Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale

Psychometric properties of the International Wellbeing Index in community-dwelling older adults

BACKGROUND

This is the first study to analyze the psychometric properties of the International Wellbeing Index (IWI), which comprises the Personal Wellbeing Index (PWI) and National Wellbeing Index (NWI), among community-dwelling older adults.

METHODS

The IWI was applied to 1106 community-dwelling adults aged 60 years and over. The sample was additionally assessed using scales for comorbidity, disability, mood, general orientation to life, social support, health-related quality of life, and two questions assessing satisfaction with life as a whole and with life in Spain. The PWI and NWI were separately analyzed for acceptability, internal consistency, convergent and discriminative validity, and precision. Linear regression analyses of the PWI and the NWI were also conducted.

RESULTS

Mean scores were 71.0 ± 13.5 for the PWI and 49.5 ± 14.4 for the NWI. No floor or ceiling effects were detected. Cronbach's α was 0.88 for the PWI and 0.92 for the NWI. Factor analysis identified two factors in the IWI, and one factor in the PWI and NWI respectively. The PWI showed a correlation of 0.50 with the "satisfaction with life as a whole" item, and the NWI showed a correlation of 0.73 with the "satisfaction with life in Spain" item. There were significant differences in scores: in the PWI, according to gender, age, social support, education and depression; and in the NWI, according to education and depression. The regression model identified psychosocial, health and functional factors as determinants of the PWI (explained variance: 46.8%).

CONCLUSIONS

The IWI displays good acceptability and is a consistent, valid and precise measure of global quality of life in older adults.

Increased Framingham 10-year risk of coronary heart disease in middle-aged and older patients with psychotic symptoms

OBJECTIVE

The Framingham 10-risk of coronary heart disease (CHD) has been a widely studied estimate of cardiovascular risk in the general population. However, few studies have compared the relative risk of developing CHD in antipsychotic-treated patients with different psychiatric disorders, especially in older patients with psychotic symptoms. In this study, we compared the 10-year risk of developing CHD among middle-aged and older patients with psychotic symptoms to that in the general population.

METHOD

We analyzed baseline data from a study examining metabolic and cardiovascular effects of atypical antipsychotics in patients over age 40 with psychotic symptoms. After excluding patients with prior history of CHD and stroke, 179 subjects were included in this study. Among them, 68 had a diagnosis of schizophrenia, 42 mood disorder, 38 dementia, and 31 PTSD. Clinical evaluations included medical and pharmacologic treatment history, physical examination, and clinical labs for metabolic profiles. Using the Framingham 10-year risk of developing CHD based on the Framingham Heart Study (FHS), we calculated the risk CHD risk for each patient, and then compared relative risk in each psychiatric diagnosis to the risks reported in the FHS.

RESULTS

The mean age of entire sample was 63 (range 40-94) years, 68% were men. The Framingham 10-year risk of CHD was increased by 79% in schizophrenia, 72% in PTSD, 61% in mood disorder with psychosis, and 11% in dementia relative to the risk in general population from the FHS.

CONCLUSIONS

In this sample of middle-aged and older patients with psychotic symptoms, we found a significantly increased 10-year risk of CHD relative to the estimated risk from FHS, with the greatest increased risk for patients with schizophrenia and PTSD. Development of optimally tailored prevention and intervention efforts to decrease different risk components in these patients could be an important step to help decrease the risks of CHD and overall mortality in this vulnerable population.

Assessment of memory function: the relation between daily observation and neuropsychological test performance

BACKGROUND

The aim of the study was to explore the value of a daily observation scale in the assessment of patients' memory function by nurses on a geriatric ward.

METHODS

An observational study of 50 geriatric inpatients was carried out. The relationship between the memory items of the Nurses' Behavioral Rating Scale for Geriatric Inpatients (GIP) and four types of neuropsychological memory tests was examined: visual paired-associate learning (Visual Association Test, VAT), word-list learning (Eight Word Test, 8WT from the Amsterdam Dementia Screening, ADS), and the subtests Route Recall and Story Recall from the Rivermead Behavioural Memory Test (RBMT). Correlations with the overall measures assessing level of dementia such as the Mini-mental State Examination (MMSE), Clinical Dementia Rating scale (CDR) and the 15-item Geriatric Depression Scale (GDS-15) were examined as well.

RESULTS

The Pearson's correlation coefficients between GIP and the four memory tests were between 0.45 and 0.71 (p < 0.01). The GIP correlations with the MMSE and CDR were 0.63 and 0.46, respectively (p < 0.01). No significant correlation was found with the GDS-15. Statistically significant differences in GIP memory scores between patients with dementia and non-demented patients were found (p < 0.01).

CONCLUSIONS

Results indicate that an observation scale of memory function may have value for providing information about the underlying memory impairment. The results of nurses' observations may be used in triage contributing to the diagnostic process by selecting patients requiring further neuropsychological assessment.

Clinical profiles of patients colonized or infected with extended-spectrum beta-lactamase producing Enterobacteriaceae isolates: a 20 month retrospective study at a Belgian University Hospital

Background

Description of the clinical pictures of patients colonized or infected by ESBL-producing Enterobacteriaceae isolates and admitted to hospital are rather scarce in Europe. However, a better delineation of the clinical patterns associated with the carriage of ESBL-producing isolates may allow healthcare providers to identify more rapidly at risk patients. This matter is of particular concern because of the growing proportion of ESBL-producing Enterobacteriaceae species isolates worldwide.

Methods

We undertook a descriptive analysis of 114 consecutive patients in whom ESBL-producing Enterobacteriaceae isolates were collected from clinical specimens over a 20-month period. Clinical data were obtained through retrospective analysis of medical record charts. Microbiological cultures were carried out by standard laboratory methods.

Results

The proportion of ESBL-producing Enterobacteriaceae strains after exclusion of duplicate isolates was 4.5% and the incidence rate was 4.3 cases/1000 patients admitted. Healthcare-associated acquisition was important (n = 104) while community-acquisition was less frequently found (n = 10). Among the former group, two-thirds of the patients were aged over 65 years and 24% of these were living in nursing homes. Sixty-eight (65%) of the patients with healthcare-associated ESBL, were considered clinically infected. In this group, the number and severity of co-morbidities was high, particularly including diabetes mellitus and chronic renal insufficiency. Other known risk factors for ESBL colonization or infection such as prior antibiotic exposure, urinary catheter or previous hospitalisation were also often found. The four main diagnostic categories were: urinary tract infections, lower respiratory tract infections, septicaemia and intra-abdominal infections. For hospitalized patients, the median hospital length of stay was 23 days and the average mortality rate during hospitalization was 13% (Confidence Interval 95%: 7-19). Escherichia coli, by far, accounted as the most common ESBL-producing Enterobacteriaceae species (77/114; [68%]) while CTX-M-1 group was by far the most prevalent ESBL enzyme (n = 56).

Conclusion

In this retrospective study, the clinical profiles of patients carrying healthcare-associated ESBL-producing Enterobacteriacae is characterized by a high prevalence rate of several major co-morbidities and potential known risk factors. Both, the length of hospital stay and overall hospital mortality rates were particularly high. A prospective case-control matched study should be designed and performed in order to control for possible inclusion bias.

One-year change in anterior cingulate cortex white matter microstructure: relationship with late-life depression outcomes

OBJECTIVE

differences in white matter structure measured with diffusion tensor imaging (DTI) are associated with late-life depression, but results examining how these differences relate to antidepressant remission are mixed. To better describe these relationships, the authors examined how 1-year change in DTI measures are related to 1-year course of depression.

DESIGN

one-year cross-sectional follow-up to a 12-week clinical trial of sertraline.

SETTING

outpatients at an academic medical center.

PARTICIPANTS

twenty-nine depressed and 20 never-depressed elderly subjects. Over the 1-year period, 16 depressed subjects achieved and maintained remission, whereas 13 did not.

MEASUREMENTS

one-year change in fractional anisotropy (FA) and diffusivity in frontal white matter, as measured by DTI.

RESULTS

contrary to our hypotheses, depressed subjects who did not remit over the study interval exhibited significantly less change in anterior cingulate cortex (ACC) white matter FA than did never-depressed or depressed-remitted subjects. There were no group differences in other frontal or central white matter regions. Moreover, there was a significant positive relationship between change in Montgomery-Asberg Depression Rating Scale (MADRS) and change in ACC FA, wherein greater interval decline in FA was associated with greater interval decline in MADRS.

CONCLUSION

older depressed individuals who remit exhibit white matter changes comparable with what is observed in never-depressed individuals, whereas nonremitters exhibit significantly less change in ACC FA. Such a finding may be related to either antidepressant effects on brain structure or the effects of chronic stress on brain structure. Further work is needed to better understand this relationship.

Effect of depression on prognosis in heart failure

Depression is a common comorbid condition in heart failure, and there is growing evidence that it increases the risks of mortality and other adverse outcomes, including rehospitalization and functional decline. The prognostic value of depression depends, in part, on how it is defined and measured. The few studies that have compared different subsets of patients with depression suggest that major (or severe) depression is a stronger predictor of mortality than is minor (or mild) depression. Whether depression is a causal risk factor for heart failure mortality, or simply a risk marker, has not yet been established, but mechanistic research has identified several plausible behavioral and biologic pathways. Further research is needed to clarify the relationships among depression, heart failure, and adverse outcomes, as well as to develop efficacious interventions for depressive disorders in patients with heart failure.

Maintenance treatment of depression in old age: a randomized, double-blind, placebo-controlled evaluation of the efficacy and safety of donepezil combined with antidepressant pharmacotherapy

CONTEXT

Cognitive impairment in late-life depression is a core feature of the illness.

OBJECTIVE

To test whether donepezil hydrochloride and antidepressant therapy is superior to placebo and antidepressant therapy in improving cognitive performance and instrumental activities of daily living and in reducing recurrences of depression over 2 years of maintenance treatment.

DESIGN

Randomized, double-blind, placebo-controlled maintenance trial.

SETTING

University clinic.

PARTICIPANTS

One hundred thirty older adults aged 65 years and older with recently remitted major depression.

INTERVENTIONS

Random assignment to maintenance antidepressant pharmacotherapy and donepezil or to maintenance antidepressant pharmacotherapy and placebo.

MAIN OUTCOME MEASURES

Global neuropsychological performance, cognitive instrumental activities of daily living, and recurrent depression.

RESULTS

Donepezil and antidepressant therapy temporarily improved global cognition (treatment × time interaction, F₂,₂₁₆ = 3.78; P = .03), but effect sizes were small (Cohen d = 0.27, group difference at 1 year). A marginal benefit to cognitive instrumental activities of daily living was also observed (treatment × time interaction, F₂,₁₃₇ = 2.94; P = .06). The donepezil group was more likely than the placebo group to experience recurrent major depression (35% [95% confidence interval {CI}, 24%-46%] vs 19% [95% CI, 9%-29%], respectively; log-rank χ² = 3.97; P = .05; hazard ratio = 2.09 [95% CI, 1.00-4.41]). Post hoc subgroup analyses showed that of 57 participants with mild cognitive impairment, 3 of 30 participants (10% [95% CI, 0%-21%]) receiving donepezil and 9 of 27 participants (33% [95% CI, 16%-51%]) receiving placebo had a conversion to dementia over 2 years (Fisher exact test, P = .05). The mild cognitive impairment subgroup had recurrence rates of major depression of 44% with donepezil vs 12% with placebo (likelihood ratio = 4.91; P = .03). The subgroup with normal cognition (n = 73) showed no benefit with donepezil and no increase in recurrence of major depression.

CONCLUSIONS

Whether a cholinesterase inhibitor should be used as augmentation in the maintenance treatment of late-life depression depends on a careful weighing of risks and benefits in those with mild cognitive impairment. In cognitively intact patients, donepezil appears to have no clear benefit for preventing progression to mild cognitive impairment or dementia or for preventing recurrence of depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00177671.

Multifactorial fall prevention for pairs of frail community-dwelling older fallers and their informal caregivers: a dead end for complex interventions in the frailest fallers

OBJECTIVE

To assess whether a multifactorial fall prevention program was more effective than usual geriatric care in preventing falls and reducing fear of falling in frail community-dwelling older fallers, with and without cognitive impairment, and in alleviating subjective caregiver burden in caregivers.

DESIGN, SETTING, AND PARTICIPANTS

A randomized, 2 parallel-group, single-blind, multicenter trial conducted in 36 pairs of frail fallers, who were referred to a geriatric outpatient clinic after at least 1 fall in the past 6 months, and their informal caregivers.

INTERVENTION

Groups of 5 pairs of patients and caregivers received 10 twice-weekly, 2-hour sessions with physical and psychological components and a booster session.

MEASUREMENTS

The primary outcome was the fall rate during a 6-month follow-up. Additionally, we measured fear of falling and subjective caregiver burden. Data on the secondary outcome measures were collected at baseline, directly after, and at 3 and 6 months after the last session of the intervention.

RESULTS

Directly after the intervention and at the long-term evaluation, the rate of falls in the intervention group was higher than in the control group, although these differences were not statistically significant (RR = 7.97, P = .07 and RR = 2.12, P = .25, respectively). Fear of falling was higher in the intervention group, and subjective caregiver burden did not differ between groups.

CONCLUSION

Although we meticulously developed this pairwise multifactorial fall prevention program, it was not effective in reducing the fall rate or fear of falling and was not feasible for caregivers, as compared with regular geriatric care. Future research initiatives should be aimed at how to implement the evidence-based principles of geriatric fall prevention for all frail fallers rather than developing more complex interventions for the frailest.

Does age at onset have clinical significance in older adults with bipolar disorder?

OBJECTIVE

While age at onset may be useful in explaining some of the heterogeneity of bipolar disorder (BD) in large, mixed age groups, investigations to date have found few meaningful clinical differences between early versus late age at onset in older adults with BD.

METHODS

Data were collected from sixty-one subjects aged 60 years and older, mean (SD) age 67.6 (7.0), with BD I (75%) and II (25%). Subjects were grouped by early (< 40 years; n = 43) versus late (≥ 40 years; n = 18) age at onset. Early versus late onset groups were compared on psychiatric comorbidity, medical burden, and percentage of days well during study participation.

RESULTS

Except for family history of major psychiatric illnesses, there were no differences between the groups on demographic or clinical variables. Patients with early and late onset experienced similar percentages of days well; however, those with early onset had slightly more percentage of days depressed than those with late onset (22% versus 13%)

CONCLUSION

Distinguishing older adults with BD by early or late age at onset has limited clinical usefulness.

A comparison of the frequencies of risk factors for depression in older black and white participants in a study of indicated prevention

BACKGROUND

To compare the frequencies of risk factors, we describe risks for depression as a function of race among consecutively admitted participants in a randomized clinical trial of indicated depression prevention in later life.

METHODS

Seventy-two black and 143 white participants were screened for risk factors for depression.

RESULTS

Black participants were more likely to have fewer years of education and lower household income. They were more likely to be obese, live alone, experience functional disability, have a history of alcohol and drug abuse, and have lower scores on the Mini-mental State Examination and the Executive Interview (EXIT). White participants were not found to have greater prevalence or higher mean score on any risk factor. On average, black participants experienced approximately one more risk factor than white participants (t(213) = 3.32, p = 0.0011).

CONCLUSIONS

In our sample, black participants had higher frequencies of eight risk factors for depression and a greater mean number of risk factors compared to white participants.

Differentially abundant transcripts in PBMC of hospitalized geriatric patients with hip fracture compared to healthy aged controls

The abundance of a selection of transcript species involved in inflammation, immunosenescence and stress response was compared between PBMC of 35 geriatric patients with hip fracture in acute phase (days 2-4 after hospitalization) or convalescence phase (days 7-10) and 28 healthy aged controls. Twenty-nine differentially abundant transcripts were identified in acute phase versus healthy ageing. Twelve of these transcripts remained differentially abundant in convalescence phase, and 22 were similarly differentially abundant in acute phase of geriatric infectious diseases. Seven of these 22 transcripts were previously identified as differentially abundant in PBMC of healthy aged versus healthy young controls, with further alteration for CD28, CD69, LCK, CTSD, HMOX1, and TNFRSF1A in acute phase after geriatric hip fracture and infectious diseases. The next question is whether these alterations are common to other geriatric diseases and/or preexist before the clinical onset of the diseases.

Hip fracture post-operation dysnatremia and Na+-courses in different cognitive and functional patient groups

The aim of the study was to investigate Na(+)-course of hip fracture patients in relation to demographic and clinical parameters. Data on 155 older hip fracture patients were analyzed retrospectively. Clinical parameters and serum Na(+) on admission (Na1), during 24h pre-op. (Na2), during 24h post-op. (Na3), and pre-discharge (Na4) were recorded. Hyponatremia and hypernatremia rates pre- and post-operation were 26.5%, 2.6%, 24.5% and 5.8%. Higher Na3 (138.76 ± 4.4 mEq/l) vs. Na1 (137.69 ± 4.5 mEq/l) (p = 0.004) and correlation between age and Na3 (p = 0.021) was found. Mean serum Na(+) of impaired mental status (IMS) vs. normal patients and of partially/independent vs. dependent patients were higher (p < 0.05). More complications occurred in IMS patients tending to higher Na3 in patients with complications. No differences in Na(+)-courses were found according to sex or co-morbidities. Dysnatremia is highly prevalent in older hip fracture patients. A distinct post-operative increase in serum Na(+) was found, higher in the cognitively and functionally impaired patients. It seems that the Na(+) increase characterizes more IMS patients who suffer more complications, but does not necessarily indicate complications. We recommend surveillance of serum Na(+), particularly in cognitively and functionally impaired older patients in whom the risk of hypernatremia and complications is higher.

Hepatitis C treatment eligibility and comorbid medical illness in methadone maintenance (MMT) and non-MMT patients: a case-control study

Comorbid medical illness is common in patients with chronic hepatitis C (HCV) infection and in methadone treatment (MMT) patients, yet little is known about the impact of medical illness on HCV treatment eligibility. Medical illness and HCV treatment eligibility were compared in a case-control study of 80 MMT patients entering an HCV treatment trial and 80 matched non-MMT patients entering HCV treatment in a gastroenterology clinic. 91% of MMT and 85% of non-MMT patients had chronic medical conditions. Despite similar medical severity ratings, a significantly higher proportion (77%) of non-MMT patients were eligible for HCV treatment than were MMT patients (56%) (p<.01). Specific comorbid medical and psychiatric illness led to ineligibility in only 18% of MMT and 16% of non-MMT patients. However, failure to complete the medical evaluation process was significantly (p<.001) more likely to cause ineligibility among MMT patients (19%) than non-MMT patients (0%).

Comorbidity in aging and dementia: scales differ, and the difference matters

BACKGROUND

Accurate assessment of the effect of dementia on healthcare utilization and costs requires separation of the effects of comorbid conditions, often poorly accounted for in existing claims-based studies.

OBJECTIVE

To determine whether two different types of comorbidity and risk adjustment scales, the Chronic Disease Score (CDS) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), perform similarly in older persons with and without dementia.

METHODS

All subjects in the community-outreach diagnostic program of the University of Washington Alzheimer's Disease Research Center Satellite were included (N = 619). Subjects' mean age was 75 ± 9 years; 40% were cognitively normal, 17% were cognitively impaired but not demented, and 43% were demented. CDS and CIRS-G scores (neuropsychiatric disorders excluded to reduce colinearity with group) were examined across strata of age, education, and cognitive classification by using analysis of variance, analysis of covariance, and linear regression.

RESULTS

CIRS-G scores were sensitive to factors known to be associated with chronic disease burden, including age (F = 21.3 [df = 2, 616], p <0.001), education (F = 6.6 [df = 3, 614], p <0.001), and cognitive status (F = 40.5 [df = 2, 616], p <0.001), whereas the CDS was not. In the subset of persons with CDS scores of 0 (40% of the total sample), CIRS-G scores ranged from very low to high burden of disease and remained significantly different across age, education, and cognitive status groups. In regression analyses predicting CIRS-G score, CDS score and cognitive status interacted (β = -0.10, t = 1.9 [df = 1, 609], p = 0.06). After controlling for age, the amount of variance shared by the CIRS-G-13 and CDS differed by cognitive group (>32% for normal and mildly impaired groups combined, 17% for dementia).

CONCLUSION

Different methods of measuring and adjusting for comorbidity are not equivalent, and dementia amplifies the discrepancies. The CDS, if used to control for comorbidity in comparative studies of healthcare utilization and costs for persons with and without dementia, will underestimate burden of comorbid disease and artificially inflate the costs attributed to dementia.

Impact of liposomal doxorubicin-based adjuvant chemotherapy on autonomy in women over 70 with hormone-receptor-negative breast carcinoma: A French Geriatric Oncology Group (GERICO) phase II multicentre trial

RATIONALE

Breast cancer is a disease of ageing. Functional independence in elderly patients, measured with the Katz activities of daily living (ADL) scale, predicts overall survival and the need for welfare support. Few prospective studies have examined the feasibility of adjuvant chemotherapy and its impact on autonomy in women over 70 years of age with high-risk breast cancer. This multicentre phase II trial was designed to assess the impact of adjuvant anthracycline-based chemotherapy on these patients' autonomy.

DESIGN AND METHODS

In a two-stage Fleming design, women aged ≥70 years with histologically proven hormone-receptor-negative early breast cancer and a significant risk of recurrence (pN+ or "high risk" pN0) received 4 cycles of nonpegylated liposomal doxorubicin 60 mg/m(2) and cyclophosphamide 600 mg/m(2) every 3 weeks postoperatively, on an outpatient basis. The primary endpoint was the change in the ADL score during chemotherapy. Secondary endpoints include comprehensive geriatric, quality-of-life and acceptability assessments, tolerability, and long-term outcome. The results for the primary endpoint and other scales at completion of adjuvant chemotherapy are reported here, while long-term follow-up is not yet complete.

RESULTS

Forty patients (median age 75 [70-82]) were enrolled between February 2006 and November 2007. Chemotherapy had no deleterious impact on ADL, cognition, mental status, or the frequency of comorbidities. In contrast, the number of patients at risk of malnutrition, based on the Mini Nutritional Assessment, more than doubled between baseline and the end of chemotherapy, rising from 15% to 38%. Quality-of-life deteriorated in terms of social and role functioning, likely owing to fatigue, loss of appetite, nausea and vomiting. Treatment acceptability was good. The main adverse effect was neutropenia, 15% of the patients experiencing febrile neutropenia. No cardiac toxicity or toxic deaths occurred.

CONCLUSION

This study demonstrates the feasibility of an adjuvant chemotherapy regimen combining nonpegylated liposomal doxorubicin and cyclophosphamide in fit elderly women <85 years with breast cancer. Although chemotherapy had an impact on social and role functioning, autonomy was not impaired and toxicity was acceptable. Special attention should be paid to nutritional status before and after treatment.

Quantifying the pain experience in hip and knee osteoarthritis

PURPOSE

The present study investigated whether the conceptualization of hip and knee osteoarthritis pain implicit in the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Medical Outcomes Study Short-Form 36 (SF-36) scales is complete, or whether the addition of another scale, such as the Short-Form McGill Pain Questionnaire (MPQ-SF), provides a more complete characterization. Furthermore, the impact that mental health symptoms and catastrophizing had on these scales was investigated.

METHODS

Before hip and knee arthroplasty, 200 patients completed surveys of demographic data, the WOMAC pain scale, the MPQ-SF, the SF-36 Bodily Pain scale, the Pain Catastrophizing Scale and the Hospital Anxiety and Depression Scale. Correlations between scales were calculated and linear regression modelling was used to determine the impact of mental health and catastrophizing on these three pain measures.

RESULTS

A strong correlation between the WOMAC and SF-36 pain scales (r=-0.70) was found; however, both correlated only moderately with the MPQ-SF (r=0.36 and r=-0.36, respectively). Linear regression modelling showed that the Pain Catastrophizing Scale significantly predicted a greater score on all three pain scales (P<0.05).

CONCLUSIONS

The addition of the MPQ-SF appears to add to a more complete quantification of the pain experience in hip and knee osteoarthritis.

Can standardized sleep questionnaires be used to identify excessive daytime sleeping in older post-acute rehabilitation patients?

OBJECTIVES

Excessive daytime sleeping is associated with poorer functional outcomes in rehabilitation populations and may be improved with targeted interventions. The purpose of this study was to test simple methods of screening for excessive daytime sleeping among older adults admitted for postacute rehabilitation.

DESIGN

Secondary analysis of data from 2 clinical samples.

SETTING

Two postacute rehabilitation (PAR) units in southern California.

PARTICIPANTS

Two hundred twenty-six patients older than 65 years with Mini-Mental State Examination (MMSE) score higher than 11 undergoing rehabilitation.

MEASUREMENTS

The primary outcome was excessive daytime sleeping, defined as greater than 15% (1.8 hours) of daytime hours (8 am to 8 pm) sleeping as measured by actigraphy.

RESULTS

Participants spent, on average, 16.2% (SD 12.5%) of daytime hours sleeping as measured by actigraphy. Thirty-nine percent of participants had excessive daytime sleeping. The Pittsburgh Sleep Quality Index (PSQI) was significantly associated with actigraphically measured daytime sleeping (P = .0038), but the Epworth Sleepiness Scale (ESS) was not (P = .49). Neither the ESS nor the PSQI achieved sufficient sensitivity and specificity to be used as a screening tool for excessive daytime sleeping. Two additional models using items from these questionnaires were not significantly associated with the outcome.

CONCLUSIONS

In an older PAR population, self-report items from existing sleep questionnaires do not identify excessive daytime sleeping. Therefore we recommend objective measures for the evaluation of excessive daytime sleeping as well as further research to identify new self-report items that may be more applicable in PAR populations.

Factors Associated With Loneliness of Noninstitutionalized and Institutionalized Older Adults

Objectives: First, to seek if sociodemographic and health factors contribute differentially to the explanation of loneliness in institutionalized and noninstitutionalized older adults; and second, to analyze the influence of institutionalization on loneliness. Method: This work was based on two surveys of older adults aged 60 years or more in Spain. A group of 234 community-dwelling people and 234 nursing homes residents were selected ( n = 468). Logistic regression models were applied using the six-item De Jong Gierveld Loneliness Scale as dependent variable. Results: Depression was associated with loneliness in both populations. Sex and marital status contributed to explain loneliness among those living at home, whereas gathering with family, friends, and neighbors showed a significant effect in the institutionalized group. Institutionalization per se showed a strong effect on loneliness. Discussion: Findings have potential implications for targeting older adults at risk for loneliness.

Prevalence of major depressive disorder and minor depressive disorder in an elderly Korean population: results from the Korean Longitudinal Study on Health and Aging (KLoSHA)

OBJECTIVE

We investigated the prevalence, risk factors and impact of major depressive disorder (MDD) and minor depressive disorder (MnDD) in a randomly selected community-dwelling Korean elderly population.

METHOD

This study was conducted as a part of the Korean Longitudinal Study on Health and Aging (KLoSHA). A study population of 1118 Korean elders was randomly sampled from residents of Seongnam, Korea aged 65 years or older. Standardized face-to-face interviews and neurological and physical examinations were conducted on 714 respondents using the Korean version of Mini International Neuropsychiatric Interview. MDD was diagnosed according to the DSM-IV criteria, and MnDD according to research criteria proposed in Appendix B of the DSM-IV criteria.

RESULTS

Age-, gender- and education-standardized prevalence rates in Korean elders aged 65 years or older were estimated as 5.37% (95% CI=3.72-7.03) for MDD, 5.52% (95% CI=3.84-7.19) for MnDD, and 10.89% (95% CI=8.60-13.17) for overall late-life depression (LLD). A prior MDD episode (OR=3.07, 95% CI=1.38-6.82 in MDD, OR=3.44, 95% CI=1.49-7.94 in MnDD), female gender (OR=3.55, 95% CI=1.53-8.24 in MDD, OR=2.68, 95% CI=1.19-6.04 in MnDD) and history of stroke or TIA (OR=3.45, 95% CI=1.62-7.35 in MDD, OR=2.95, 95% CI=1.34-6.52 in MnDD) were associated with the risks of both MDD and MnDD. Lack of formal education (OR=2.75, 95% CI=1.30-5.85) and low income (OR=2.83, 95% CI=1.02-7.88) were associated with the risk of MDD only. Quality of life (QOL) of the MDD and MnDD patients was worse than that of non-depressed elders (P<0.001, ANOVA).

CONCLUSION

MnDD was as prevalent as MDD in Korean elders and impacted QOL as MDD did. MnDD patients may increase in the future with accelerated population aging and westernization of lifestyle in Korea.

Predicting the Longer-term Outcomes of Total Hip Replacement

Objective.

The objective of this study was to identify the patient-level predictors (age, sex, body mass index, mental health, and comorbidity) for a sustained functional outcome at a minimum 1 year of followup after total hip replacement (THR).

Methods.

We reviewed data from our registry on 636 consecutive patients from 1998 to 2005. Demographic data and the outcome scores of the Western Ontario McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short-form 36 (SF-36) scores were extracted from the database. Longitudinal regression modeling was performed to identify the predictive factors of interest. Fourteen percent of patients were missing outcomes data at 1 year of followup.

Results.

The mean followup in our cohort was 3.3 years (range 1–6 yrs) and there were no revisions for aseptic loosening performed during this time. Mean clinical outcome scores were found to be relatively constant for the 6 years after surgery. Older age, year of followup, and greater comorbidity were identified as negative prognostic factors for a sustained functional outcome following THR (p < 0.05).

Conclusion.

Understanding of longterm surgical outcomes should be appropriately used to set realistic patient expectations of surgery.

Disability in late-life major depression: patterns of self-reported task abilities, task habits, and observed task performance

This article describes patterns of concordance/discordance between self-reported abilities ("can do") and habits ("does do") and observed task performance of daily living tasks in three groups of older adults: late life depression with mild cognitive impairment (n=53), late life depression without mild cognitive impairment (n=64), and non-depressed, cognitively normal controls (n=31). Self-reported data were gathered by interview in participants' homes, followed by observation of task performance. Significant differences in the patterns of response were found between controls and respondents with both late life depression and mild cognitive impairment for the cognitive instrumental activities, and between the two depressed groups and controls for the physical instrumental activities. For both sets of activities, controls exhibited the greatest overestimation of task performance. No differences were found among the groups for the less complex functional mobility and personal care tasks. However, for the more complex instrumental activities, concordance was close to, or less than, chance. The findings led us to conclude that when performance testing is not feasible, self-reports of functional status that focus on habits may be more accurate than those that focus on abilities.

Vascular function in older adults with depressive disorder

BACKGROUND

Cerebrovascular disease plays an important role in depressive disorder, especially in older adults. An understanding of vascular function in depression is important etiologically and to develop innovative treatments that may improve prognosis by ameliorating vascular damage.

METHODS

This study assessed endothelial function, arterial stiffness, and atherosclerosis in a variety of vessel beds in 25 elderly subjects with depressive disorder compared with 21 nondepressed control subjects. Subjects underwent pulse wave velocity, pulse wave analysis, carotid intima media thickness analysis, and magnetic resonance imaging. A subset (16 patients and 15 control subjects) had assessment of biopsied small artery dilatation to acetylcholine to further assess endothelial function.

RESULTS

The mean sample age was 72.4 years with an average age at onset for depression of 60 years. Mean carotid intima media thickness was significantly higher in depressed subjects (p < .01). Pulse wave velocity was 1.6 m/sec higher in depressed subjects (borderline significance). There was a significant reduction in the dilatation response to acetylcholine in preconstricted small arteries (p = .01). On magnetic resonance imaging, depressed subjects had significantly more dilated Virchow-Robin spaces in the basal ganglia (p = .01). Depressed subjects had greater volume of white matter lesions in all regions, but this did not reach statistical significance. There were no baseline differences in vascular risk.

CONCLUSIONS

Depression in the elderly is associated with poorer endothelial function and more atherosclerosis. This is associated with a greater white matter hyperintensities lesion load and basal ganglia microangiopathy. The use of vasoprotective drugs to improve endothelial function or retard atherosclerosis as depression-modifying agents should be explored.

Metabolic syndrome and the functional outcomes of hip and knee arthroplasty

OBJECTIVE

Patients with an elevated systemic inflammatory state are known to report greater pain with knee osteoarthritis (OA). We investigated the influence of risk factors of metabolic syndrome (MetS) on patient function before and after hip and knee replacement surgery.

METHODS

A total of 677 consecutive patients with primary knee replacement and 547 consecutive patients with primary hip replacement with at least one MetS risk factor were reviewed from our joint registry. Demographic variables of age, sex, and comorbidity were retrieved. MetS risk factors were defined as body mass index (BMI) > 30 kg/m(2), diabetes, hypertension, and hypercholesterolemia. Baseline and 1-year Western Ontario McMaster University Osteoarthritis Index (WOMAC) scores were compared across patients by number of MetS risk factors, ranging from 1 to 4. Linear regression modeling was used to evaluate the effects of the MetS risk groups and the individual metabolic abnormalities on predicting baseline and 1-year WOMAC scores. Knee and hip patients were reviewed separately.

RESULTS

The knee and hip patients showed a significant difference in sex distribution, BMI, and mean comorbidity across risk groups (p < 0.05). Unadjusted analysis showed that baseline and 1-year WOMAC scores, for both knee and hip patients, increased significantly with increasing number of MetS risk factors (p < 0.05). The linear regression model with the individual metabolic abnormalities was found to be more predictive of outcome than one with the number of MetS risk factors. Hypertension and obesity were the metabolic factors most predictive of a poorer outcome following hip surgery as compared to just obesity for knee patients.

CONCLUSION

Patient function following joint replacement surgery, particularly hip surgery, is negatively affected by metabolic abnormalities perhaps secondary to the systemic proinflammatory state. This knowledge should be used when counseling patients prior to surgery.

Process evaluation of a trial evaluating a multidisciplinary nurse-led home visiting programme for vulnerable older people

PURPOSE

This article describes the content of and adherence with a nurse-led home visiting programme (Dutch Geriatric Intervention Programme; DGIP) for vulnerable older people. The randomised Dutch EASYcare Study showed positive patient endpoints for DGIP. Describing content and adherence is rarely performed, but highly important for understanding the results of trials.

METHOD

DGIP is a complex multicomponent intervention tailored to the patients' needs. This process evaluation describes these components and patient characteristics and creates meaningful clusters of these specific components using hierarchical cluster analysis. Both patient/caregiver and physician adherence rates and possible predictors were investigated.

RESULTS

In line with the heterogeneity among the subjects, the individual treatment plans turned out to be highly tailored. Cluster analysis identified five clusters of intervention components. DGIP turned out to be largely unsuitable for one group of very vulnerable older participants in urgent need of more care. Overall, physician adherence was 75% and was better than patient adherence (51% complete/partial adherence). Adherence levels increased when both patients, caregivers and physicians received recommendations.

CONCLUSIONS

The content of a multicomponent tailored home-visiting programme was very diverse, matching the heterogeneity among frail elderly subjects. Detailed process and cluster analysis helped to understand the content of the intervention, sharpen target criteria and identify possibilities to improve adherence.

The influence of menopause status and postmenopausal use of hormone therapy on presentation of major depression in women

OBJECTIVE

The purpose of this study was to determine whether there are differences in depression characteristics among premenopausal, perimenopausal, and postmenopausal women with major depressive disorder. This study also evaluated these differences between postmenopausal women with major depressive disorder who are taking and not taking hormone therapy.

METHODS

Analyses conducted with data from the Sequenced Treatment Alternatives to Relieve Depression study focused on female outpatients with nonpsychotic major depressive disorder seeking treatment in 41 primary or psychiatric care settings across the United States. Baseline demographic and clinical characteristics were compared among women not taking hormone therapy who were premenopausal (n = 950), perimenopausal (n = 380), or postmenopausal (n = 562). These comparisons were also made between postmenopausal women (n = 768) taking (n = 171) or not taking (n = 562) hormone therapy.

RESULTS

After adjusting for sociodemographic and clinical baseline differences, premenopausal women were more likely to present with irritability than were either perimenopausal or postmenopausal women and were more likely to have decreased appetite and less likely to have early-morning insomnia than were perimenopausal women. Postmenopausal women were more likely to have suicidal ideation and poorer physical functioning than were either of the other groups and were more likely to have sympathetic arousal and gastrointestinal symptoms than were premenopausal women. After adjusting for baseline differences, postmenopausal women taking hormone therapy had better physical functioning, fewer melancholic features, less sympathetic arousal, and more lack of involvement in activities than did women not taking hormone therapy.

CONCLUSIONS

Menopause status and postmenopausal use of hormone therapy may influence the clinical presentation of major depressive episodes in women.

Evidence of early retinal microvascular changes in patients with type 2 diabetes and depression

OBJECTIVE

To examine retinal vascular caliber, an indicator of early microvascular disease and depression in patients with Type 2 diabetes.

METHODS

We conducted a clinic-based study, comparing participants with Type 2 diabetes with major depression (n = 43), without depression (n = 49), and healthy controls without diabetes or depression (n = 54). Retinal vascular caliber was measured from digital photographs. Depression status was determined, using standardized clinical assessment.

RESULTS

After adjusting for age and gender, participants with diabetes and depression had larger arteriolar and venular calibers (147.7 microm for arteriolar and 215.7 microm for venular calibers) than participants with diabetes but without depression (143.3 microm and 213.9 microm) and healthy controls (135.8 microm and 202.5 microm, p for trend = .002 for arteriolar and p = .02 for venular caliber). In multivariate models adjusting for duration of diabetes, systolic blood pressure, cigarette smoking, serum glucose, Cerebrovascular Risk Factor Scale, Cumulative Illness Rating Scale, and retinopathy levels, this relationship remained significant for retinal arterioles (p = .02) but not for retinal venules (p = .10).

CONCLUSIONS

These data show that patients with Type 2 diabetes with major depression have wider retinal arterioles, supporting the concept that depression is associated with early microvascular changes in Type 2 diabetes.

Reward/Punishment reversal learning in older suicide attempters

OBJECTIVE

Suicide rates are high in old age, and the contribution of cognitive risk factors remains poorly understood. Suicide may be viewed as an outcome of an altered decision process. The authors hypothesized that impairment in reward/punishment-based learning, a component of affective decision making, is associated with attempted suicide in late-life depression. They expected that suicide attempters would discount past reward/punishment history, focusing excessively on the most recent rewards and punishments. The authors further hypothesized that this impairment could be dissociated from executive abilities, such as forward planning.

METHOD

The authors assessed reward/punishment-based learning using the probabilistic reversal learning task in 65 individuals age 60 and older: suicide attempters, suicide ideators, nonsuicidal depressed elderly, and nondepressed comparison subjects. The authors used a reinforcement learning computational model to decompose reward/punishment processing over time. The Stockings of Cambridge test served as a control measure of executive function.

RESULTS

Suicide attempters but not suicide ideators showed impaired probabilistic reversal learning compared to both nonsuicidal depressed elderly and nondepressed comparison subjects, after controlling for effects of education, global cognitive function, and substance use. Model-based analyses revealed that suicide attempters discounted previous history to a higher degree relative to comparison subjects, basing their choice largely on reward/punishment received on the last trial. Groups did not differ in their performance on the Stockings of Cambridge test.

CONCLUSIONS

Older suicide attempters display impaired reward/punishment-based learning. The authors propose a hypothesis that older suicide attempters make overly present-focused decisions, ignoring past experiences. Modification of this "myopia for the past" may have therapeutic potential.

Duloxetine and care management treatment of older adults with comorbid major depressive disorder and chronic low back pain: results of an open-label pilot study

OBJECTIVE

In older adults, major depressive disorder (MDD) and chronic low back pain (CLBP) are common and mutually exacerbating. We predicted that duloxetine pharmacotherapy and Depression and Pain Care Management (DPCM) would result in (1) significant improvement in MDD and CLBP and (2) significant improvements in health-related quality of life, anxiety, disability, self-efficacy, and sleep quality.

DESIGN AND INTERVENTION

Twelve week open-label study using duloxetine up to 120 mg/day + DPCM.

SETTING

Outpatient late-life depression research clinic.

PATIENTS

Thirty community-dwelling adults >60 years old.

OUTCOME MEASURES

Montgomery Asberg Depression Rating Scale (MADRS) and McGill Pain Questionnaire-Short Form (MPQ-SF).

RESULTS

46.7% (n = 14) of the sample had a depression remission. All subjects who met criteria for the depression remission also had a pain response. 93.3% (n = 28) had a significant pain response. Of the subjects who met criteria for a low back pain response, 50% (n = 14) also met criteria for the depression remission. The mean time to depression remission was 7.6 (SE = 0.6) weeks. The mean time to pain response was 2.8 (SE = 0.5) weeks. There were significant improvements in mental health-related quality of life, anxiety, sleep quality, somatic complaints, and both self-efficacy for pain management and for coping with symptoms. Physical health-related quality of life, back pain-related disability, and self-efficacy for physical functioning did not improve.

CONCLUSIONS

Serotonin and norepinephrine reuptake inhibitors like duloxetine delivered with DPCM may be a good choice to treat these linked conditions in older adults. Treatments that target low self-efficacy for physical function and improving disability may further increase response rates.

[Comorbidity in the elderly: utility and validity of assessment tools]

Comorbidity is common in the elderly and contributes to the complexity of this population subgroup. This problem is a risk factor for major adverse events such as functional decline, disability, dependency, poor quality-of-life, institutionalization, hospitalization and death, but is not the most important factor. Age and risk of functional decline rather than comorbidity (understood as a compilation of diseases) are the main characteristics defining the target population attended by geriatricians. Comorbidity indexes should not be interpreted independently in the elderly, but within a context of comprehensive geriatric assessment that includes age-related preclinical dysfunctions, frailty measures, and functional, mental and psychosocial issues. The clinical management of comorbidity in the elderly requires advanced knowledge of geriatrics because the treatment of one condition may worsen or lead to the development of others and because preclinical physiological dysfunctions modulate drug response. Recommending a specific comorbidity index is difficult and depends on multiple factors, due to their psychometric characteristics, applicability in the elderly and their construct. However, the Cumulative Illness Rating Scale, in the version adapted to the elderly, could be highly suitable. Other instruments, such as the Charlson index, the Index of CoExistent Disease and the Kaplan index are also valid and reproducible.

Poor sleep quality predicts onset of either major depression or subsyndromal depression with irritability during interferon-alpha treatment

Major depressive disorder (MDD) often occurs during pegylated IFN-alpha2 (IFN-alpha) treatment. Identifying who is at risk for MDD in this population is essential, and epidemiological studies suggest that sleep may be related to depression risk. Controlling for pre-existing depression symptoms, we therefore examined whether sleep quality prior to IFN-alpha treatment would predict subsequent MDD incidence during IFN-alpha treatment. Adults with hepatitis C but without current clinical MDD (n=86) were evaluated prior to IFN-alpha treatment and then prospectively monitored during treatment using self-report measures of sleep quality (PSQI), depression (BDI), and anger and irritability (AIAQ), as well as with Structured Clinical Interviews for DSM-IV Axis I Disorders (SCID-I). During IFN-alpha treatment, 19% developed MDD, 19% developed subsyndromal depression with irritability, and one developed mania. Controlling for baseline depression symptoms and past history of depression, patients with worse sleep quality (PSQI > or = 10) prior to treatment had a significantly shorter time until they developed MDD or any severe psychiatric problem. These findings may have important implications for understanding, predicting, and possibly preventing depression, particularly in individuals treated with IFN-alpha.

Alone? Perceived social support and chronic interpersonal difficulties in suicidal elders

BACKGROUND

Social networks may protect depressed elders against suicidal behavior. However, conflict in important relationships may undermine the sense of social support, potentially negating the protective effects. Thus, we investigated the role of chronic interpersonal difficulties and perceived social support in depressed elders with and without suicidal thoughts and attempts.

METHODS

106 individuals aged 60 years and older participated in this cross-sectional, case-control study. They were placed in three groups: suicidal depressed, non-suicidal depressed and non-depressed. Following a detailed clinical characterization, we assessed perceived social support (Interpersonal Support Evaluation List), and chronic interpersonal difficulties (Inventory of Interpersonal Problems). Using general linear models, we explored the relationship between suicidal thoughts/attempts, social support, and chronic interpersonal difficulties. We also examined whether lower perceived social support explained the relationship between chronic interpersonal difficulties and suicidal thoughts/attempts.

RESULTS

Suicidal depressed elders reported the lowest levels of perceived social support (belonging, tangible support, and self-esteem) and higher levels of chronic interpersonal difficulties (struggle against others and interpersonal hostility), compared to both non-suicidal depressed and non-depressed elders. The relationship between chronic interpersonal difficulties and suicidal behavior was partially explained by low perceived social support.

CONCLUSIONS

The experience of strong affects, interpersonal struggle, and hostility in relationships may undermine the sense of social support in depressed elders, possibly leading them to contemplate or attempt suicide. Depressed elders with a history of interpersonal difficulties need to be carefully monitored for suicidal behavior.

Effect of age on the frequency of anxiety disorders in major depression with psychotic features

OBJECTIVE

To compare the frequency of anxiety disorders in older and younger persons with major depressive disorder with psychotic features.

DESIGN

Cross-sectional.

SETTING

University medical centers.

PARTICIPANTS

Two hundred fifty-nine persons (N = 117 aged 18-59 years and N = 142 aged > or =60 years) with major depressive disorder with psychotic features who were enrolled in the Study of the Pharmacotherapy of Psychotic Depression (STOP-PD).

MEASUREMENTS

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) defined anxiety disorders were determined by Structured Clinical Interview for DSM-IV interview at baseline assessment. Younger and older participants were compared on the frequencies of any current anxiety disorder and any lifetime anxiety disorder, as well as the frequencies of individual anxiety disorders.

RESULTS

Older persons had significantly lower frequencies of any current anxiety disorder and any lifetime anxiety disorder, even after controlling for relevant demographic and clinical variables. With respect to specific anxiety disorders, older persons had significantly lower frequencies of current and lifetime panic disorder, current and lifetime social anxiety disorder, and current and lifetime posttraumatic stress disorder.

CONCLUSION

The findings of this study are consistent with those of community-based epidemiologic surveys that anxiety disorders are less prevalent in older than younger adults. Because of the rigorous assessment used in STOP-PD, our findings suggest that the age-related decline in the prevalence of anxiety disorders is not simply due to a failure to detect cases in older people, as has been previously suggested.

Detecting Disabilities in Older Patients With Cancer: Comparison Between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13

Purpose

Comprehensive geriatric assessment (CGA) is a multidimensional method used by geriatricians and oncologists to detect and evaluate multiple age-related problems and to plan and coordinate interventions. Because its main drawback is the time required, efforts have been made to evaluate screening instruments suitable for preliminarily assessing elderly patients. The main aim of this study was to establish the accuracy of the Vulnerable Elders Survey-13 (VES-13) in predicting the presence of abnormalities revealed by CGA.

Patients and Methods

Patients age ≥ 70 years with a histologically or cytologically confirmed diagnosis of a solid or hematologic tumor underwent both CGA and a VES-13 assessment, and the reliability and validity of VES-13 were analyzed.

Results

Fifty-three percent of the 419 elderly patients with cancer (mean age, 76.8 years) were vulnerable on VES-13; the rates of disabilities on CGA and activities of daily living (ADLs)/instrumental activities of daily living (IADLs) scales were 30% and 25%, respectively. The sensitivity and specificity of VES-13 were 87% and 62%, respectively, versus CGA and 90% and 70%, respectively, versus ADL/IADL scales.

Conclusions

On the basis of our data, VES-13 is highly predictive of impaired functional status and can thus be considered a useful preliminary means of assessing older patients with cancer before undertaking a full CGA.

Age-related decline in white matter tract integrity and cognitive performance: a DTI tractography and structural equation modeling study

Age-related decline in microstructural integrity of certain white matter tracts may explain cognitive decline associated with normal aging. Whole brain tractography and a clustering segmentation in 48 healthy individuals across the adult lifespan were used to examine: interhemispheric (corpus callosum), intrahemispheric association (cingulum, uncinate, arcuate, inferior longitudinal, inferior occipitofrontal), and projection (corticospinal) fibers. Principal components analysis reduced cognitive tests into 6 meaningful factors: (1) memory and executive function; (2) visuomotor dexterity; (3) motor speed; (4) attention and working memory; (5) set-shifting/flexibility; and (6) visuospatial construction. Using theory-based structural equation modeling, relationships among age, white matter tract integrity, and cognitive performance were investigated. Parsimonious model fit demonstrated relationships where decline in white matter integrity may explain age-related decline in cognitive performance: inferior longitudinal fasciculus (ILF) with visuomotor dexterity; the inferior occipitofrontal fasciculus with visuospatial construction; and posterior fibers (i.e., splenium) of the corpus callosum with memory and executive function. Our findings suggest that decline in the microstructural integrity of white matter fibers can account for cognitive decline in normal aging.

[Comorbidity and multimorbidity indexes in the elderly patients]

This article was written to reflect the importance of a correct quantification of the complexity of the elderly patient and its potential possibilities in clinical practice. From the decision to perform a laboratory test to the decision of the benefits of a determinate surgery through adjusting pathologies in several studies, most of our decisions depend on the complexity of our patients. Our decisions should be based on objective criteria that categorize the patients who may benefit from our decisions. One way is with comorbidity indexes. Another objective of this article was to review available methods to measure comorbidity and to assess its validity in the elderly. A search was made, with the keywords comorbidity, multi-morbidity and complexity associated with the elderly patient. The different methods were compared and different indexes are offered depending on our study's patients.

The synovial fluid adiponectin-leptin ratio predicts pain with knee osteoarthritis

The relationship between adipokines, such as leptin and adiponectin, and cartilage degeneration is being increasingly recognized. We asked what the relationship is between these hormones and patient-reported knee osteoarthritis (OA) pain. We collected demographic data, Short Form McGill Pain scores, Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scores, and synovial fluid (SF) samples from 60 consecutive patients with severe knee OA at the time of joint replacement surgery. SF samples were analyzed for leptin and adiponectin using specific ELISA. Non-parametric correlations and linear regression modeling were used to identify the relationship between the adipokines and pain levels. The correlations between the individual adipokines and the pain scales were low to moderate and consistently less than that for the corresponding adiponectin/leptin (A/L) ratio. Linear regression modeling showed that the A/L ratio was a significant predictor of a greater level of pain on the MPQ-SF (p=0.03) but not the WOMAC pain scale (p=0.77). A greater A/L ratio was associated with less pain with severe knee OA and this metabolic pathway may represent a target for novel therapeutics.

Diffusion tensor tractography findings in schizophrenia across the adult lifespan

In healthy adult individuals, late life is a dynamic time of change with respect to the microstructural integrity of white matter tracts. Yet, elderly individuals are generally excluded from diffusion tensor imaging studies in schizophrenia. Therefore, we examined microstructural integrity of frontotemporal and interhemispheric white matter tracts in schizophrenia across the adult lifespan. Diffusion tensor imaging data from 25 younger schizophrenic patients (< or = 55 years), 25 younger controls, 25 older schizophrenic patients (> or = 56 years) and 25 older controls were analysed. Patients with schizophrenia in each group were individually matched to controls. Whole-brain tractography and clustering segmentation were employed to isolate white matter tracts. Groups were compared using repeated measures analysis of variance with 12 within-group measures of fractional anisotropy: (left and right) uncinate fasciculus, arcuate fasciculus, inferior longitudinal fasciculus, inferior occipito-frontal fasciculus, cingulum bundle, and genu and splenium of the corpus callosum. For each white matter tract, fractional anisotropy was then regressed against age in patients and controls, and correlation coefficients compared. The main effect of group (F(3,92) = 12.2, P < 0.001), and group by tract interactions (F(26,832) = 1.68, P = 0.018) were evident for fractional anisotropy values. Younger patients had significantly lower fractional anisotropy than younger controls (Bonferroni-corrected alpha = 0.0042) in the left uncinate fasciculus (t(48) = 3.7, P = 0.001) and right cingulum bundle (t(48) = 3.6, P = 0.001), with considerable effect size, but the older groups did not differ. Schizophrenic patients did not demonstrate accelerated age-related decline compared with healthy controls in any white matter tract. To our knowledge, this is the first study to examine the microstructural integrity of frontotemporal white matter tracts across the adult lifespan in schizophrenia. The left uncinate fasciculus and right cingulum bundle are disrupted in younger chronic patients with schizophrenia compared with matched controls, suggesting that these white matter tracts are related to frontotemporal disconnectivity. The absence of accelerated age-related decline, or differences between older community-dwelling patients and controls, suggests that these patients may possess resilience to white matter disruption.

EORTC elderly task force position paper: approach to the older cancer patient

As a result of an increasing life expectancy, the incidence of cancer cases diagnosed in the older population is rising. Indeed, cancer incidence is 11-fold higher in persons over the age of 65 than in younger ones. Despite this high incidence of cancer in older patients, solid data regarding the most appropriate approach and best treatment for older cancer patients are still lacking, mostly due to under-representation of these patients in prospective clinical trials. The clinical behaviour of common malignant diseases, e.g. breast, ovarian and lung cancers, lymphomas and acute leukaemias, may be different in older patients because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. The decision to treat or not these patients should be based on patients' functional age rather than the chronological age. Assessment of patients' functional age includes the evaluation of health, functional status, nutrition, cognition and the psychosocial and economic context. The purpose of this paper is to focus on the influence of age on cancer presentation and cancer management in older cancer patients and to provide suggestions on clinical trial development and methodology in this population.

BDNF Val66Met genotype and 6-month remission rates in late-life depression

Although not observed in younger adult cohorts, in older individuals the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism is associated with major depressive disorder (MDD) risk. It is further associated with subjective social support and magnetic resonance imaging (MRI) hyperintense lesions, clinical features independently related to MDD. We examined the relationship between this polymorphism and antidepressant remission rates in an elderly sample with MDD, while also testing for mediation effects of social support and hyperintensities. A total of 229 elderly Caucasian subjects with MDD completed baseline assessments, 1.5 T MRI, and BDNF genotyping. They received antidepressant medication under a structured treatment algorithm and were evaluated for remission at 3 and 6 months. At the 3-month evaluation, BDNF Val66Met genotype was not associated with remission (Wald's χ²=2.51, P=0.1131). When not controlling for multiple comparisons, Met66 allele carriers were more likely to be remitted at 6 months (χ²=4.32, P=0.0377) with an odds ratio of 1.82 (95% CI: 1.04, 3.22). This effect persisted after controlling for lesion volume and social support, neither of which mediated this relationship. Thus in this exploratory analysis, the Met66 allele may be associated with increased odds of remission in older subjects, but also with increased time to remission as there was no 3-month effect.

Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery

BACKGROUND

: This study evaluated the incidence of postoperative delirium (POD) in elderly patients undergoing general surgery, the risk factors associated with POD, and its impact on hospital stay and mortality.

METHODS

: Patients aged over 65 years who had emergency or elective operations were eligible for this case-control study. Risk factors significantly associated with POD using univariable analysis were entered into multivariable analysis, to establish those independently associated with POD.

RESULTS

: A total of 351 patients (357 admissions) were enrolled in the study. The incidence of POD was 13.2 per cent (17.9 per cent for emergency operations). Independent variables associated with POD were: age above 75 years, co-morbidity, preoperative cognitive impairment, psychopathological symptoms and abnormal glycaemic control. Median length of hospital stay was 21 (range 1-75) days for patients with POD versus 8 (range 1-79) days for control patients (P < 0.001). The hospital mortality rate was 19 and 8.4 per cent respectively (P = 0.021).

CONCLUSION

: The incidence of POD is high in elderly patients for both emergency and elective surgery, leading to an increase in hospital stay and perioperative mortality. To minimize POD, associated risk factors of co-morbidity, cognitive impairment, psychopathology and abnormal glycaemic control must be identified and treated.