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Traumatic brain injury (TBI) is a significant problem in older adults. In persons aged 65 and older, TBI is responsible for more than 80,000 emergency department visits each year; three-quarters of these visits result in hospitalization as a result of the injury. Adults aged 75 and older have the highest rates of TBI-related hospitalization and death. Falls are the leading cause of TBI for older adults (51%), and motor vehicle traffic crashes are second (9%). Older age is known to negatively influence outcome after TBI. Although geriatric and neurotrauma investigators have identified the prognostic significance of preadmission functional ability, comorbidities, sex, and other factors such as cerebral perfusion pressure on recovery after illness or injury, these variables remain understudied in older adults with TBI. In the absence of good clinical data, predicting outcomes and providing care in the older adult population with TBI remains problematic. To address this significant public health issue, a refocusing of research efforts on this population is justified to prevent TBI in the older adult and to discern unique care requirements to facilitate best patient outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the relationship between leptin and unintentional weight loss in older adults. DESIGN: Prospective cohort study over 2 years. SETTING: University-affiliated Veterans Affairs Medical Center. PARTICIPANTS: The subjects were 105 community-dwelling male veterans aged 65 and older who had participated in a prospective cohort study on nutrition and health conducted at the Veterans Affairs Puget Sound Health Care System from 1986 to 1989. MEASUREMENTS: Anthropometric data and fasting blood specimens were collected at baseline and annually for the subsequent 2 years. Stored blood specimens were analyzed for leptin, insulin, glucose, C-reactive protein, sex hormone binding globulin, and testosterone levels. RESULTS: Over 2 years, 75 men were weight stable (weight loss <4% of baseline) and 30 men had unintentional weight loss (weight loss>4% of baseline). The baseline body mass index (BMI) and leptin levels for the two groups were not statistically different. Positive correlations existed between leptin level and BMI at each time point for weight-stable and weight-loss subjects. Furthermore, a significant relationship existed between changes in leptin and changes in BMI over 1 year in multiple regression analysis (r = .436, P < .001 after the first year; and r = .630, P = .027 after the second year). CONCLUSIONS: Like in younger adults, plasma leptin levels remained proportional to BMI, and changes in BMI were accurately reflected by changes in leptin levels in older individuals. Fasting leptin levels did not predict involuntary weight loss over 2 years of follow-up. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P < .001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects' perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P < .001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia). [ABSTRACT FROM AUTHOR]

OBJECTIVES: To learn whether managed care patients with Alzheimer's disease (AD) are more or less costly to care for than patients with other forms of dementia or patients without dementia during the last few years of life. DESIGN: Case control study. SETTING: A health maintenance organization base population. PARTICIPANTS: Three groups of subjects (mean age 85) who were deceased members of a dementia registry obtained from a health maintenance organization base population: 263 subjects with clinically diagnosed probable AD, 133 subjects with other forms of dementia, and 100 cognitively intact controls. MEASUREMENTS: Utilization records were examined for the 3 years preceding death. RESULTS: In all subcategories and in aggregate, utilization and costs of care were either similar or lower for patients with AD than for the other groups, even after controlling for age, gender, and comorbidity. CONCLUSIONS: Persons with AD do not incur higher costs than persons with other types of dementia or age-matched persons without dementia in a mature health maintenance organization during the last few years of life, when utilization is likely to be highest. [ABSTRACT FROM AUTHOR]

Examines interventions in physician-elderly patient interactions. Observational studies; Unique needs of elderly patient compromising communication with physicians; Structural context intervention and geriatric assessment units; Randomized controlled trial and physician-elderly patient interactions; Ethnicity and minority issues.

The article presents a response from the American Geriatrics Society to the letter to the editor "Misuse of Beers Criteria" by Marc S. Berger in the July 2014 issue.

The article presents an introductory statement pertaining to the exponential growth of older people published within the issue.

OBJECTIVES: To describe the types and potential clinical significance of medication administration errors in assisted living (AL). DESIGN: Cross-sectional observational study. SETTING: This study was conducted in 12 AL settings in three states (Oregon, Washington, and New Jersey). PARTICIPANTS: Participants included 29 unlicensed assistive personnel and 510 AL residents. MEASUREMENTS: Medication administration observations, chart review, and determination of rates, types, and potential clinical significance of errors using standardized methodology. RESULTS: Of 4,866 observations, 1,373 errors were observed (28.2% error rate). Of these, 70.8% were wrong time, 12.9% wrong dose, 11.1% omitted dose, 3.5% extra dose, 1.5% unauthorized drug, and 0.2% wrong drug. Excluding wrong time, the overall error rate dropped to 8.2%. Of the 1,373 errors, three were rated as having potential clinical significance. CONCLUSION: A high number of daily medications are given in AL. Wrong time accounted for the majority of the errors. The bulk of the medications are low risk and routine; to promote optimal care delivery, clinicians need to focus on high-risk medications and residents with complex health problems. [ABSTRACT FROM AUTHOR]

The American College of Cardiology/American Heart Association (ACC/AHA) published guidelines for preoperative cardiac risk stratification in 1996. Although clinician practice may differ from the guidelines, it remains unclear whether deviation from these guidelines affects clinical outcomes. This study sought to determine if discordance between clinician practice and the ACC/AHA guidelines affects perioperative cardiac outcomes. Eight hundred twenty-three patients who underwent 864 consecutive preoperative evaluations performed from 1995 to 1997 at a tertiary care academic medical center were prospectively followed. Clinician recommendations for preoperative cardiac testing were compared with ACC/AHA guideline recommendations. Frequencies of perioperative cardiac complications were compared between concordant and discordant testing recommendations. There were 33 perioperative cardiac complications (3.8%). Overall, there was no difference in the frequency of complications when there was discordance with the ACC/AHA guidelines compared with concordance (4.1% vs 3.7%, p = 0.81). The ACC/AHA guidelines recommended cardiac testing for 236 patients (27.3%). Clinicians ordered testing in half of those cases (n = 112). There was a lower frequency of cardiac complications when clinicians did not perform testing as recommended by the ACC/AHA guidelines (3.2% vs 10.7%, p = 0.02). Conversely, clinicians ordered cardiac testing in 45 patients (7%) when not recommended by the guidelines. Patients in this group had a trend toward more cardiac complications (6.7% vs 2.4%, p = 0.09). In conclusion, the failure of clinicians to follow the ACC/AHA guidelines when perioperative testing was recommended did not result in a higher frequency of cardiac complications. [Copyright &y& Elsevier]

Background: Vascular disease is a risk factor for Alzheimer's disease (AD) and related dementia in older adults. Retinal artery/vein occlusion (RAVO) is an ophthalmic complication of systemic vascular pathology. Whether there are associations between RAVO and dementia risk is unknown.Objective: To determine whether RAVOs are associated with an increased risk of developing vascular dementia or AD.Methods: Data from Adult Changes in Thought (ACT) study participants were analyzed. This prospective, population-based cohort study followed older adults (age ≥65 years) who were dementia-free at enrollment for development of vascular dementia or AD based on research criteria. RAVO diagnoses were extracted from electronic medical records. Cox-regression survival analyses were stratified by APOEɛ4 genotype and adjusted for demographic and clinical factors.Results: On review of 41,216 person-years (4,743 participants), 266 (5.6%) experienced RAVO. APOEɛ4 carriers who developed RAVO had greater than four-fold higher risk for developing vascular dementia (Hazard Ratio [HR] 4.54, 95% Confidence Interval [CI] 1.86, 11.10, p = 0.001). When including other cerebrovascular disease (history of carotid endarterectomy or transient ischemic attack) in the model, the risk was three-fold higher (HR 3.06, 95% CI 1.23, 7.62). No other conditions evaluated in the secondary analyses were found to confound this relationship. There was no effect in non-APOEɛ4 carriers (HR 1.03, 95% CI 0.37, 2.80). There were no significant associations between RAVO and AD in either APOE group.Conclusion: Older dementia-free patients who present with RAVO and carry the APOEɛ4 allele appear to be at higher risk for vascular dementia. [ABSTRACT FROM AUTHOR]

Lack of a unitary operational definition of mild cognitive impairment (MCI) has resulted in mixed prevalence rates and unclear predictive validity regarding conversion to dementia and likelihood of reversion. We examined 1,721 nondemented participants aged 65 and older from the Adult Changes in Thought (ACT) community-based cohort. Participants were followed longitudinally through biennial visits (average years assessed = 5.38). Categorization of MCI was based on: 1) deviation of neuropsychological test scores from a benchmark based on either standard or individualized expectations of a participant's mean premorbid cognitive ability, and 2) cutoff for impairment (1.0 versus 1.5 standard deviations [sd] below benchmark). MCI prevalence ranged from 56-92%; using individualized benchmarks and less stringent cutoffs produced higher rates. During follow-up, 17% of the cohort developed dementia. Examination of sensitivity, specificity, and predictive validity revealed that the criterion of 1.5 sd from the standardized benchmark was optimal, but still had limited predictive validity. Participants meeting this criterion at their first visit were three times more likely to develop dementia and this increased to seven times if participants had this diagnosis at the second timepoint as well. Those who did not have an MCI diagnosis at their first visit, but did at their second, had a significant increase of risk (but to a lesser extent than those diagnosed at both visits), while those who had an MCI diagnosis at their first visit, but not their second, did not have a significantly increased risk. These results highlight how assessing MCI stability greatly improves prediction of risk. [ABSTRACT FROM AUTHOR]

Objectives. We estimated dementia incidence rates, life expectancies with and without dementia, and percentage of total life expectancy without dementia. Methods. We studied 3605 members of Group Health (Seattle, WA) aged 65 years or older who did not have dementia at enrollment to the Adult Changes in Thought study between 1994 and 2008. We estimated incidence rates of Alzheimer’s disease and dementia, as well as life expectancies with and without dementia, defined as the average number of years one is expected to live with and without dementia, and percentage of total life expectancy without dementia. Results. Dementia incidence increased through ages 85 to 89 years (74.2 cases per 1000 person-years) and 90 years or older (105 cases per 1000 person-years). Life expectancy without dementia and percentage of total life expectancy without dementia decreased with age. Life expectancy with dementia was longer in women and people with at least a college degree. Percentage of total life expectancy-without dementia was greater in younger age groups, men, and those with more education. Conclusions. Efforts to delay onset of dementia, if successful, would likely benefit older adults of all ages. [ABSTRACT FROM AUTHOR]

Alzheimer's disease (AD) and other dementias are likely preceded by a protracted preclinical state. Thus, identification of biomarkers that signal potential points of intervention during this prodromal phase (during which patients are largely able to compensate for their cognitive deficits) is of paramount importance. Insulin is a pancreatic hormone with potent central nervous system effects, and insulin dysregulation has been implicated in the pathogenesis of both AD and vascular dementia. The aim of the current study was to determine whether circulating insulin differs as a function of mild cognitive impairment (MCI) diagnosis, and whether this relationship is mediated by sex and apolipoprotein E (APOE) genotype. A sample of 549 nondemented participants aged 65 and over from the Adult Changes in Thought community-based cohort underwent cognitive testing and blood draw to determine fasting levels of plasma insulin. Subjects were categorized as having normal cognitive functioning, amnestic MCI, or nonamnestic MCI. Results showed that the relationship between insulin and diagnostic category is moderated by sex, such that men with nonamnestic or amnestic MCI have higher fasting plasma insulin than cognitively normal men, while women with amnestic MCI have lower fasting plasma insulin than cognitively normal women. Exploratory analyses suggest that APOE ℇ4 genotype may further influence the relationship between sex and insulin. Future research will help determine whether insulin dysregulation results in differential effects on vascular function and AD pathology as a function of sex and/or APOE genotype. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the association between dynamic measures of renal function ascertained over time and onset of dementia. Design Prospective community cohort study. Setting Group Health, Seattle, Washington. Participants Two thousand nine hundred sixty-eight adults aged 65 and older followed for the development of dementia over a median of 6.0 years (interquartile range 3.1-10.1 years). Measurements Time-varying measures of renal function were constructed based on 49,340 serum creatinine measurements and included average estimated glomerular filtration rate (eGFR), eGFR trajectory, and variability in eGFR around this trajectory over 5-year exposure windows. The association between these three eGFR exposure measures and risk of dementia was estimated using a Cox regression model adjusted for other participant characteristics. Time-varying measures of urine protein by dipstick were also adjusted for in sensitivity analyses. Results Participants with a lower eGFR had a higher incidence of dementia, but this did not reach statistical significance in adjusted analyses (omnibus P = .14). There were trends toward a higher adjusted incidence of dementia in participants with positive eGFR trajectories (omnibus P = .07) and greater variability in eGFR (omnibus P = .04) over time. The results of sensitivity analyses, including those in which time-varying measures of proteinuria were included, were consistent with those of the primary analysis. Conclusion In a community cohort of older adults followed for a median of 6 years, strong associations were not found between measures of kidney disease severity and progression and incident dementia. [ABSTRACT FROM AUTHOR]

Mild cognitive impairment (MCI) is proposed to be a prodrome to dementia in some older adults. However, the presentation of MCI in the community can differ substantially from clinic-based samples. The aim of the current study is to demonstrate the effects of different operational definitions of MCI on prevalence estimates in community-dwelling older adults. A consecutive series of 200 participants aged 65 and over from the Adult Changes in Thought (ACT) community-based cohort were approached to undergo comprehensive neuropsychological and medical evaluation; 159 were included in the final analyses. Nondemented subjects were categorized using various diagnostic criteria for MCI. In a novel approach, neuropsychological test scores were evaluated using an individualized benchmark as a point of test comparison, as well as traditional methods that entail comparison to age-based normative data. Diagnostic criteria were further subdivided by severity of impairment (1.0 vs. 1.5 standard deviations [sd] below the benchmark) and extent of impairment (based on a single test or an average of tests within a cognitive domain). MCI prevalence rates in the sample were highly dependent on these diagnostic factors, and varied from 11% to 92% of the sample. Older groups tended to show higher prevalence rates, although this was not the case across all diagnostic schemes. The use of an individualized benchmark, less severe impairment cutoff, and impairment on only a single test all produced higher rates of MCI. Longitudinal follow-up will determine whether varying diagnostic criteria improves sensitivity and specificity of the MCI diagnosis as a predictor for dementia. [ABSTRACT FROM AUTHOR]

Mild cognitive impairment (MCI) is proposed to be a prodrome to dementia in some older adults. However, the presentation of MCI in the community can differ substantially from clinic-based samples. The aim of the current study is to demonstrate the effects of different operational definitions of MCI on prevalence estimates in community-dwelling older adults. A consecutive series of 200 participants aged 65 and over from the Adult Changes in Thought (ACT) community-based cohort were approached to undergo comprehensive neuropsychological and medical evaluation; 159 were included in the final analyses. Nondemented subjects were categorized using various diagnostic criteria for MCI. In a novel approach, neuropsychological test scores were evaluated using an individualized benchmark as a point of test comparison, as well as traditional methods that entail comparison to age-based normative data. Diagnostic criteria were further subdivided by severity of impairment (1.0 vs. 1.5 standard deviations [sd] below the benchmark) and extent of impairment (based on a single test or an average of tests within a cognitive domain). MCI prevalence rates in the sample were highly dependent on these diagnostic factors, and varied from 11% to 92% of the sample. Older groups tended to show higher prevalence rates, although this was not the case across all diagnostic schemes. The use of an individualized benchmark, less severe impairment cutoff, and impairment on only a single test all produced higher rates of MCI. Longitudinal follow-up will determine whether varying diagnostic criteria improves sensitivity and specificity of the MCI diagnosis as a predictor for dementia. [ABSTRACT FROM AUTHOR]

Background: Alzheimer disease and other dementing disorders are major sources of morbidity and mortality in aging societies. Proven strategies to delay onset or reduce risk for dementing disorders would be greatly beneficial. Objective: To determine whether regular exercise is associated with a reduced risk for dementia and Alzheimer disease. Design: Prospective cohort study. Setting: Group Health Cooperative, Seattle, Washington. Participants: 1740 persons older than age 65 years without cognitive impairment who scored above the 25th percentile on the Cognitive Ability Screening Instrument (CASI) in the Adult Changes in Thought study and who were followed biennially to identify incident dementia. Measurements: Baseline measurements, including exercise frequency, cognitive function, physical function, depression, health conditions, lifestyle characteristics, and other potential risk factors for dementia (for example, apolipoprotein E ε4); biennial assessment for dementia. Results: During a mean follow-up of 6.2 years (SD, 2.0), 158 participants developed dementia (107 developed Alzheimer disease). The incidence rate of dementia was 13.0 per 1000 person- years for participants who exercised 3 or more times per week compared with 19.7 per 1000 person-years for those who exercised fewer than 3 times per week. The age- and sex-adjusted hazard ratio of dementia was 0.62 (95% CI, 0.44 to 0.86; P = 0.004). The interaction between exercise and performance-based physical function was statistically significant (P = 0.013). The risk reduction associated with exercise was greater in those with lower performance levels. Similar results were observed in analyses restricted to participants with incident Alzheimer disease. Limitations: Exercise was measured by self-reported frequency. The study population had a relatively high proportion of regular exercisers at baseline. Conclusion: These results suggest that regular exercise is associated with a delay in onset of dementia and Alzheimer disease, further supporting its value for elderly persons. [ABSTRACT FROM AUTHOR]

Objectives: In nursing home settings, providers often think that most percutaneous endoscopic gastrostomy (PEG) tubes are placed in older people, some perhaps inappropriately. We sought to describe the relationships between patient age and the indications for, the decision making behind, and the outcomes of gastrostomy and jejunostomy placement in an urban hospital to give perspective to those of us working in long-term care settings. Design: Retrospective, observational study. Setting: Urban hospital. Participants: Two hundred thirty-nine inpatients who underwent gastrostomy or jejunostomy (G/J) placement. Measurements: Hospital records were reviewed for patient demographics, disease process, decision making, and short-term outcomes associated with G/J placement. Mortality at 30 days and 1 year was obtained by a search of the National Death Index. The prevalence of these variables in those aged 65 years and older was compared to the prevalence in those younger than 65 with associations calculated both unadjusted and adjusted for gender, place of residence, underlying condition, and Charlson comorbidity index. Results: Patients who were aged 65 years and older were more likely to be female with more comorbid illnesses and were more likely to have had a stroke that precipitated their difficulty eating. They were more likely to have been referred by a medical specialist, to have been seen by a speech pathologist, and to have had their procedure without general anesthesia. The older patients had a shorter mean hospital length of stay with fewer complications but had higher mortality rates at 30 days and 1 year. Conclusion: Patient age was associated with gender and type of disease process and may have influenced the decisions made during the hospital stay. Despite a higher burden of chronic illness, older patient age was not associated with adverse short-term outcomes but was associated with higher mortality rates after discharge. [Copyright &y& Elsevier]

Objectives: To assess the reliability and interobserver agreement of stroke identification on neuroimaging in patients presenting with dementia. Design: Comparison study between neurologists, radiology reports, and autopsy. Setting: Dementia registry within a health maintenance organization. Participants: Dementia patients with computed tomography (CT) scans obtained near the time of diagnosis and postmortem neuropathological examinations (N=99). Measurements: Three neurologists independently read CT scans for the presence and locations of strokes. Radiology reports from these scans were reviewed. The results from neurologists, radiologists, and autopsies were compared. Results: The positive predictive value for CT-observed strokes compared with their presence on autopsy was 0.44 to 0.49, regardless of the specialty of the observer. Strokes were present at autopsy in 46 of 99 cases. Agreement between neurologists on the presence of strokes was fair to moderate (kappa=0.27–0.56). Less agreement was found between neurologists and radiologists (kappa=0.00–0.11). Results improved slightly when each case was evaluated as any stroke present versus no stroke on imaging (kappa=0.34–0.75) or for the presence of multiple strokes (kappa=0.17–0.69). Conclusion: There is only fair to moderate agreement between observers regarding the identification of strokes on CT scans in patients presenting with dementia. Furthermore, strokes identified on imaging were present on pathology only half the time. [ABSTRACT FROM AUTHOR]

Abstract: To investigate developmental and vascular risk factors for Alzheimer''s disease (AD), we examined 90 incident cases of probable AD in a cohort of 1859 individuals followed prospectively for six years. The presence of the APOE-ε4 allele was the strongest risk factor, and with increasing survival age, the effect of ε4 diminished. Among ε4 positives, developmental risk factors such as smaller head circumference (≤54.4cm) and having more than four children in the household at age 2–3 were independently associated with incident AD (hazard ratio (HR)=2.6 (95% CI 1.04–6.3) and 3.3 (1.2–9.2), respectively). Among ε4 negatives, vascular risk factors were related to AD risk (self-reported diagnoses of transient ischemic attack and diabetes (HR=5.1, 95% CI 1.7–15.5; HR 3.3, 95% CI 1.4–8.1)). These findings indicate that clinical AD is a result of early life as well as later life risk factors, and that genetic predisposition to the disease may modify the constellation of predictors. [Copyright &y& Elsevier]

Objectives: To assess the influence of education on the association between apolipoprotein E and cognitive change. Design: Prospective cohort. Participants: HMO-based sample of 2168 non-demented community-dwelling elderly followed over 6 years. Measurements: Generalized estimating equations were used with the difference between baseline and follow-up cognitive abilities screening instrument (CASI) as the outcome variable. Results: At follow-up, 6% of the sample had a decline of 1.5 S.D. or greater on the CASI. Compared to individuals without an APOE4 allele, individuals with a single APOE4 allele did not have greater CASI decline. By contrast, individuals with two APOE4 alleles experienced greater decline in cognitive performance and the magnitude of that decline decreased as years of educational attainment increased. These relationships held after adjusting for age, gender, ethnicity, depression, diabetes, and history of vascular disease. Conclusion: Lower education was associated with steep 4-year cognitive decline for APOE4 homozygotes but not for APOE4 heterozygotes. Potentially modifiable host factors such as education could influence the association of high-risk genotypes and cognitive decline. [Copyright &y& Elsevier]

To study whether subjective memory deterioration is associated with future dementia in older people.A population-based prospective cohort study begun in 1994 with biennial follow-up interviews.Community-based members of Group Health Cooperative, a large health maintenance organization in the Seattle area.A sample of 1,883 subjects, dementia free, aged 65 and older, who scored 91 or higher on the 100-point Cognitive Ability Screening Instrument (CASI) at study entry.Subjective memory was assessed by asking whether memory had changed on 5-point Likert scales (e.g., 1=definitely improved, 3=no change, 5=definitely deteriorated) with regard to five items: remembering names, faces, friends, and appointments and judging the time. The items were summed for a possible total score ranging from 5 to 25. Subjective memory deterioration was defined as present if the total score was 20 or above. Cognitive performance was measured using the CASI. Incident dementia cases were identified usingDiagnostic and Statistical Manual of Mental Disorders, Fourth Editioncriteria.Of 1,883 subjects, 126 developed dementia during 5 years of follow-up. Subjective memory deterioration was associated with cognitive decline and incident dementia. Age modified the association between subjective memory deterioration and future dementia. For persons reporting subjective memory deterioration at the ages of 70, 75, and 80, the hazard ratios of developing dementia were 6.0 (95% confidence interval (CI)=2.1–18), 3.2 (95% CI=1.6–6.2) and 1.6 (95% CI=0.86–3.1), respectively.Subjective memory deterioration was found to precede the development of dementia in older people with normal cognitive screening results. These findings suggest that a high level of subjective memory deterioration in persons with normal objective cognitive function may identify a subset of individuals at greater risk for developing dementia. [ABSTRACT FROM AUTHOR]

Purpose: To determine the association between self-reported exercise tolerance and the risk of unanticipated postoperative nursing home placement in adults undergoing major surgery.Methods: Consecutive community-dwelling adults (N = 586) referred to a medical clinic for evaluation before undergoing major nonemergent surgery at a tertiary care academic medical center were prospectively followed between 1995 and 1997. The main outcome measure was unanticipated postoperative nursing home placement.Results: Overall, 12% (40/324) of patients with poor preoperative exercise tolerance (inability to walk four blocks and climb two flights of stairs without symptomatic limitation) had unanticipated nursing home placement compared with 4% (10/262) of patients with good exercise tolerance. Patient and surgical characteristics associated with nursing home placement in univariate analyses included poor preoperative exercise tolerance, increasing age, living alone, history of heart failure, taking five or more preoperative medications, longer anesthesia duration, and orthopedic surgery. Patients who were married were at lower risk. After adjusting for all other patient and surgical factors, poor preoperative exercise tolerance (odds ratio [OR] = 2.8; 95% confidence interval [CI]: 1.3 to 6.2) and serious postoperative complications (OR = 4.7; 95% CI: 2.1 to 10.5) remained associated with postoperative nursing home placement.Conclusion: Poor preoperative exercise tolerance was an independent predictor of unanticipated nursing home placement following major nonemergent surgery. [Copyright &y& Elsevier]

Background: Alzheimer disease is an increasingly common con-dition in older people. Knowledge of life expectancy after the diagnosis of Alzheimer disease and of associations of patient characteristics with survival may help planning for future care. Objective: To investigate the course of Alzheimer disease after initial diagnosis and examine associations hypothesized to corre-late with survival among community-dwelling patients with Alz-heimer disease. Design: Prospective observational study. Setting: An Alzheimer disease patient registry from a base pop-ulation of 23 000 persons age 60 years and older in the Group Health Cooperative, Seattle, Washington. Patients: 521 newly recognized persons with Alzheimer disease enrolled from 1987 to 1996 in an Alzheimer disease patient reg-istry. Measurements: Baseline measurements included patient demo-graphic features, Mini-Mental State Examination score, Blessed Dementia Rating Scale score, duration since reported onset of symptoms, associated symptoms, comorbid conditions, and selected signs. Survival was the outcome of interest. Results: The median survival from initial diagnosis was 4.2 years for men and 5.7 years for women with Alzheimer disease. Men had poorer survival across all age groups compared with females. Survival was decreased in all age groups compared with the life expectancy of the U.S. population. Predictors of mortality based on proportional hazards models included a baseline Mini-Mental State Examination score of 17 or less, baseline Blessed Dementia Rating Scale score of 5.0 or greater, presence of frontal lobe release signs, presence of extrapyramidal signs, gait disturbance, history of falls, congestive heart failure, ischemic heart disease, and diabetes at baseline. Limitations: The base population, although typical of the sur-rounding Seattle community, may not be representative of other, more diverse populations. Conclusions: In this sample of community-dwelling... [ABSTRACT FROM AUTHOR]

This cross-sectional analysis evaluated the association between ethnicity and cognitive performance and determined whether education modifies this association for nondemented older people (103 African Americans, 1,388 Japanese Americans, 2,306 Caucasians) in a study of dementia incidence. African Americans scored lower (median 89 out of 100) than Japanese Americans (93) and Caucasians (94) on the Cognitive Abilities Screening Instrument (CASI). Education affected CASI scores differently. The gap decreased between African Americans in high education groups compared with Japanese Americans and Caucasians. Adjustment for gender, depression, and comorbidities did not change this association. The increased ethnic discrepancy in cognitive test scores in low education groups may reflect differential educational quality. [ABSTRACT FROM AUTHOR]

Objectives To describe the effects of age and education for the Cognitive Abilities Screening Instrument (CASI), a 25-item test of cognitive function. Design Cross-sectional descriptive study of the initial enrollment in a community-based prospective cohort study. Participants A total of 2524 cognitively intact older adults over age 65 who were members of a major health maintenance organization, and who consented to participate in a longitudinal study. Measurements Summary scores for the CASI are given in the form of mean, median and percentile distributions specific for age and educational level. Results Based upon maximum likelihood analyses, age and education were significant (p <0.0001) predictors of total CASI score. Increased age and lower education were associated with a lower CASI score, as well as an increased spread in score distribution. Gender was also significantly related (p <0.01) to total CASI, with women having a slightly higher distribution of scores. Mean total scores ranged from CASI=82.2 (SD=9.0) in subjects aged 90–95 who had less than a high school degree to CASI=94.8 (SD=3.8) in subjects aged 65–69 with at least a high school education. Conclusions Like most cognitive screening instruments, performance on the CASI in non-demented persons is influenced by age and education. The reference values for 5-year age categories described in this article should be useful for clinicians and research investigators when using the CASI as a measure of cognitive function. Copyright © 1999 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]