive impairment often coexist, interact and are differentially associated with function depending on age. Considering that depressive symptoms are a modifiable problem, their detection in hospital settings may help clinicians in targeting subjects at high risk of functional disability., (Copyright 2004 John Wiley & Sons, Ltd.)

Objective: We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population., Methods: All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status., Results: After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years)., Conclusion: We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.

To estimate the relative effects of coexisting nondementia illnesses on the probability of functional disability, depending on the presence of cognitive impairment or dementia, we used data from the baseline case-control assessment of a longitudinal study of aging and dementia. Our study included 668 subjects (345 nondemented, 98 cognitively impaired, and 225 demented), aged 75 and older. Demented subjects had greater disability prevalence on all specific instrumental activities of daily living (IADL) and activities of daily living (ADL) items than cognitively impaired subjects who, in turn, had greater disability than nondemented subjects. Somatic illnesses were found to be associated with particular tasks in item specific models; decreasing MMSE was strongly associated with the probability of IADL and ADL disability, which increased dramatically in the presence of somatic illnesses among cognitively impaired as well as demented subjects. Attention to illnesses among cognitively impaired and demented people may shed light on remediable factors crucial to their daily functioning.

The goal of this study was to describe the evolution of dementia severity in a very old dementia population. We investigated a representative group of demented subjects gathered from a population-based study (n = 223). Changes in cognition, functioning, and performance on global scales were followed over a period of 7 years. At baseline, 19% of the demented subjects were found to be severely impaired according to the Clinical Dementia Rating scale, 41% according to the Mini-Mental State Examination score, and 31% according to Katz activities of daily living scale. After 7 years these proportions were 78%, 93%, and 68%, respectively. The probability of surviving 3 years, 5 years, and 7 years after baseline examination was 48%, 28%, and 15%, respectively. Over a 7-year follow-up period, subjects suffering from questionable-mild dementia had a mean survival of 3.9 years (95% confidence interval 3.3-4.5), whereas subjects with severe dementia survived on average 2.9 years (95% confidence interval 2.5-3.2). Male gender, lower education, and poor cognitive and functional status were associated with shorter survival in milder cases, whereas the only factors that predicted shorter survival in more severe cases were older age and poor functional status. Long-term survivors in dementia are not rare, and as the absolute number of demented people is increasing, expanding our knowledge of these persons is of high public health importance.

Background: The relationship between education and Alzheimer disease (AD) or dementia has been widely examined and the evidence obtained is mixed. Several hypotheses have been proposed to explain the observed association between them., Objective: To further understand the relationship between education and incidence of clinically diagnosed AD or dementia., Subjects and Methods: A community-based, dementia-free cohort of 1296 aged 75 years and older was followed up to detect incident AD or dementia cases using Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria. The vital status of all subjects who underwent the clinical examination at follow-up (n = 983) was ascertained for 5 years further. Data were analyzed with Cox proportional hazards model after adjustment for main potential confounders., Results: Over an average (SD) of 2.8 (1.0) years of follow-up, 147 subjects were diagnosed as having dementia (109 subjects as having AD). Among those who were clinically examined at follow-up, 88 died with dementia (68 died with AD) within 5 years. Subjects with a low level of education (<8 vs > or =8 years) had a relative risk of 2.6 (95% confidence interval, 1.5-4.4) for AD and 1.7 (95% confidence interval, 1.1-2.6) for dementia. A low educational level was significantly related to all-cause mortality (relative risk, 1.3; 95% confidence interval, 1.0-1.7; P<.05), but not to the mortality of subjects with AD (relative risk, 1.1; 95% confidence interval, 0.5-2.2) or dementia (relative risk, 0.9; 95% confidence interval, 0.5-1.5)., Conclusions: A low level of education is related to an increased incidence of clinical AD or dementia, but not to the mortality of subjects with AD or dementia. These findings can be accounted for by the "cognitive reserve" hypothesis. Alternatively, the observed association between educational level and incidence of AD or dementia may partly reflect detection bias, by which subjects with a low level of education tend to be clinically diagnosed at an earlier point in time.

The lack of biologic markers for Alzheimer's disease and vascular dementia, the controversy regarding the definition of vascular dementia, and the new evidence of vascular risk factors for Alzheimer's disease suggest that the traditional differentiation between Alzheimer's disease and vascular dementia is no longer very clear. We believe that both vascular and degenerative mechanisms contribute to the development of dementia, especially in very old age. The question of whether they are two independent parallel processes or interacting pathologies needs to be clarified.

The hypothesis that Alzheimer's disease (AD) and vascular dementia (VaD) differ in the pattern of episodic memory was examined in this study. Demented patients with AD and VaD and normal old adults were assessed on episodic memory tasks, including free recall and recognition of slowly and rapidly presented unrelated words and free and cued recall of organizable words. Results showed a general deficit in both demented groups across all memory variables, although the AD and VaD patients were indistinguishable across all measures. The normal old showed proficient utilization of more study time, organizability, and category cues. By contrast, the AD and VaD patients were able to benefit from cognitive support only when guidance was provided at both encoding and retrieval. In addition, in the normal old, recall of unrelated words was characterized by a relatively equal contribution from primary and secondary memory, whereas the demented patients relied predominantly on primary memory. The results suggests a similarity between AD and VaD patients with regard to the nature of the episodic memory impairment, despite etiologic differences between the diseases.

Vascular dementia, the second most common dementia after Alzheimer disease, has great potential for prevention and treatment. Epidemiological data provide the basis for planning primary prevention and clinical trials. Nevertheless, general consensus on disease definition and diagnostic criteria are still not well defined. Despite these limitations, some results from the Kungsholmen project, an epidemiological longitudinal study of people 75 years and older, are presented here.

Five-year follow-up of a community-based, 77+ old cohort including incident dementia cases was used to evaluate the impact of dementia on the risk of death, taking into account other chronic conditions potentially related to death, and contrasting Alzheimer's disease (AD), and vascular dementia (VaD). In this population, 70% of the dementia cases died during the five years after diagnosis, with a mortality rate specific for dementia of 2.4 per 100 person-years. After controlling for sociodemographic variables and comorbidity, 14% of all deaths could be attributed to dementia with a risk of death among demented subjects twice as high as that for non-demented people. Mortality risk ratios were 2.0 (95% confidence interval 1.5-2.7) for AD and 3.3 (95% confidence interval 2.0-5.3) for VaD. This study confirms that dementing disorders are a major risk factor for death. Even in the oldest old (85+), dementia shortens life, especially among women.

The elderly population is increasing more than any other sector of the population. Dementia, a prevalent condition in the elderly, increases disability, morbidity and mortality among older people. For these reasons the possibility of predicting progression and prognosis has enormous importance. Despite the fact that dementia has gained widespread recognition in the past few decades, the knowledge of its natural history, in terms of progression and prognosis are not yet completely understood. However, thanks to longitudinal research, which has only recently begun to proliferate, not only is better comprehension of the continuity of the cognitive decline possible, but also the identification of some prognostic factors.

Objective: To detect prognostic factors in very old demented subjects with Alzheimer's disease (AD), vascular dementia (VaD), and other types of dementia (OD)., Design: Follow-up clinical examinations of dementia patients from a population-based study after 3- and 7-year intervals., Setting and Participants: In an established population aged 75 years and older in Stockholm, Sweden, there were 133 cases of AD, 52 of VaD, and 38 of OD., Main Outcome Measures: Predictors of survival at 3- and 7-year follow-up examinations were evaluated by Cox proportional hazard models. Progression was measured as the annual rate of change in Mini-Mental State Examination (MMSE) scores. Linear models were used to evaluate predictors of progression., Results: Older age, male gender, low education, comorbidity, and functional disability predicted shorter 7-year survival in the 223 prevalent dementia cases. Other factors, including type of dementia, dementia severity, and duration of the disease were not significant. The average rate of cognitive decline in the 81 mild to moderate demented subjects who survived 3 years was 2.4 MMSE points per year. Type of dementia (AD vs OD), higher baseline cognitive function, and greater functional disability predicted faster decline. Despite similar survival probability, predictors of death varied as a function of dementia type: Older age (for AD and VaD), comorbidity (for AD and OD), and functional dependency (for VaD). In AD, prognostic factors were similar to those described for the combined dementia groups, with the exception of an accelerated cognitive decline among women., Conclusions: Although methodological difficulties exist, it is possible to identify demented subjects with worse prognoses (shorter survival and faster cognitive decline) by using clinical and demographic data. Clinicians and healthcare planners should be aware of the potential usefulness of functional dependence as a prognostic indicator. Finally, the need for careful clinical examinations of demented subjects is stressed by the increased mortality found among those demented who are also affected by other chronic conditions.

Data from the total urban elderly population (75 years and older) in Kungsholmen, Stockholm, were used to calculate age- and sex-specific prevalence of hypertension. Blood pressure was measured as part of the examination in the population survey (the Kungsholmen Project). The blood pressure of 1751 elderly people and any antihypertensive treatment were recorded. The prevalence of hypertension was 54 and 59 per 100 population for men and women, respectively. No great variation was observed with age or sex. Isolated systolic hypertension was most frequent with increasing prevalence in advanced ages, while isolated diastolic hypertension and systolic and diastolic hypertension showed a tendency of decreased prevalence with age. In the subjects studied, 18% were being treated for hypertension. Hypertension was detected in 47% of those not undergoing treatment. Among those, 76% had high blood pressure measurements. Our data demonstrate that hypertension is a prevalent disease in the very old, in both sexes, and support the need for hypertension screening programs as well as programs to evaluate the efficacy and benefits of treatment in this age group.

This study investigated the severity of dementia in relation to disease type and sociodemographic variables. The dementia cases were detected with a two-phase study design in a population aged over 74 years in Stockholm. The prevalence of questionable, mild, moderate, and severe dementia was 1.0, 3.1, 5.5, and 2.3 per 100, respectively. Women aged over 84 had the highest prevalence of severe dementia. More severe cases and a higher institutionalization rate were present for vascular dementia than for Alzheimer's disease. Fifty-five percent of the demented subjects but only 3% of the nondemented were institutionalized. The institutionalized demented subjects were affected mostly by moderate-severe dementia (88.6%), while the noninstitutionalized were affected more often by a questionable-mild form (68.3%).