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

Community-based adaptive physical activity program for chronic stroke: feasibility, safety, and efficacy of the Empoli model

OBJECTIVE

To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community.

METHODS

Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain.

RESULTS

After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P<.00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P<.003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P=.01).

CONCLUSION

APA-stroke appears to be safe, feasible, and efficacious in a community setting.

Cross-cultural validation of the Scales for Outcomes in Parkinson's Disease-Psychosocial questionnaire (SCOPA-PS) in four Latin American countries

OBJECTIVE

To conduct a cross-national validation of the Scales for Outcomes in Parkinson's Disease-PsychoSocial questionnaire (SCOPA-PS) in four Latin American Countries.

METHODS

Data quality (missing items), scale assumptions (item-test correlation), internal consistency (Cronbach's alpha, item homogeneity), factor structure, content validity, and precision (standard error of measurement, SEM) of the scale were explored, as was convergent validity with motor symptoms (Clinical Impression of Severity Index [CISI-PD], Scales for Outcomes in Parkinson's Disease-Motor Scale), emotional status (Hospital Anxiety and Depression Scale) and health-related quality of life (Parkinson Disease Questionnaire-39). Known-groups validity was studied by category of severity, based on Hoehn and Yahr staging (HY), CISI-PD, and disease duration.

RESULTS

Three hundred thirty-one Parkinson's disease (PD) patients with usable data participated (mean age 64.7 years; 42.3% female; mean PD duration 8.5 years; HY, 1 to 5). Data quality (missing items <10%), scale assumptions (item-total correlation = 0.43 - 0.71) and internal consistency of SCOPA-PS (Cronbach's alpha = 0.87; item homogeneity = 0.38) were satisfactory. Factor analysis suggested a unifactorial structure. High convergent validity was found for depression (r(S) = 0.61), anxiety (r(S) = 0.62), and health-related quality of life (r(S) = 0.82). Known-groups validity analyses indicated a gradual influence of severity category and disease duration on SCOPA-PS scores (P < 0.0001). SEM value was 8.24 (7 to 12 in previous studies). These magnitudes may be indicative of the threshold for a real change and a minimum important difference.

CONCLUSIONS

The Latin American versions of the SCOPA-PS displayed appropriate psychometric attributes.

Factors associated with resistance to dementia despite high Alzheimer disease pathology

BACKGROUND

Autopsy series have shown that some elderly people remain with normal cognitive function during life despite having high burdens of pathologic lesions associated with Alzheimer disease (AD) at death. Understanding why these individuals show no cognitive decline, despite high AD pathologic burdens, may be key to discovery of neuroprotective mechanisms.

METHODS

A total of 36 subjects who on autopsy had Braak stage V or VI and moderate or frequent neuritic plaque scores based on Consortium to Establish a Registry for Alzheimer's Disease (CERAD) standards were included. Twelve had normal cognitive function and 24 a diagnosis of AD before death. Demographic characteristics, clinical and pathologic data, as well as antemortem brain volumes were compared between the groups.

RESULTS

In multiple regression analysis, antemortem hippocampal and total brain volumes were significantly larger in the group with normal cognitive function after adjusting for gender, age at MRI, time from MRI to death, Braak stage, CERAD neuritic plaque score, and overall presence of vascular disease.

CONCLUSION

Larger brain and hippocampal volumes were associated with preserved cognitive function during life despite a high burden of Alzheimer disease (AD) pathologic lesions at death. A better understanding of processes that lead to preservation of brain volume may provide important clues for the discovery of mechanisms that protect the elderly from AD.

Risk for depression during interferon-alpha treatment is affected by the serotonin transporter polymorphism

BACKGROUND

Major depressive disorder (MDD) occurs in a subset of patients receiving interferon-alpha treatment, although many are resilient to this side effect. Genetic differences in the serotonin reuptake transporter promoter (5-HTTLPR) may interact with the inflammatory system and influence depression risk.

METHODS

A cohort of 71 nondepressed hepatitis C patients about to receive interferon-alpha was prospectively followed, employing a diagnostic structured clinical interview (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID-I]) and self-report questionnaires. Patients were genotyped for the 5-HTTLPR (L(G), L(A), and S) and the variable number of tandem repeats (VNTR) polymorphism in the second intron. Kaplan-Meier analyses were used to compare major depression incidence. Genotype effects on sleep quality (Pittsburgh Sleep Quality Index) and Beck Depression Inventory (BDI) were assessed using mixed-effect repeated-measure analyses.

RESULTS

The L(A) allele was associated with a decreased rate of developing MDD (Mantel-Cox log rank test p < .05) with the L(A)/L(A) genotype being the most resilient. This genotype was also associated with better sleep quality [F(61.2,2) = 3.3, p < .05]. The ability of baseline sleep quality to predict depression incidence disappeared when also including genotype in the model. Conversely, the relationship of neuroticism with depression incidence (B = .07, SE = .02, p < .005) was not mitigated when including genotype.

CONCLUSIONS

Using a prospective design, 5-HTTLPR is associated with MDD incidence during interferon-alpha treatment. Preliminary evidence that this effect could be mediated by effects on sleep quality was observed. These findings provide support for a possible interaction between inflammatory cytokine (interferon-alpha) exposure and 5-HTTLPR variability in MDD.

Escitalopram for older adults with generalized anxiety disorder: a randomized controlled trial

CONTEXT

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in older adults; however, few data exist to guide clinicians in efficacious and safe treatment. Selective serotonin reuptake inhibitors (SSRIs) are efficacious for younger adults with GAD, but benefits and risks may be different in older adults.

OBJECTIVE

To examine the efficacy, safety, and tolerability of the SSRI escitalopram in older adults with GAD.

DESIGN, SETTING, AND PARTICIPANTS

A randomized controlled trial in primary care practices and related specialty clinics in Pittsburgh, Pennsylvania, of 177 participants aged 60 years or older with a principal diagnosis of GAD randomized to receive either escitalopram or placebo and conducted between January 2005 and January 2008.

INTERVENTIONS

Twelve weeks of 10 to 20 mg/d of escitalopram (n = 85) or matching placebo (n = 92).

MAIN OUTCOME MEASURES

Cumulative response defined by Clinical Global Impressions-Improvement score of much or very much improved; time to response; and anxiety and role functioning changes measured by the Clinical Global Impressions-Improvement scale, Hamilton Anxiety Rating Scale, Penn State Worry Questionnaire, Late-Life Function and Disability Instrument activity limitations subscale, and the role-emotional impairment and social function subscales of the Medical Outcome Survey 36-item Short Form.

RESULTS

In the primary analytic strategy in which participants (n = 33) were censored at the time of dropout, mean cumulative response rate for escitalopram was 69% (95% confidence interval [CI], 58%-80%) vs 51% (95% CI, 40%-62%) for placebo (P = .03). A conservative intention-to-treat analysis showed no difference in mean cumulative response rate between escitalopram and placebo (57%; 95% CI, 46%-67%; vs 45%; 95% CI, 35%-55%; P = .11). Participants treated with escitalopram showed greater improvement than with placebo in anxiety symptoms and role functioning (Clinical Global Impressions-Improvement scale: effect size, 0.93; 95% CI, 0.50-1.36; P < .001; Penn State Worry Questionnaire: 0.30; 95% CI, 0.23-0.48; P = .01; activity limitations: 0.32; 95% CI, 0.01-0.63; P = .04; and the role-emotional impairment and social function: 0.96; 95% CI, 0.03-1.90; P = .04). Adverse effects of escitalopram (P < .05 vs placebo) were fatigue or somnolence (35 patients [41.1%]), sleep disturbance (12 [14.1%]), and urinary symptoms (8 [9.4%]).

CONCLUSIONS

Older adults with GAD randomized to escitalopram had a higher cumulative response rate for improvement vs placebo over 12 weeks; however, response rates were not significantly different using an intention-to-treat analysis. Further study is required to assess efficacy and safety over longer treatment durations.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00105586.

Elders with first psychiatric hospitalization for depression

OBJECTIVE

Little is known about the first psychiatric hospitalization episode of older adults with depression. The purpose of this study is to describe the proportion and characteristics of first-time inpatients admitted for late-life depression.

METHODS

Guided by the Network Episode Model and the Andersen model, this study identifies and compares the characteristics of depressed older adults with (n = 108) and those without (n = 77) prior psychiatric hospitalization, upon admission into the geropsychiatric unit, using logistic regression. Data on a lifetime history of inpatient psychiatric treatment, clinical characteristics, demographics, social resources, and psychosocial/medical service use were obtained from patients' medical records and self-reports.

RESULTS

Compared with patients who had prior psychiatric admission, first-time inpatients were associated with having: (1) late-onset depression (OR = 14.99); (2) no lifetime psychotic symptoms (OR = 0.21); (3) lower scores on the Brief Psychiatric Rating Scale (BPRS) at admission (OR = 0.96); (4) higher numbers of doctors seen (OR = 1.46); and (5) lower use of senior centers 6 months prior to the admission (OR = 0.12).

CONCLUSIONS

Depressed older adults' prior psychiatric inpatient service utilization is closely related to their past and current psychiatric needs. Also, the two groups show significant differences in health and social service use prior to the psychiatric hospitalization. However, severity of depression at admission was not different.

Apathy after hip fracture: a potential target for intervention to improve functional outcomes

The authors examined apathy symptoms, their improvement, and their association with functional recovery after a hip fracture. Of 126 participants, 37% had clinically significant apathy symptoms, which predicted functional outcome (i.e., poorer recovery from the fracture among those with higher baseline apathy). Of participants with high baseline apathy, approximately one-third improved; these participants had a better functional outcome than those with persistently high apathy scores. It is concluded that apathy symptoms are common after a hip fracture, but improve in one-third of individuals, with a concomitant functional recovery after hip surgery. Interventions to prevent or improve apathy in elderly persons deserve further attention.

Concurrent anxiety and substance use disorders among outpatients with major depression: clinical features and effect on treatment outcome

BACKGROUND

Depressed patients often present with comorbid anxiety and/or substance use disorder. This report compares the four groups defined by the disorders (anxiety disorder, substance use disorder, both, and neither) in terms of baseline clinical and sociodemographic features, and in terms of outcomes following treatment with citalopram (a selective serotonin reuptake inhibitor).

METHODS

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial enrolled 2838 outpatients with non-psychotic major depressive disorder (MDD) from 18 primary and 23 psychiatric care clinics. Clinical and sociodemographic features were assessed at baseline. These baseline features and the treatment outcomes following treatment with citalopram were compared among the four groups.

RESULTS

Participants with non-psychotic MDD and comorbid anxiety and/or substance use disorder showed several distinctive baseline sociodemographic and clinical features. They also showed greater depression severity; length of illness; likelihood of anxious, atypical or melancholic features; more intolerance/attrition; and worse remission/response outcomes with treatment. Participants with either anxiety or substance use disorder showed outcomes generally intermediate between those with both and those with neither.

CONCLUSIONS

Comorbid anxiety and/or substance use disorder are clinically identifiable, and their presence may define distinct MDD subgroups that have more problems and worse pharmacological treatment outcomes. They may benefit from more aggressive, multi-faceted treatment and psychosocial rehabilitation targeted at reducing their psychological comorbidity and functional impairment.

Quality of life and multimorbidity of elderly outpatients

INTRODUCTION

Substantial medical research has established an inverse relationship between quality of life and illness. However, there exists minimal evidence for such a connection in the context of stable and controlled diseases.

OBJECTIVE

We wished to correlate multimorbidity with quality of life for elderly patients who suffer from stable chronic diseases.

METHODS

We used a tool to evaluate quality of life, namely World Health Organization quality of life-BRIEF, together with a scale of multimorbidity known as the Cumulative Illness Rating Scale - Geriatric Version. Furthermore, the quality of life data were correlated with scores recorded on the Cumulative Illness Rating Scale - Geriatric Version, the number of drugs used, and individual perceptions of health and age.

RESULTS

We studied 104 elderly patients who suffered from chronic diseases. The patients had exhibited neither acute events nor secondary complications, their cognition was intact, and they were functionally independent. The Cumulative Illness Rating Scale - Geriatric Version showed an inverse correlation with the physical domain (p= 0.008) and a tendency toward an inverse correlation with the psychological domain (p= 0.052). Self-perception of health showed a high correlation with the physical domain (p= 0.000), psychological domain (p= 0.000) and environmental domain (p= 0.000). The number of drugs used correlated only with the physical domain (p= 0.004). Age and social domain showed a tendency toward a positive correlation (p= 0.054).

DISCUSSION

We uncovered an inverse relationship between quality of life and multimorbidity in a group of patients who suffered from stable chronic diseases, with no functional limitations, pain or complications. Our data suggest that a patient's knowledge that they have a certain clinical condition changes their subjective assessment of quality of life in the related domain.

CONCLUSION

The perceived quality of life of the sample was affected by multimorbidity in the physical domain, with a tendency toward commensurate effects in the psychological domain.

Does major depressive disorder with somatic delusions constitute a distinct subtype of major depressive disorder with psychotic features?

BACKGROUND

Among patients with major depression with psychotic features, little is known about the extent to which those with and without somatic delusions differ.

METHODS

The first 183 participants in the STOP-PD study were divided into two groups based on the presence or absence of somatic delusions and were compared on multiple demographic and clinical characteristics.

RESULTS

In the multivariate analysis, those with somatic delusions reported more somatic symptoms, rated their health as worse, and were less likely to have persecutory delusions.

CONCLUSIONS

Based on the methods we used, we could not detect meaningful differences between subjects with and without somatic delusions. This suggests that the presence of irrational somatic ideation does not define a distinct clinical subgroup among patients with psychotic depression. This finding needs to be replicated.

Pattern of brain atrophy in elderly patients with depression revealed by voxel-based morphometry

In this study, we explored to what extent brain abnormalities can be identified in specific brain structures of patients suffering from late onset depression. We examined the structural difference in regional gray and white matter volume between 14 community-dwelling patients suffering from geriatric depression and 20 age-matched non-depressed normal subjects by voxel-based morphometry (VBM) based on magnetic resonance imaging. All subjects also underwent an extensive neuropsychological assessment. Compared with control subjects, patients with depression were impaired in measures of verbal and visual memory, construction, executive ability, and information-processing speed. VBM of gray matter revealed a significant decrease of volume in the right rostral hippocampus, in the right amygdala and in the medial orbito-frontal cortex (gyrus rectus) bilaterally. In the correlation analysis of gray matter volume with the score of the geriatric depression scale, we observed a negative correlation with the medial orbito-frontal cortex (gyrus rectus) bilaterally. There were no differences in white matter volumes between patients with depression and healthy control subjects. The most important limitation of this study was sample size. A larger sample size may have improved detection of changes not reaching significance. Furthermore, our results may not be generalizable across depression severity or to hospitalized patients. The findings are consistent with our hypothesis that depression in the elderly is associated with local gray matter dysfunction.

Healthy cognitive aging and leisure activities among the oldest old in Japan: Takashima study

BACKGROUND

Little is known regarding the normative levels of leisure activities among the oldest old and the factors that explain the age-associated decline in these activities.

METHODS

The sample included 303 cognitively intact community-dwelling elderly persons with no disability in Activities of Daily Living (ADL) and minimal dependency in Instrumental ADL (IADL) in Shiga prefecture, Japan. We examined (i) the nature and frequency of leisure activities, comparing the oldest old versus younger age groups; (ii) factors that explain the age-associated differences in frequencies of engagement in these activities; and (iii) domain-specific cognitive functions associated with these activities, using three summary index scores: physical and nonphysical hobby indexes and social activity index.

RESULTS

The oldest old (85 years old or older) showed significantly lower frequency scores in all activity indexes, compared with the youngest old (age 65-74 years). Gait speed or overall mobility consistently explained the age-associated reduction in levels of activities among the oldest old, whereas vision or hearing impairment and depressive symptoms explained only the decline in social activity. Frequency of engagement in nonphysical hobbies was significantly associated with all cognitive domains examined.

CONCLUSIONS

Knowing the factors that explain age-associated decline in leisure activities can help in planning strategies for maintaining activity levels among elderly persons.

An in-home geriatric programme for vulnerable community-dwelling older people improves the detection of dementia in primary care

BACKGROUND/OBJECTIVE

Dementia is under-diagnosed in primary care. This study investigated whether an in-home geriatric assessment and management programme could improve the identification of patients with dementia in primary care.

METHODS

A secondary analysis was performed, using data of a randomised controlled trial that studied the effects of an in-home geriatric evaluation and management programme compared with usual care. In this trial, 151 vulnerable community-dwelling patients, aged 70 years and older, participated: 86 in the intervention group and 66 in de control group. The effect of the programme on the dementia detection rate was determined by comparing the number of new dementia diagnoses in both study arms at 6 months follow-up.

RESULTS

Of all 151 participants, 38 (25%) had a registered dementia diagnosis at baseline. During follow-up, 23 of 113 patients without a registered dementia diagnosis at baseline were identified as suffering from dementia. The difference between the numbers of new dementia diagnoses in the intervention group (19 of 66 patients) and the control group (4 of 47 patients) was significant. (p = 0.02)

CONCLUSION

An in-home geriatric assessment and management programme for vulnerable older patients improves the detection of dementia and can therefore contribute to overcoming of under-diagnosis of dementia.

Obesity and outcomes after sacrocolpopexy

OBJECTIVE

The purpose of this study was to compare outcomes after sacrocolpopexy (SC) between obese and healthy-weight women.

STUDY DESIGN

Baseline and postoperative data were analyzed from the Colpopexy And Urinary Reduction Efforts (CARE) randomized trial of SC with or without Burch colposuspension in stress continent women with stages II-IV prolapse. Outcomes and complications were compared between obese and healthy-weight women.

RESULTS

CARE participants included 74 obese (body mass index >/=30 kg/m(2)), 122 overweight (25-29.9 kg/m(2)), and 125 healthy-weight (18.5-24.9 kg/m(2)) women, and 1 underweight (< 18.5 kg/m(2)) woman. Compared to healthy-weight women, obese women were younger (59.0 +/- 9.9 vs 62.1 +/- 10.3 yrs; P = .04), more likely to have stage II prolapse (25.7% vs 11.2%; P = .01), and had longer operative times (189 +/- 52 vs 169 +/- 58 min; P = .02). Two years after surgery, stress incontinence, prolapse, symptom resolution, and satisfaction did not differ between the obese and healthy-weight groups.

CONCLUSION

Most outcomes and complication rates after SC are similar in obese and healthy-weight women.

Suicidal ideation and suicide attempts among middle-aged and older patients with schizophrenia spectrum disorders and concurrent subsyndromal depression

This study examines the prevalence and correlates of current suicidal ideation and past suicide attempts among patients aged 40 and older with schizophrenia spectrum disorders and concurrent depressive symptoms. Nearly half the sample (n = 132) reported having attempted suicide once or more in their lifetime; those who had attempted, exhibited greater depression and psychopathology. A regression analysis revealed that only past suicide attempts and hopelessness significantly accounted for the presence of current suicidal ideation. Surprisingly, current suicidal ideation did not differ by diagnosis, race/ethnicity, marital status, living situation, age, education, or severity of medical illness. Overall, suicidal ideation and the presence of past suicide attempts were remarkably prevalent, highlighting the need for continued clinical vigilance with this patient population. The impact of hopelessness and general psychopathology, as well as the insignificance of demographic characteristics and medical illness severity warrant further investigation.

Effects of an adapted physical activity program in a group of elderly subjects with flexed posture: clinical and instrumental assessment

BACKGROUND

Flexed posture commonly increases with age and is related to musculoskeletal impairment and reduced physical performance. The purpose of this clinical study was to systematically compare the effects of a physical activity program that specifically address the flexed posture that marks a certain percentage of elderly individuals with a non specific exercise program for 3 months.

METHODS

Participants were randomly divided into two groups: one followed an Adapted Physical Activity program for flexed posture and the other one completed a non-specific physical activity protocol for the elderly. A multidimensional clinical assessment was performed at baseline and at 3 months including anthropometric data, clinical profile, measures of musculoskeletal impairment and disability. The instrumental assessment of posture was realized using a stereophotogrammetric system and a specific biomechanical model designed to describe the reciprocal position of the body segments on the sagittal plane in a upright posture.

RESULTS

The Adapted Physical Activity program determined a significant improvement in several key parameters of the multidimensional assessment in comparison to the non-specific protocol: decreased occiput-to-wall distance, greater lower limb range of motion, better flexibility of pectoralis, hamstrings and hip flexor muscles, increased spine extensor muscles strength. Stereophotogrammetric analysis confirmed a reduced protrusion of the head and revealed a reduction in compensative postural adaptations to flexed posture characterized by knee flexion and ankle dorsiflexion in the participants of the specific program.

CONCLUSION

The Adapted Physical Activity program for flexed posture significantly improved postural alignment and musculoskeletal impairment of the elderly. The stereophotogrammetric evaluation of posture was useful to measure the global postural alignment and especially to analyse the possible compensatory strategies at lower limbs in flexed posture.

Fatigue and functional dependence in older cancer patients

OBJECTIVES

Functional dependence is a costly manifestation of aging that compromises the quality of life of elderly individuals and their caregivers. In this study, we hypothesized that fatigue may be a cause of functional dependence in older cancer patients. To establish whether fatigue was associated with dependence in 1 or more activities of daily living (ADLs) or instrumental activities of daily living (IADLs), and declining performance status (PS). In addition, we studied the prevalence of fatigue and its correlation with anemia, depression, and nutritional status.

MATERIALS AND METHODS

Retrospective cross-sectional study of 214 patients aged 70 and older were seen over a 3-month period by the Senior Adult Oncology Program of the H. Lee Moffitt Cancer Center in Tampa, FL. Each patient was screened with a questionnaire assessing ADLs, IADLs, PS, cognitive impairment, depression, and malnutrition. In addition, each patient underwent assessment of fatigue with the fatigue symptom inventory and a determination of complete blood counts and complete chemical panel.

RESULTS

Fatigue was reported by 81% of the patients. The interference score of fatigue seemed to be a mediator for dependencies in ADLs and IADLs (P < 0.001 and 0.001), and poorer PS (P < 0.001).

CONCLUSIONS

Fatigue is a common chronic problem for older cancer patients and may represent a major cause of functional dependence.

Effects of non-selective non-steroidal anti-inflammatory drugs on the aggressiveness of prostate cancer

BACKGROUND

Inflammatory mediators have a role in the initiation and progression of prostate cancer. Observed anti-cancer effects of non-steroidal anti-inflammatory drugs (NSAIDs) have consisted largely of those that inhibit inflammatory mechanisms thought to promote an aggressive disease phenotype. Epidemiologic studies have supported a chemopreventive effect but there is little research on a possible protective role against prostate cancer aggressiveness and progression to advanced disease.

METHODS

We conducted a population-based exploratory study, using cross-sectional and case-cohort approaches to assess, the effect of NSAIDs on indicators of prostate cancer aggressiveness. The study population consisted of 1,619 randomly selected patients with a further over-sampling of 453 prostate cancer mortality cases. All had been curatively treated by radical prostatectomy or external-beam radiotherapy and were sampled using the Ontario Cancer Registry. Aggressiveness of disease at diagnosis, represented by Gleason score, and risk of prostate cancer death were compared across NSAID exposure groups.

RESULTS

The adjusted odds ratio (OR) of a total Gleason score of 8-10 versus 2-6 indicated a non-significant protective effect of NSAIDs (OR: 0.74, 95% CI: 0.47-1.17). We did not observe an association with risk of prostate cancer death overall (HR: 1.03, 95% CI: 0.79-1.34), but a secondary analysis indicated that NSAID users surviving five years may be protected from early prostate cancer death (HR: 0.54, 95% CI: 0.26-1.13).

CONCLUSION

Although estimates were not statistically significant, this exploratory study indicates a possible negative association between NSAID use and disease aggressiveness. Larger investigations with more precise exposure measurements are recommended.

Sex differences in correlates of suicide attempt lethality in late life

OBJECTIVE

Suicide attempts are more lethal in men than in women and this sex difference is more pronounced in old age, when suicide rates in men are highest in most countries, including the United States. To understand this sex difference, the authors assessed correlates of suicide attempt lethality in older men and women.

METHOD

Our cross-sectional study enrolled 125 adults (84 aged 50-69 and 41 aged 70 and older) with major depression and a suicide attempt admitted to community and university hospitals in Rochester, NY. and Pittsburgh, PA. Assessments included a structured diagnostic interview, the Lethality Scale, the Suicide Intent Scale, the Cumulative Illness Rating Scale (CIRS) measuring burden of physical illness, and the Mini-Mental Status Examination (MMSE).

RESULTS

Attempt lethality was higher in older (70+) than in younger (50-69) men and lower in older than in younger women. Association between suicidal intent and attempt lethality was the strongest in older men compared with the other groups. Higher attempt lethality in older men was partly explained by their higher levels of intent, and not by CIRS, MMSE, substance use disorders, or living alone. In younger, but not in older women, suicide intent was correlated with attempt lethality.

CONCLUSION

Older men act more decisively on their suicidal intent than older women and this difference is more pronounced with increasing age. These findings might partially explain the sex differences in suicide deaths worldwide.

An open-label study of citalopram for major depression following traumatic brain injury

Major depression is associated with substantial psychosocial dysfunction and post-concussive symptomatology following traumatic brain injury (TBI). Studies to date of anti-depressant treatment for major depression post-TBI have been limited by small sample size. The goal of the present study is to examine the rates of response and remission associated with citalopram treatment for major depression following traumatic brain injury. Subjects with major depression following mild-to moderate TBI were treated with open-label citalopram with a starting dose of 20 mg/day to a maximum of 50 mg/day for either 6 weeks (n = 54) or 10 weeks (n = 26). The Hamilton Depression Rating Scale (HAMD) was used to assess depression severity. Response was defined by a 50% reduction in HAMD score, and remission was defined by a HAMD score of < or =7. The mean HAMD at baseline and 6 weeks were 23.66 (SD 6.8) and 16.30 (SD 9.3), respectively (t[53] = 7.157, p < 0.0001). The mean HAMD at 10 weeks was 12.96 (SD 7.9) (t[25] = 7.323, p < 0.0001). At 6 weeks, 54 subjects were assessed and 27.7% responded with 24.1% in remission. At 10 weeks, 26 subjects were assessed and 46.2% responded with 26.9% in remission. The response rate in the present sample was substantially lower than previously reported for patients with TBI, but comparable to the results of the largest effectiveness trial of citalopram for general out-patients with major depression in the absence of TBI.

Does depression predict adverse outcomes for older medical inpatients? A prospective cohort study of individuals screened for a trial

OBJECTIVE

to examine the relationship between depressive symptoms and hospital outcomes in an unselected consecutive sample of older medical inpatients.

DESIGN

a prospective cohort study of individuals screened for a trial.

SETTING

medical wards of UK district general hospital in rural East Anglia.

PARTICIPANTS

six hundred and seventeen medical inpatients aged 65+ were randomly selected from consecutive admissions. Baseline measures: 15-item Geriatric Depression Scale (GDS-15), the Abbreviated Mental Test Score (AMTS) and the Cumulative Illness Rating Scale-Geriatric (CIRS-G).

MAIN OUTCOME MEASURES

length of hospital stay; discharge to a community hospital (for rehabilitation), institutional care or usual place of residence; dying in hospital.

RESULTS

depressive symptoms are independently associated with an increased likelihood of inpatient death and transfer to a community hospital for rehabilitation, but are not associated with longer length of stay.

CONCLUSIONS

research evaluating effectiveness of identification and treatment of depression in older medical inpatients should consider including inpatient death and use of rehabilitation services as potential outcomes.

Relationship between self-reported and performance-based tests in a hip and knee joint replacement population

Our objectives were: (1) to assess the relationship between self-reported measures (Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Medical Outcomes Study Short Form-36 (SF-36)) and a performance-based timed-up-and-go (TUG) test in a hip and knee joint replacement population and (2) to determine the predictors of postoperative functional status as measured by the 12-week WOMAC and TUG scores. We surveyed 200 patients undergoing primary hip or knee replacement surgery for demographic data and outcome scores at baseline and 12-week follow-up. There was a weak correlation between preoperative TUG scores and preoperative SF-36 physical function scores (r = -0.28, p < 0.0001), SF-36 role-physical scores (r = -0.21, p = 0.0022) and WOMAC (r = 0.29, p < 0.0001) scores. The relationship was stronger between the postoperative TUG scores and WOMAC scores (r = 0.43, p < 0.0001), SF-36 physical function scores (r = -0.39, p < 0.0001) and SF-36 role-physical (r = -0.33, p < 0.0001) scores. Significant predictors for the TUG test at 12-week follow-up were age (p = 0.004) and preoperative TUG scores (p < 0.0001). Given low-to-moderate relationship between self-reported and performance-based tools, both tests are needed to assess the true level of patient disability.

Impact of close family members on older adults' early response to depression treatment

This study of 130 depressed older adults and their spouses or adult children examined the impact of caregiver burden specific to patients' depressive symptoms on patients' response to antidepressant treatment. Primary care patients completed medical, psychiatric, and neuropsychological assessments prior to treatment, and interviews were conducted with their identified family member. As hypothesized, caregivers' depression-specific burden predicted greater depression severity for the patient at the 6th week of treatment after accounting for patients' pretreatment characteristics, caregivers' depressive symptoms, and caregivers' relationship satisfaction. Future research may identify family attitudes and behaviors that stem from burden and compromise older adults' ability to recover from depression.

Generalized anxiety disorder severity scale validation in older adults

OBJECTIVES

The Generalized Anxiety Disorder Severity Scale (GADSS) is a validated measure of Generalized Anxiety Disorder (GAD) symptom severity. Given the high prevalence of GAD in the elderly and the need for a validated scale to assess GAD severity in this age group, the authors examined the psychometric properties of the GADSS in the elderly.

DESIGN, SETTING, PARTICIPANTS

The authors examined a sample of 134 elderly subjects (age 60 and above) who met diagnostic criteria for current GAD, 33 healthy elderly comparison subjects (age 60 and above) and 186 younger subjects (age 18-60) diagnosed with GAD.

RESULTS

The GADSS had a high internal consistency in the elderly subjects (raw Cronbach's alpha = 0.76). Pearson correlations showed a significant positive correlation between GADSS, Hamilton Rating Scale for Anxiety and Penn State Worry Questionnaire. Pearson correlations showed an inverse significant correlation between GADSS and the Medical Outcome Study SF-36. There was no correlation between GADSS and Mini Mental State Examination or Cumulative Illness Rating Scale for Geriatrics.

CONCLUSIONS

The results showed a good convergent, concurrent, and discriminant validity of the GADSS when used for elderly with GAD. The authors conclude that GADSS is a valid measure of GAD symptom severity in older adults.

Frontal white matter anisotropy and antidepressant remission in late-life depression

Introduction

Neuroanatomic features associated with antidepressant treatment outcomes in older depressed individuals are not well established. This study used diffusion tensor imaging to examine frontal white matter structure in depressed subjects undergoing a 12-week trial of sertraline. We hypothesized that remission would be associated with higher frontal anisotropy measures, and failure to remit with lower anisotropy.

Methods

74 subjects with Major Depressive Disorder and age 60 years or older were enrolled in a twelve-week open-label trial of sertraline and completed clinical assessments and 1.5T magnetic resonance brain imaging. The apparent diffusion coefficient (ADC) and fractional anisotropy (FA) were measured in regions of interest placed in the white matter of the dorsolateral prefrontal cortex, anterior cingulate cortex, and corpus callosum. Differences in ADC and FA values between subjects who did and did not remit to treatment over the study period were assessed using generalized estimating equations, controlling for age, sex, medical comorbidity and baseline depression severity.

Results

Subjects who did not remit to sertraline exhibited higher FA values in the superior frontal gyri and anterior cingulate cortices bilaterally. There were no statistically significant associations between ADC measures and remission.

Conclusions

Failure to remit to sertraline is associated with higher frontal FA values. Functional imaging studies demonstrate that depression is characterized by functional disconnection between frontal and limbic regions. Those individuals where this disconnection is related to structural changes as detected by DTI may be more likely to respond to antidepressants.

Trial Registration

ClinicalTrials.gov NCT00339066

Impacts of poor social support on general health status in community-dwelling korean elderly: the results from the korean longitudinal study on health and aging

OBJECTIVE

We investigated the influence of social support on health, quality of life (QOL), and the risk of depression in elderly Korean people.

METHODS

This study was conducted as a part of the Korean Longitudinal Study on Health and Aging (KLoSHA). A total of 787 nondemented community-dwelling elderly aged 65 years or older were recruited and underwent clinical evaluations for dementia and psychiatric disorders conformed to Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Clinical Assessment Battery (CERAD-K) and the Korean version of the Mini-International Neuropsychiatric Interview (MINI), respectively. Social support was assessed using the Medical Outcome Study Social Support Survey (MOS-SSS). Poor social support (PSS) was defined as having a MOS-SSS score below the 25(th) percentile of the entire sample. General health status was comprehensively evaluated using the modified Cumulative Illness Rating Scale (CIRS), the Korean version of the Geriatric Depression Scale (GDS-K), Mini-Mental Status Examination (MMSE-KC), Korean Activities of Daily Living (KADL), and Korean Instrumental Activities of Daily Living (KIADL). Health-related QOL was evaluated using the Short Form 36 (SF-36).

RESULTS

Low educational attainment and living alone were associated with PSS. Geriatric depression was more prevalent in the PSS group (OR=3.05, 95% CI=1.77-5.27) than in the normal social support (NSS) group. Among the various forms of social support, positive social interaction was significantly associated with risk of geriatric depression (OR=2.25, 95% CI=1.07-4.73). Although health-related QOL was lower in the PSS group than in the NSS group, the ADL and IADL scores of the subjects in the PSS group were better than those of the subjects in the NSS group. In the subjects with geriatric depression, PSS was associated with more severe depression, higher medical morbidity, and poor QOL.

CONCLUSION

PSS had a negative influence on the general health status and QOL among community-dwelling elderly and was an independent risk factor of geriatric depression.

Relationship of general medical burden, duration of illness and age in patients with bipolar I disorder

OBJECTIVE

This study was aimed at evaluating general medical burden in a group of 111 patients with bipolar I disorder.

METHODS

Data were drawn from participants entering the Bipolar Disorder Center for Pennsylvanians (BDCP) protocol. General medical burden was assessed by completing the Cumulative Illness Rating Score (CIRS) from chart review.

RESULTS

The mean age of the sample was 42.1 (11.5), mean CIRS total score was 4.7 (2.9), and mean number of categories endorsed was 3.4 (1.7). Medical burden showed a positive relationship with increasing age and with duration of illness. CIRS scores and number of organ/system categories endorsed were significantly higher in patients with more than 21 years of illness than in patients with 0-9 years of illness (p<.0001) or with 10-20 years of illness (p<.0001). Medical burden was related to duration of illness even after controlling for age. The most frequently endorsed illness categories were cardiovascular disease, (with hypertension and hyperlipidemia being the most frequent conditions) and endocrine/metabolic (with obesity, thyroid dysfunction, and type 2 diabetes being the most common conditions).

CONCLUSIONS

Patients with bipolar disorder carry a substantial burden of general medical conditions, related to age and duration of illness. These results suggest that the development and testing of specific interventions that target medical risk factors and medical burden in patients with bipolar disorder are urgently needed, especially early in the course of the illness, when patients appear to accumulate medical comorbidity at a rapid rate.

Comorbidities, not age, impact outcomes in autologous stem cell transplant for relapsed non-Hodgkin lymphoma

High-dose chemotherapy followed by autologous peripheral blood stem cell transplantation is a widely applied treatment for advanced non-Hodgkin lymphoma (NHL), but few studies have analyzed the tolerability and outcomes in older patients compared with younger patients treated in a homogeneous manner. We retrospectively reviewed 152 consecutive patients who underwent autologous stem cell transplantation (ASCT) following BEAM conditioning (carmustine, etoposide, cytarabine, and melphalan) for NHL from January 2000 through August 2004 at our institution. We compared 59 patients age > or =60 years and 93 patients age <60 years. Supportive care was identical for all patients. The frequency of comorbidities was similar between both groups. CD34+ cell doses, days to neutrophil recovery, and days to platelet count >20,000/mm3 were similar in younger and older patients, although days to platelet count >50,000/mm3 were longer in the older patients (median 30.0 days versus 22.5 days, P = .01). Patients over the age of 60 were more likely to develop grade III/IV mucositis than their younger counterparts (37.7% versus17.4%, P = .0063). Otherwise, the frequency of other grade III/IV toxicities were similar between younger and older patients. Treatment-related mortality (TRM) was similar between older and younger patients (8.5% versus 5.4%, P = .45). Although age was not associated with TRM, the Charlson Comorbidity Index Score was significantly correlated with TRM (P = .03). Median disease-free survival was similar between older and younger patients (21.8 months versus 29.9 months, P = .93), as was overall survival (OS) (47.7 months versus 62.5 months, P = .20). After controlling for age, the Charlson Comorbidity Index Score influenced OS [P = .013]. Overall, our cohort of patients with NHL over the age of 60 who underwent ASCT following BEAM conditioning experienced toxicities and survival similar to their younger counterparts. Comorbidities significantly influenced TRM and OS in this retrospective cohort. Future study should focus on improving tolerability of conditioning and careful prospective evaluation of comorbidities and their association with outcomes.

Correlates of suicidality among patients with psychotic depression

The independent association of age and other factors with suicidality in patients with major depression with psychotic features was examined. Of the 183 study participants, 21% had a suicide attempt during the current episode. Male gender, Hispanic background, past suicide attempt, higher depression scores, and higher cognitive scores were each independently associated with greater intensity of current suicidality. Older age was independently associated with a lower risk of a lifetime suicide attempt. These findings reinforce the evidence that patients with psychotic depression are at high risk for suicide and underscore the importance of examining correlates of suicidality specific to patients with psychotic depression.

Concurrent validity of neuropsychiatric subgroups on caregiver burden in Alzheimer disease patients

OBJECTIVE

In a previously published study, the authors conceptualized neuropsychiatric symptoms in Alzheimer disease (AD) patients as distinct symptom profiles with differential outcomes. In the present study, our aim was to further examine the validation of the classification by considering its concurrent validity on caregiver burden.

METHOD

As described previously, neuropsychiatric symptoms, as assessed by the Neuropsychiatric Inventory, in 122 patients with AD were categorized, using cluster analysis. The presence as well as the severity and frequency of symptoms were both used in the classification. After the classification, group differences in caregiver burden, as measured by Screen for Caregiver Burden, were tested using analysis of covariance. The effects of important covariates, such as functional impairment, comorbid medical conditions, parkinsonism, age, and cognitive functioning, were examined.

RESULTS

Based on the presence of symptoms, subgroups differed in the level of caregiver distress in that caregivers of the "minimally symptomatic" and the "affective/apathetic" subgroups experienced less distress than the caregivers of the "highly symptomatic" subgroup. Based on the severity and frequency of symptoms, subgroups differed in such a way that caregivers of the "minimally symptomatic" and the "predominantly apathetic" subgroups endorsed less distress than the caregivers of the "affective" and the "highly symptomatic" subgroups.

CONCLUSION

Neuropsychiatric subgroups were able to differentially predict caregiver burden. The findings appear to lend further support to the validity of classifying neuropsychiatric symptoms in AD patients using cluster analysis.

Salivary cortisol is associated with diagnosis and severity of late-life generalized anxiety disorder

Age-associated alterations in hypothalamic-pituitary-adrenal (HPA) axis functioning may make individuals more susceptible to HPA dysregulation in the context of mood and anxiety disorders. Little to no research has been done to examine HPA axis function in generalized anxiety disorder (GAD), particularly in late-life GAD, the most prevalent anxiety disorder in the elderly. The study sample consisted of 71 GAD subjects and 40 nonanxious comparison subjects over 60 years of age. We examined the hypotheses that elderly individuals with GAD will have elevated salivary cortisol levels compared to nonanxious subjects, and that elevated cortisol levels in GAD will be associated with measures of symptom severity. We report that late-life GAD is characterized by elevated basal salivary cortisol levels, with higher peak cortisol levels and larger areas under the curve, compared to nonanxious subjects. Additionally, severity of GAD as measured by the GAD Severity Scale and the Penn State Worry Questionnaire are positively correlated with cortisol levels. These data demonstrate HPA axis dysfunction in late-life GAD and suggest the need for additional research on the influence of aging on HPA axis function in mood and anxiety disorders.

Empirically derived decision trees for the treatment of late-life depression

OBJECTIVE

Several predictors of treatment response in late-life depression have been reported in the literature. The aim of this analysis was to develop a clinically useful algorithm that would allow clinicians to predict which patients will likely respond to treatment and thereby guide clinical decision making.

METHOD

A total of 461 patients with late-life depression were treated under structured conditions for up to 12 weeks and assessed weekly with the 17-item Hamilton Rating Scale for Depression (HAM-D-17). The authors developed a hierarchy of predictors of treatment response using signal-detection theory. The authors developed two models, one minimizing false predictions of future response and one minimizing false predictions of future nonresponse, to offer clinicians two clinically useful treatment algorithms.

RESULTS

In the first model, early symptom improvement (defined by the relative change in HAM-D-17 total score from baseline to week 4), lower baseline anxiety, and an older age of onset predict response at 12 weeks. In the second model, early symptom improvement represents the principal guide in tailoring treatment, followed by baseline anxiety level, baseline sleep disturbance, and--for a minority of patients--the adequacy of previous antidepressant treatment.

CONCLUSIONS

Our two models, developed to help clinicians in different clinical circumstances, illustrate the possibility of tailoring the treatment of late-life depression based on clinical characteristics and confirm the importance of early observed changes in clinical status.

Preventing depression in later life: translation from concept to experimental design and implementation

OBJECTIVE

The authors detail the public health need for depression prevention research and the decisions made in designing an experiment testing problem solving therapy as "indicated" preventive intervention for high-risk older adults with subsyndromal depression. Special attention is given to the recruitment of African Americans because of well-documented inequalities in mental health services and depression treatment outcomes between races.

METHODS

A total of 306 subjects (half white, half African American) with scores of 16 or higher on the Center for Epidemiological Studies of Depression Scale, but with no history of major depressive disorder in the past 12 months, are being recruited and randomly assigned to either problem solving therapy-primary care or to a dietary education control condition. Time to, and rate of, incident episodes of major depressive disorder are to be modeled using survival analysis. Level of depressive symptoms will be analyzed via a mixed models approach.

RESULTS

Twenty-two subjects have been recruited into the study, and to date eight have completed the randomly assigned intervention and postintervention assessment. Four of 22 have exited after developing major depressive episodes. None have complained about study procedures or demands. Implementation in a variety of community settings is going well.

CONCLUSION

The data collected to date support the feasibility of translating from epidemiology to RCT design and implementation of empirical depression prevention research in later life.

Clinical analysis of multiple primary malignancies in the elderly

BACKGROUND

Cancer incidence raises progressively during life span; it is estimated that by the year 2030 almost 70% of all neoplasms will occur in people over 65 years old. As carcinogenesis is a multistep, time-requiring process, it is expected that as people live longer they are more likely to develop cancer, and therefore, the prevalence of multiple primary malignancies (MPM) is destined to increase with age.

PATIENTS AND METHODS

Records of all consecutive cancer patients referred to our center from January 2004 to January 2007 were reviewed. We chose the definition of MPM proposed by Warren and Gates. Multiple malignancies were assessed for elderly (>or=70 years old) and younger patients. t-Test and Mc Nemar test were used; subgroup analysis was also performed according to age stratification.

RESULTS

A total of 1,503 consecutive patients were considered; 566 were 70 years old or more (mean age 76.5 years, range 70-96 years) and 878 were younger (mean age 57 years, range 18-69 years). The prevalence of multiple malignancies in the elderly people versus younger ones was 15% and 6%, respectively (P = 0.001). As far as the elderly population is concerned, 21% (56/271) of males compared with 14% (42/295) of females had developed MPM; no significant difference was found between the subgroups with MPM or not as far as age (P = 0.16), comorbidities (P = 0.79), medications (P = 0.76), CIRS-G score and index (P = 0.47, P = 0.54), and PS (P = 0.93) are concerned. Most frequent associations among cancer types were prostate with lung (10/87, 11%), prostate with colorectal cancer (10/87, 11%), and smoking-related cancer, namely lung and head and neck cancer (X/Y, 6%).

CONCLUSIONS

Elderly patients are more likely to develop MPM compared to younger ones. Significant cancer association according to field cancerogenesis concept was the one of smoking-related cancer; other MPM patterns were apparently a random phenomenon.

Sex differences in depression symptoms in treatment-seeking adults: confirmatory analyses from the Sequenced Treatment Alternatives to Relieve Depression study

BACKGROUND

Although epidemiologic research consistently reports greater prevalence of major depressive disorder in women, small sample sizes in many studies do not allow for full elaboration of illness characteristics. This article examines sex differences in terms of illness attributes in a cohort of 2541 outpatients from across the United States who enrolled in the Sequenced Treatment Alternatives to Relieve Depression study.

METHODS

Confirmatory analyses were performed in 2541 outpatients comparing men and women with regard to sociodemographic features, comorbid Axis I and Axis III conditions, and illness characteristics. Results were compared with those of our previous report on the initial population of the first 1500 individuals enrolled in Sequenced Treatment Alternatives to Relieve Depression study.

RESULTS

In both samples, nearly two thirds of the sample (62.5%) were women. Women had greater symptom severity, but men had more episodes of major depression, despite no difference in the length of illness. No differences in age of onset emerged. As in the first cohort, women showed greater rates of an anxiety disorder, bulimia, and somatoform disorder, as well as more past suicide attempts, whereas men showed more alcohol and substance abuse. Women reported more appetite, weight, hypersomnia, interpersonal sensitivity, gastrointestinal and pain complaints, and less suicidal ideation. Irritability was equally common in men and women.

CONCLUSION

This large analysis confirmed most of the clinical features and comorbidities found to be more prevalent in the first cohort of women. In addition, this analysis corroborated previous research suggesting higher rates of atypical and anxious depression in women but refuted the notion of an "irritable depression" found in men. The report confirmed the 1.7:1 ratio for depression seen across sexes in the National Comorbidity Survey.

The quality of medical care for comorbid conditions of depressed elders

OBJECTIVES

In light of large variation in the quality of medical care, this study assesses the extent to which medical care for depressed elders is consistent with systematic quality standards.

METHOD

Using the Donabedian model, we assess factors related to two quality measures: medical service fit and medical provider contact. We assessed 110 depressed older adults with comorbid conditions through practical guidelines of medical services.

RESULTS

We found large variation in the quality of medical care and differences between two quality measures. Structure (Medigap insurance and clinical factors) and process factors (medical professional visits, ER visits, and adequacy of informal care) influenced the quality of medical care.

CONCLUSION

Emphasizing accuracy in quality measures, quality disparities by medical conditions call attention to the risky population with certain conditions targeted for closer follow-up. Appropriate medical care processes can enhance the quality.

Prevalence of behavioral symptoms: comparison of the minimum data set assessments with research instruments

OBJECTIVE

To examine the total and domain-specific prevalence of verbally and physically abusive, socially inappropriate, and care-resistive behaviors according to the Minimum Data Set (MDS) compared with research instruments in nursing home residents with severe dementia.

DESIGN, SETTING, AND METHODS

As part of a longitudinal observational study, MDS behavioral symptoms data were compared with corresponding items from the Ryden Aggression Scale and the Cohen-Mansfield Agitation Inventory for 15 nursing home residents with severe dementia. McNemar's test was used to compare the difference in the proportion of subjects who experienced any symptoms, as well as specific symptoms in several domains, according to the MDS and the research instruments. Additionally, temporal fluctuations in behavioral symptoms were descriptively and graphically summarized.

RESULTS

The MDS significantly underestimated both the total proportion of subjects experiencing any behavioral symptoms (P = .016), as well as the proportion of subjects experiencing verbally abusive symptoms (P < .002), physically abusive symptoms (P = .008), or socially inappropriate behaviors (P = .016) compared with corresponding items from the research instruments. Moreover, these behaviors exhibited considerable temporal instability, suggesting that the systematic daily collection of measures of behavioral disturbances is imperative during the week in which the MDS assessment is to be completed.

DISCUSSION

Albeit from a small study sample, our findings call into question the validity of the MDS behavioral symptom items as they are currently recorded, and suggest that a simple intervention of twice daily completion of a behavioral symptoms checklist containing the MDS items during the week of the assessment may significantly improve the accuracy of the recorded data.

Management of metastatic prostate cancer: the crucial role of geriatric assessment

Prostate cancer predominantly affects older men, with a median age at diagnosis of 68 years. Due to the increased life expectancy, management of prostate cancer in senior adults (aged >70 years) represents a major public health problem. This patient population may not receive optimal therapy for their disease, if decisions are made based on their chronological age alone. More so than age alone, health status is a major factor affecting individual life expectancy. Comorbidity is the key predictor of health status and should weigh more heavily on the treatment decision than age alone. Other important parameters to consider in senior adults are the degree of dependence in activities of daily living, the nutritional status and the presence or not of a geriatric syndrome. Although clinical trials are rarely designed specifically for senior adults, evidence suggests that healthy senior adults have similar treatment outcomes to their younger counterparts. The urological approach in senior adults with advanced prostate cancer should be fundamentally the same as in younger patients. In hormone-sensitive metastatic prostate cancer, androgen deprivation represents the first-line treatment. In senior adults, care should be given to the increased risk of metabolic syndrome, cardiovascular mortality and bone fracture. In hormone-refractory metastatic prostate cancer, chemotherapy with docetaxel (75 mg/m(2) every 3 weeks) plus low-dose prednisone is the standard and shows the same efficacy in healthy senior adults as in younger patients. The tolerance of docetaxel (3-weekly schedule) has not been specifically studied in vulnerable and frail senior adults. The place of weekly docetaxel in this setting should be further evaluated. Palliative treatments (palliative surgery, radiopharmaceutics, radiotherapy, medical treatments for pain and symptoms, pharmacological palliative therapies) should also be integrated in the global management of these patients. In conclusion, treatment decisions in senior adults should be adapted to health status. Healthy senior adults should be treated the same as younger patients. The development of guidelines for the management of localized and advanced prostate cancer in senior adults is underway.

Role of chemotherapy and novel biological agents in the treatment of elderly patients with colorectal cancer

Patients older than 65 years are the fastest growing segment of the cancer population. It is estimated that within 20 years over 75% of cases and 85% of deaths from colorectal cancer (CRC) will be in this setting. Concerns about cancer treatment in the elderly relate to comorbidities, which increase proportionally with age, physiological changes associated with aging which may influence drug metabolism and toxicity, and diminishing life expectancy, which particularly impacts decisions surrounding the benefits of adjuvant therapies. Over the last 10 years, significant improvements in the treatment of advanced CRC with combination therapy have been made. The randomized trials which have defined these improvements did not exclude elderly patients. However, the median age of patients in these trials has generally been approximately 60 years. Thus, it appears that some degree of selection is involved with younger and presumably fitter patients being the subjects in most of the pivotal trials. The availability of new molecularly targeted agents and newly improved existing agents has expanded the range of treatment options available. This variety gives greater flexibility in dealing with different subsets of patients, such as the elderly. However, some fit elderly patients seem to tolerate combination therapy reasonably well, while studies on unfit elderly subjects are needed.