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Background/Aims: In spite of the growing number of seniors who drive and their relatively frequent involvement in accidents, little is known about the cognitive substrates of road hazard recognition and their relationship with general cognitive performance in this population. We aimed to investigate, using a combination of functional MRI (fMRI) and a comprehensive neuropsychological battery, the anatomical and cognitive components of driving hazard recognition. Methods: Fourteen healthy active drivers aged between 65 and 87 years underwent neuropsychological evaluation and fMRI scanning. fMRI was performed while subjects watched a video composed of clips of driving hazards randomly interspersed with uneventful driving clips. We investigated brain areas that are recruited for hazard detection, in contrast to brain areas responding to driving without a hazard. The performance on neuropsychological tests was then regressed with the degree of activation of cortical areas related exclusively to detecting hazards. Results: Driving hazards generated significant activations, compared to non-hazards, in the lateral associative occipital cortex and in the right prefrontal cortex. Intensity of brain activation was correlated on performance on memory and cognitive control neuropsychological tests. Conclusion: Future studies can possibly address the same relationship in early dementia, as a preliminary form of investigation for driving safety.

Most medical schools do not have a separate course in geriatrics, but rather incorporate geriatrics into existing courses. Tracking and assessing curriculum content is more difficult in this setting. This paper describes and compares two approaches to assess curriculum content in geriatrics: a survey of course directors and a course objectives review. The results suggest that course directors report more geriatric content when asked as part of a regular survey than they identify as specific course objectives. Course objectives may be more reflective of the actual emphasis placed on aging-related material in courses. These two approaches appear to be complementary. Medical educators may find both self-report and course objective analysis to be useful and complementary in tracking geriatric material in the undergraduate medical curriculum.

Background. Previous evidence suggests that treatment with 3-hydroxy-3-methylglutaryl-coenzyme-A reductase inhibitors (statins) has a positive impact on dementia. We decided to investigate the association between the use of statins and the prevalence of dementia and statins’ impact on the progression of cognitive impairment. Methods. This is a case-control and a retrospective cohort study of a community-based ambulatory primary care geriatric practice. We included a convenience sample of all patients ( N � 655, mean age 78.7 � 0.3 years, 85% Caucasian, 74% women) with hypercholesterolemia or dementia, or using statins. We compared those using statins with those who do not with respect to the clinical diagnosis of dementia and its subtypes and the progression of cognitive impairment. Results. At the initial visit, 35% had dementia, and 17% were using statins. After covariate adjustments, patients on statins were less likely to have dementia (odds ratio [OR] for dementia based on composite definition � 0.23; 95% confidence interval [CI] [0.1‐0.56], p � .001, OR Alzheimer’s disease � 0.37; 95% CI [0.19‐0.74], p � .005, OR vascular dementia � 0.25; 95% CI [0.08‐0.85], p � .027). At follow-up, patients on statins showed an improvement on their Mini-Mental Status Examination score by 0.7 � 0.4 compared to a decline by 0.5 � 0.3 in controls, p � .025 (OR for no change or improvement on statins � 2.81; 95% CI [1.02‐8.43], p � .045) and scored higher on the Clock Drawing Test (difference of 1.5 � 0.1, p � .036). Conclusions. The use of statins is associated with a lower prevalence of dementia and has a positive impact on the progression of cognitive impairment.

Aging is usually associated with a progressive difficulty in learning new skills. Similarly, the dexterity in the non-dominant hand is usually decreased with age, while the dominant hand maintains a relative preservation in agility. We investigated if age-related volume loss affects the hand areas asymmetrically by comparing structural measures of the dominant hand area versus the non-dominant area. We performed a region of interest analysis of T1-weighted images focusing on the sensorimotor cortex corresponding to the hand area. We evaluated images from young subjects (younger than 65 years of age, n=38, mean age=24+/-7 years) and senior subjects (65 years or older, n=61, mean age =73+/-6 years). We observed that older adults exhibited greater leftward gray matter asymmetry of sensorimotor cortex, due in large part to more pronounced age-related loss of gray matter in the right hemisphere. These results are consistent with evidence that disuse leads to atrophy and suggest that age-related declines in gray matter, and perhaps function, may be limited by increasing the use of the non-dominant hand.

The recruitment of culturally diverse subject populations into research studies, particularly African-Americans (AA), has been the focus of intense interest by many groups.In this paper, we present the methodology utilized to create a predominantly AA cohort for the longitudinal study of risk factors in Alzheimer's disease (AD). The underlying strategy was that of identifying geographically diverse clinical venues within South Carolina (SC) where large numbers of AA patients already come to seek medical care.This strategy was successful, although recruitment rates for AA subjects (43.4%) still fell below those for white subjects (70.3%; p = 0.0025). Subject characteristics of AA subjects that chose to enroll were not substantially different from those that declined to participate. The demographic characteristics of this cohort were largely similar to those of the SC Alzheimer Disease Registry, a population-based database. The problems of standardization of subject recruitment and assessment across diverse clinical venues are also addressed.The utilization of geographically diverse sites for research recruitment where minorities already receive medical care is one practical solution to the problem of minority participation in research. Multi-site recruitment to improve minority recruitment can be accomplished with acceptable standardization and inter-rater reliability.

Background Pain constitutes a constant challenge facing staff and residents of skilled nursing facilities (SNF) and nursing homes (NH). Many SNF and NH have not adopted a uniform plan to assess and treat pain for their residents despite published literature that demonstrates that the implementation of scales improves detection and treatment of pain. The objective of this study was to analyze the baseline pain level in the institutionalized elderly, and then implement a standard pain scale for its assessment and evaluation, while simultaneously identifying challenges in adopting this standardized method. Methods As part of a Quality Improvement Project (QI), a total of 40 patients were chosen at random in 2 of the major skilled care and dementia units at a Columbia area nursing home, 20 patients from each. A chart review was conducted to document the presence or absence of pain syndromes, pain medications used, and use of standardized tools for the evaluation of pain. Documentation regarding diagnosis of depression and behavioral problems were also noted as potential markers for the manifestation of pain. Verbal and nonverbal pain scales were introduced and approved by the medical and nursing staff. Training sessions for the administration of such tools were implemented. A baseline evaluation of pain level was obtained applying these newly adopted tools. One cycle using the PDSA (Plan-Do-Study and Act) model for QI was followed. Results Our evaluation showed that 84.2% (32/38) of our study population were females, and the mean age was 91.4 years. Fifty percent (19/38) of patients had mild to moderate pain. Because of nonstandardized approaches to analgesia, some regimens rendered clear potential for toxicity: ie, receiving more than 3 grams per day of acetaminophen. Most patients with cognitive deficits had lower levels of moderate pain (9.5% [2/21]) but higher levels of mild pain (33.3% [7/21]) when compared with patients with normal cognition or mild cognitive deficits (35.3% [6/17] and 17.6% [3/17], respectively). Nursing staff adopted successfully the chosen pain tools and gave positive feedback after the trial period, indicating that they were helpful tools to identify pain and treat it promptly. Active participation of nursing staff through the process of decision making, tailoring of the pain assessment scales, and feedback during the period of implementation of pain assessment tools was perceived to facilitate better results. New cycles of pain evaluation and improvement were scheduled. Conclusions Pain evaluation and management is of paramount importance because of its high prevalence and demonstrated deleterious effects on both quality of life and long-term survival. Tools for verbal and nonverbal evaluation of pain are necessary in both NH and SCF. Also, regular cognitive and behavioral assessment may help evaluate pain by providing additional information to physicians, nurses, and other caregivers when treatment becomes more challenging and complex. The use of standard standing orders can easily help decrease the potential of toxicity related to the use of analgesics.

Background. The effect of antihypertensive medications on cognitive function has not been well studied. The authors’ objectives were to investigate the cross-sectional and longitudinal association between the use of antihypertensive medications and cognitive function and to compare different antihypertensive medication classes with regard to this association in an elderly population. Methods. The medical records of a convenience sample of patients (n ¼ 993 cross-sectional and 350 longitudinal; mean age, 76.8 6 0.3 years; 74% women; 87% White) followed at a geriatric practice were reviewed. Data abstracted included demographics, medical history (Alzheimer’s disease [AD] or vascular dementia [VaD]), use of antihypertensive medications, and results of cognitive assessments (the Mini-Mental Status Examination [MMSE] and the Clock Draw Test [CDT]). Results. In the cross-sectional analysis, antihypertensive use was not associated with MMSE (p . .05), CDT (p . .05), or dementia diagnosis (odds ratio for AD, 0.8; 95% confidence interval [CI], 0.6 to 1.2; odds ratio for VaD, 1.6; 95% CI, 0.6 to 4.0). In the longitudinal analysis, antihypertensive use was associated with a lower rate of cognitive decline on the MMSE (� 0.8 6 2 points in users vs � 5.8 6 2.5 points in nonusers; p ¼ .007) and on the CDT (� 0.3 6 0.8 points in users vs � 2.2 6 0.8 points in nonusers; p ¼ .002), and with a lower risk for the development of cognitive impairment (odds ratio, 0.56; 95% CI, 0.38 to 0.83; p ¼ .004). The trend was similar in patients with baseline AD (p ¼ .02). Patients taking diuretics (p ¼ .007), angiotensin-converting enzyme inhibitors (p ¼ .016), and beta-blockers (p ¼ .014) had a lower rate of cognitive decline, and patients taking angiotensin receptor blockers (p ¼ .016) had improved cognitive scores. Conclusions. Antihypertensive use, particularly diuretics, angiotensin-converting enzymes inhibitors, beta-blockers, and angiotensin receptor blockers, may be associated with a lower rate of cognitive decline in older adults, including those with AD. Until a randomized clinical trial confirms our results, findings of this observational study should be interpreted with caution.

Background and aims: In a pilot study of community-dwelling geriatric clinic patients (N=48, aged 63–90) we examined the use of a questionnaire to classify frailty status by comparing it with standardized markers of frailty. The questionnaire, developed by Strawbridge et al. in 1998, defines frailty as difficulty in more than one of four domains of functioning: physical, cognitive, sensory, and nutritive. Methods: Subjects were classified as frail or not frail by questionnaire and assignment was compared with testing of physical and cognitive measures in cross-sectional analysis. Demographic variables, functional inventories, physical activity levels, clinician impression of frailty, and 3-year health outcomes were also examined. Results: Thirty-three percent of subjects were classified as frail. Frailty classification by the Strawbridge questionnaire was correlated to Timed Up and Go and repetitive Sit-to-Stand tests, bimanual dexterity and cognitive tests. A discrepancy was found between assignment of cognitive difficulty, by questionnaire and cognitive performance. When overall Strawbridge frailty scores were modified to account for those with poor cognitive performance who did not report cognitive difficulty, the prevalence of frailty increased to 42%. At 3-year follow-up, the modified Strawbridge frailty classification (p

As an adjunct to the general and cancer-specific clinical and diagnostic examinations, comprehensive geriatric assessment (CGA) is an integral tool that examines factors affecting the course of disease and the outcome of treatment. The principal areas of focus of the CGA include the patient's functional, physical, mental, emotional, pharmacotherapeutic, and socioeconomic status.We describe the role of CGA in the identification and management of frail elderly patients. The literature is reviewed to outline the components, programmatic configurations, and process of CGA. Information from systematic reviews of clinical trials of different CGA program models is summarized, and observations relating to the research agenda concerning the applicability of CGA and CGA principles to management of older cancer patients are discussed.Since age itself is not predictive of outcome in an elderly cancer patient, the CGA helps to distinguish between elderly patients who should be treated with intent to cure and those who will benefit from clinical oncologic and geriatric co-management.A more accurate evaluation of prognostic indicators that includes CGA parameters could lead to a higher number of older patients being included in clinical cancer trials and being treated effectively in practice. It would also identify those who would benefit from gero-oncologic CGA and ongoing management aimed at maintaining function and community living.

Background. This study surveyed opinions and self-reported practices of physicians involved in the care of elderly individuals regarding geriatric hypertension management and included a national random sample (n = 1060) of health care professionals in the United States. Methods. This is a cross-sectional self-conducted survey using a questionnaire developed to assess the opinions related to blood pressure (BP) and aging, BP selection, BP target, lifestyle modifications, and first-line drug choice. We also tested the impact of the patient's age on the respondents' answers. A national random sample (n = 1060) of health care professionals in the United States was selected. Results. We received 412 (39%) questionnaires. Thirty-five percent considered that the increase in BP with age is a normal process of aging, and 25% considered treating hypertension in an 85-year-old patient to have more risks than benefits. Sixty-nine percent considered systolic blood pressure to be the most important pressure. Respondents were more likely to start antihypertensive therapy at a lower BP and target a lower BP in 65-year-old patients compared with 85-year-old patients (p