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The article discusses the case study of a 62-year-old man suffering from a clogged sensation and hearing loss in one year. The various symptoms and the treatments given to the patient for otitis media are also analyzed.

Background. The role of the orexigenic hormone ghrelin is of major interest in the altered appetite regulation of the elderly. Methods. Basal and postprandial levels of active and total ghrelin were measured in 15 younger (mean age 35.4 years) and 19 older (80.7 years) participants following a carbohydrate-rich test meal. Results. Our results showed that older participants felt postprandially less hungry and more full. Although basal levels were not significantly different, active and total ghrelin levels declined postprandially only in the younger study participants. Highly significant differences between the two age groups were shown for the changes of the area under the curve for active ghrelin (p = .024). Conclusions. Our study demonstrates for the first time that differences in hunger and satiety sensations in relation to age are paralleled by a substantially different response of acylated and total ghrelin, that is, the absence of a postprandial decline in ghrelin levels. Key Words: Ghrelin--Leptin--Elderty--Appetite regulation--Insulin. doi: 10.1093/geronedglp 174

Background. Red cell distribution width (RDW) is a quantitative measure of variability in the size of circulating erythrocytes with higher values reflecting greater heterogeneity in cell sizes. Recent studies have shown that higher RDW is associated with increased mortality risk in patients with clinically significant cardiovascular disease (CVD). Whether RDW is prognostic in more representative community-based populations is unclear. Methods. Seven relevant community-based studies of older adults with RDW measurement and mortality ascertainment were identified. Cox proportional hazards regression and meta-analysis on individual participant data were performed. Results. Median RDW values varied across studies from 13.2% to 14.6%. During 68,822 person-years of follow-up of 11,827 older adults with RDW measured, there was a graded increased risk of death associated with higher RDW values (p < .001). For every 1% increment in RDW, total mortality risk increased by 14% (adjusted hazard ratio [HR]: 1.14; 95% confidence interval [CI]: 1.11-1.17). In addition, RDW was strongly associated with deaths from CVD (adjusted HR: 1.15; 95% Cl: 1.12-1.25), cancer (adjusted HR: 1. l 3; 95% CI: 1.07-1.20), and other causes (adjusted HR: 1.13; 95% CI: 1.07-1.18). Furthermore, the RDW-mortality association occurred in all major demographic, disease, and nutritional risk factor subgroups examined. Among the subset of 1,603 older adults without major age-associated diseases, RDW remained strongly associated with total mortality (adjusted HR: 1.32; 95% CI: 1.21-1.44). Conclusions. RDW is a routinely reported test that is a powerful predictor of mortality in community-dwelling older adults with and without age-associated diseases. The biologic mechanisms underlying this association merit investigation. Key Words: Aging--Erythrocyte Indices--Mortality--Risk Factors. doi: 10.1093/gerona/glp 163

Background. Fails are common in older people with Parkinson's disease (PD) and are likely to be related to gait disturbances associated with the condition. Although several studies have evaluated differences in basic gait parameters in people with PD, none have directly evaluated the stability of the upper body during gait. Methods. Temporospatial gait parameters and acceleration patterns at the head and pelvis were measured in three groups of older people: 33 controls without PD (mean age 67 [+ or -] 4 years), 33 older people with PD and no history of falls (mean age 63 [+ or -] 4 years), and 33 older people with PD and a history of falls (mean age 67 [+ or -] 2 years). Harmonic ratios of head and pelvis accelerations in each plane were calculated to provide an indicator of upper body stability. Results. Compared with the control group, older people with PD exhibited significantly reduced walking speed and step length and increased step timing variability. Acceleration patterns were also significantly less rhythmic at the head and pelvis in all three planes. After adjusting for differences in walking speed and step timing variability, PD fallers exhibited significantly less rhythmic accelerations at the pelvis in the vertical and anteroposterior planes than PD nonfallers. Conclusions. Acceleration patterns during gait differ between older people with and without PD and between older people with PD who do and do not fall. These findings suggest that an inability to control displacements of the torso when walking may predispose older people with PD to falls. Key Words: Parkinson's disease--Gait--Balance--Accidental falls.

Background. Cognitive impairment is an important contributor to disability. Limited clinical trial evidence exists regarding the impact of physical exercise on cognitive function (CF). We report results of a pilot study to provide estimates of the relative impact of physical activity (PA) on l-year changes in cognitive outcomes and to characterize relationships between changes in mobility disability and changes in cognition in older adults at increased risk for disability. Methods. Sedentary persons (102) at increased risk for disability (aged 70-89 years) were randomized to moderate_intensity PA or health education. Participants were administered the Digit Symbol Substitution Test (DSST), Rey Auditory Verbal Learning Test (RAVLT), modified Stroop test, and Modified Mini-Mental State Examination at baseline and 1 year. Results. Group differences were not significant but improvements in cognitive scores were associated with improvements in physical function. Specifically, the DSST significantly correlated with change in the Short Physical Performance Battery score (r = .38, p = .0002), in chair stand score (r = .26, p = .012), in balance score (r = .21, p = .046), and in 400-m gait speed (r = .15, p = .147). Change recall on the RAVLT and in the Stroop test was also positively correlated with changes in chair stand and balance, respectively. Conclusions. These results provide further support for the benefits of exercise on CF in older adults. An adequately powered clinical trial of PA involving older adults at increased risk for cognitive disability is needed to expand the indications for prescribing exercise for prevention of decline in brain function. Key Words: Exercise--Cognition--Aging--Prevention--LIFE study.

Background. Bioelectrical impedance analysis (BIA) is a noninvasive rapid and simple bedside technique that can be used to predict total body water (TBW), extracellular water (ECW), and intracellular water (ICW) and identify altered fluid distribution following critical illness. Methods. An equivalence study of BIA in 32 hospitalized elderly patients was compared with reference standard dilutional measurements of deuterated water (TBW) and sodium bromide (ECW). The results were compared with anthropometric equations commonly used to predict TBW. Results. There was variability in TBW content among the participating hospitaiized elderly patients. This variability was within ([+ or -]5 L) and the percent difference between the standard and BIA was as follows: mean (range) -4.1% (- 18.5 to 11.2). BIA reliably predicted TBW and ECW in individual participants, whereas standard prediction equations uniformly over- or underestimated TBW in individuals and whole group population. Conclusion. TBW in hospitalized elderly patients can be estimated noninvasively by bedside BIA. Standardized anthropometric equations have to be used with caution in this population. Key Words: Total body water--Body composition in aging Bioelectrical impedance.

Stroke remains a leading cause of disability for older adults. While is it well established in the literature that exercise programs can have significant benefit, many stroke survivors do not [...]

Background. Many older individuals decline functionally during hospitalization, and the deleterious consequences of bed rest may be one cause. This study reports on the effect of 10 days of bed rest on multiple functional parameters in healthy older adults. Methods. Healthy older men and women (n = 11, 67 [+ or -] 5 years old) remained on bed rest for 10 days continuously, and consumed a eucaloric diet providing the Recommended Dietary Allowance for protein. Measures of lower extremity strength and power, aerobic capacity and physical performance, as well as physical activity were performed before and after bed rest. Results. All measures of lower extremity strength were significantly lower after bed rest including isotonic knee extensor strength (-13.2 [+ or -] 4.1%, p = .004) and stair-climbing power (-14 [+ or -] 4.1%, p = .01). Maximal aerobic capacity was 12% lower after bed rest (p = .04), whereas measures of physical performance (Short Physical Performance Battery, and a five-item physical performance test) were not significantly different. Voluntary physical activity decreased after bed rest, and the percentage of time spent inactive increased (7.6 [+ or -] 1.8%, p = .004). There were no medical complications. Conclusions. In healthy older adults, 10 days of bed rest results in a substantial loss of lower extremity strength, power, and aerobic capacity, and a reduction in physical activity, but has no effect on physical performance. Identification of interventions to maintain muscle function during hospitalization or periods of bed rest in older adults should be a high priority. Key Words: Aging--Geriatric--Bed rest--Strength Power--Aerobic capacity--Function.

Background. The role of the ubiquitin-proteasome system in the vascular senescence and atherosclerotic progression of elderly patients is unclear. We evaluated ubiquitin-proteasome activity in carotid plaques of asymptomatic elderly and adult patients. Methods. Plaques were obtained from 28 elderly and 18 adult patients undergoing carotid endarterectomy. Plaques were analyzed for ubiquitin levels, proteasome 20S activity, p16 and p53, nitrotyrosine, matrix metalloproteinase-9 (MMP-9) and collagen content (immunohistochemistry and enzyme-linked immunosorbent assay). Serial sections were incubated with specific antibodies anti-human leukocyte antigen (HLA)-DR, anti CD68 and anti-CD3. Results. Compared to plaques obtained from adult patients, plaques of elderly patients had more ubiquitin levels (257.4 [+ or -] 118.9 ng/mg vs 110 [+ or -] 14.4 ng/mg, p < .001), nitrotyrosine (3.8 [+ or -] 0.55 nmol/pg vs 1.1 [+ or -] 0.19 nmol/pg, p < .001), p53 and p16 staining (p < .01), and MMP-9 levels (14.6 [+ or -] 2.5 [micro]g/mg vs 3.2 [+ or -] 0.1.8 [micro]g/mg, p < .001), along with a lesser collagen content (21.9 [+ o r -] 4.8% vs 7.1 [+ or -] 2.8%, p < .05) and less proteasome 20S activity (24.2 [+ or -] 6.9 pmol/ mg vs 78.4 [+ or -] 10.3 pmol/mg, p < .001). Conclusions. Our data suggest that reduction of proteasome activity promotes vascular cell senescence, thereby contributing to the pathogenesis of human atherosclerosis. Key Words: Atherosclerosis--Ubiquitin-proteasome.

Background. Power is critical to mobility and activities of daily living and is a key determinant of independence and falls prevention. Therefore, the quantification of power in older persons is critical. The power tests currently available are often expensive, potentially dangerous, and not reflective of everyday activities. We present a modification of an existing field test that uses ambulation up a standard access ramp to quantify functional power in older individuals. Methods. Three hundred sixty-three women and 157 men, aged 73.1 [+ or -] 7.0 years, ambulated up a standard access ramp (1:12 rise/ran ratio) as quickly as possible. Each person performed one practice and two timed trials. Results. Comparisons with accepted power measures and reported patterns of change with aging supported the validity of the ramp power test. The test was found to be reliable across multiple trials and days. Pair-wise comparisons showed that for women the test was sensitive to differences in power output by half-decade, whereas for men it could distinguish between 9 of the 15 comparisons among age groups. Percentile scores are reported by half-decade for power in both genders. In > 1200 trials performed during this study, only one injury (a slightly strained hamstring) occurred. Conclusions. The ramp power test is valid and reliable and can safely distinguish power by half-decade in women and among the majority of age groups in men. Its safety, low cost, and ease of administration make it a feasible diagnostic tool to assess functional power levels in ambulatory older persons.

Background. The study aim was to determine the kinetics of serum pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in hip-fracture patients over a month postfracture, and their relationship to postoperative (postop) complications and cognitive level. Methods. Forty-one elderly hip-fracture patients were prospectively followed. Serum was obtained during the first 10 hours postfracture and presurgery, 48-60 hours postop, 7 and 30 days postop, measuring CRP, interleukin-1[beta] (1L-1[beta]), IL-6, IL-8, tumor necrosis factor-[alpha] (TNF-[alpha]), IL-10, and IL-1 receptor antagonist (IL-1RA). Results. A significant increase was found postop for CRP, IL-6, TNF-[alpha], IL-1RA (p < .001), IL-10 (p < .002), and IL-8 (p = .05). CRP kinetics curves were higher in patients with complications as a group, and in those suffering from infections, delirium, and cardiovascular complications (p < .05). IL-6 increase in patients with complications approached significance. Additional complications appeared in patients with impaired mental status (IMS) versus cognitively normal patients (p = .037). Higher kinetics curves in the IMS patients were found for CRP and IL-6 (p < .05). Analyzing the interaction effect of complications and IMS on CRP and cytokines production demonstrated that the increase in CRP was independently related to complications and IMS. IL-6, IL-8, and IL-10 were higher in IMS patients but not in patients with complications without IMS (p < .05). Conclusions. Serum CRP and cytokines increased drastically in postop hip-fracture elderly patients. Only CRP significantly and independently increased in IMS patients and in patients with complications, whereas cytokines significantly increased only in IMS patients. This study raises questions about possible effects that cytokine generation, after hip-fracture repair, might have on cognition and complications.

Background. There is growing evidence for the significant involvement of inflammatory processes in the development of muscle wasting in old age. Therefore, any disease accompanied by inflammation can be threatening to the muscle function in geriatric patients. Methods. Sixty-three hospitalized geriatric patients (42 female, 21 male; mean age 84.2 [+ or -] 5.7 years) were monitored weekly for muscle function (grip strength, fatigue resistance, shoulder extension strength, and hip extension strength) and for concentration of circulating C-reactive protein (CRP), fibrinogen, interleukin 6 (IL-6), and tumor necrosis factor-[alpha] alpha (TNF-[alpha]). Results. On the basis of circulating CRP and fibrinogen concentrations, 42 patients were categorized on admission as inflammatory and 21 as noninflammatory. Inflammatory patients presented significantly weaker grip strength, shoulder extension strength, and a worse fatigue resistance than did noninflammatory patients. These muscle functions were negatively correlated with the concentrations of circulating CRP and IL-6, but not with fibrinogen or TNF-[alpha]. In noninflammatory patients, the fatigue resistance improved significantly during the first week of hospitalization. In patients admitted with inflammation, no improvement of muscle function was observed. Patients who remained inflammatory for 2 weeks or more presented a significant worsening of fatigue resistance. Conclusions. Geriatric hospitalized patients presenting with inflammation show significantly worse muscle functions, which do not improve during hospitalization despite adequate treatment of the primary disease. Reduced strength and fatigue resistance are significantly related to the concentration of circulating CRP and IL-6. Standard treatment of the underlying illness and classic physical therapy are not sufficient to normalize the skeletal muscle strength and fatigue resistance in these hospitalized patients.

Background. Although diabetes in elderly persons is generally type 2, the metabolic abnormalities associated with aging suggest that elderly persons may differ from younger persons with type 2 diabetes. In addition, nonobese elderly persons with type 2 diabetes show a marked impairment in insulin release accompanied by mild insulin resistance, whereas obese elderly persons have marked insulin resistance in the presence of 'adequate' levels of insulin. Other factors that could adversely affect glucose tolerance in aging include drug use, associated disease, and other stressful conditions commonly encountered in geriatric inpatients units. The authors' objectives in this study were 1) to prospectively assess the prevalence of glucose homeostasis abnormalities among elderly hospitalized patients and the degree to which it reflects abnormalities in insulin secretion or insulin sensitivity using homeostasis model assessment of fasting glucose, insulin, and C- peptide; and 2) to define the social, functional, pathologic, and nutritional characteristics of persons with impaired glucose tolerance or diabetes. Methods. Ninety-eight patients underwent a comprehensive geriatric assessment. Determinants of glucose homeostasis were assessed using the homeostasis model assessment, which provides estimates of [beta]-cell function (%B) and insulin sensitivity (%S). Results. Twelve patients (12%) had fasting glucose concentrations greater than 110 mg/dl. Four patients had impaired fasting glucose levels greater than 110 mg/dl but less than 126 mg/dl (IFG group), and 8 patients had levels greater than 126 mg/dl (type 2 diabetes group). Except for a higher proportion of women in the IFG-diabetes group, the latter did not exhibit significant differences in functional, morbidity, or nutritional characteristics compared with the normal glucose tolerance group. The entire cohort (n = 98) presented with a mean ([+ or -] SD) %B of 71% [+ or -] 47% and a mean %S of 208% [+ or -] 198%. Compared with the normal glucose tolerance group, the IFG-diabetes group had a fasting glycemia level of 142 [+ or -] 24 mg/dl (vs 92 [+ or -] 9 mg/dl), a %B of 43% [+ or -] 21% (vs 74% [+ or -] 45%), and a mean %S of 126% [+ or -] 113% (vs 219% [+ or -] 205%). Conclusions. These data confirm the high prevalence of impaired glucose metabolism among elderly people, although the usual risk factors were not significantly increased. Marked [beta] secretory defects seem to be the rule, whereas a significant degree of insulin resistance is unusual.

Background. Disability questions require older people to report difficulties with everyday activities, using broad categorical responses. Relatively little is known about population group differences in the thresholds for reporting difficulty or inability with medium-distance mobility against tested mobility related performance. We aimed to estimate the thresholds on tested performance at which self-reports change from one category to another, across a range of sociodemographic subgroups. We also aimed to compare reported and tested performance across two national population studies. Methods. The samples were from the third O.S. National Health and Nutrition Examination Study (NHANES III) and the Longitudinal Aging Study Amsterdam (LASA). Measures of gait speed, chair stands, and peak expiratory flow rate in both studies yielded the validated index of mobility-related physical limitations (MOBLI). Latent probit models were used to estimate cutpoints (thresholds) on the index lot reporting difficulty or inability to walk a medium distance. Results. Thresholds for reporting difficulty or inability were studied by age, sex, race, educational level, and income in NHANES III. In models adjusting for the other factors, performance thresholds for reporting disability categories varied by age and income. The younger elderly persons in NHANES III on average reported difficulties or inabilities only when they reached a more severe level of tested limitation compared with older old persons. A similar pattern exists for those on higher incomes. For race, differences in threshold were present only for reporting inability, but not difficulty. Significant differences in thresholds were not present between groups defined by sex or for years of education. Comparisons between the NHANES and LASA studies show that lower reported mobility difficulty or inability prevalence in the Dutch sample is attributable both to reporting at higher levels of limitation and to better functioning. Conclusions. There is evidence of differences in thresholds for reporting mobility disability, especially across age and income groups in older Americans. Further work is needed to understand the perceptual, attitudinal, or environmental factors that cause these reporting differences.

Background. African Americans undergo joint replacement less often than do while persons. The authors studied African-American perceptions and preferences lot the care of knee and hip pain. Methods. 10 focus groups were conducted in an inner city community. Participants, older persons with chronic knee or hip pain, were asked to discuss their perceptions and preferences for the care of knee and hip pain. Transcripts were coded for thematic structure using NUD*ST software. Results. Cultural preferences and perceptions for care emerged as a major theme, Important subcategories of this theme included respect for the patient's faith and religiosity and perceptions of physician ethnicity, race, and sex. Conclusions. This sample of older inner oily African Americans expressed unique cultural perceptions and preferences for the care of their knee and hip pain. Respect for patients' faith was important, whereas physicians' race, ethnicity, and religious background were not.