Transmitter deficits in Alzheimer's disease

The pattern of neurotransmitter pathway losses in Alzheimer's disease are reviewed. Deficits of the cholinergic pathway from the nucleus basalis, the noradrenergic pathway from the locus coeruleus and the serotoninergic pathway from the raphe nuclei are established. Cortical somatostatin interneurons are affected and dopaminergic neurons may be affected although these may be late or secondary phenomena in the disease process. Other neuronal systems, particularly in the hippocampus and temporal cortex, are also damaged. However, the disease is not one of generalised neuronal atrophy since some neurons are selectively spared. The established pathway-specific losses are discussed in relation to the clinical symptomatology and the pathology of the disorder. The biochemical and histological findings are compared with similar measurements made on tissues from other dementing disorders in an attempt to trace features common to dementias. Finally, as an addendum, a hypothesis is briefly outlined which attempts to explain the common features of the affected neurons and the pathogenesis of the disorder.

Stability of a formalin-inactivated Rift Valley fever vaccine: evaluation of a vaccination campaign for cattle in Mozambique

In Africa and the Arabian Peninsula, outbreaks of Rift Valley fever (RVF) are characterized by abortions in gestating animals and high mortality rates among domestic ruminants. An immunization program using a formalin-inactivated vaccine was initiated in Mozambique in 2002 to control RVF in cattle. In this intervention, the vaccine must be transported for more than a week within the country before it can be administered to the animals, and it is practically impossible to maintain low storage temperatures during that time. Here, we evaluated the influence of transportation conditions on the efficacy of the vaccine. Sixty-three previously unvaccinated and RVF virus seronegative cattle were divided into four groups, which were given vaccine that had been stored for 1 week at 4°C (n=9, group A), at 25°C (n=8, group B), or alternating between 4 and 25°C (n=8, group C), or under the temperature conditions ordinarily occurring during transportation within Mozambique (n=38, group D). The antibody responses induced were monitored for 6-9 months and in some animals up to 21 months. Two immunizations (3 weeks apart) with the formalin-inactivated vaccine induced a long-lasting neutralizing antibody response that was still detectable up to 21 months later. The antibody titers in the animals did not differ significantly between the temperature-assigned vaccine groups A, B, and C, whereas they were significantly higher in group D. These results show that the formalin-inactivated RVF virus vaccine is stable, and, importantly, it is not adversely affected by the variation in temperature that ordinarily occurs during transport within Mozambique.

A virtual reality test battery for assessment and screening of spatial neglect

BACKGROUND

There is a need for improved screening methods for spatial neglect.

AIM

To construct a VR-test battery and evaluate its accuracy and usability in patients with acute stroke.

METHOD

VR-DiSTRO consists of a standard desktop computer, a CRT monitor and eye shutter stereoscopic glasses, a force feedback interface, and software, developed to create an interactive and immersive 3D experience. VR-tests were developed and validated to the conventional Star Cancellation test, Line bisection, Baking Tray Task (BTT), and Visual Extinction test. A construct validation to The Rivermead Behavioral Inattention Test, used as criterion of visuospatial neglect, was made. Usability was assessed according to ISO 9241-11.

RESULTS

Thirty-one patients with stroke were included, 9/31 patients had neglect. The sensitivity was 100% and the specificity 82% for the VR-DiSTRO to correctly identify neglect. VR-BTT and VR-Extinction had the highest correlation (r² = 0.64 and 0.78), as well as high sensitivity and specificity. The kappa values describing the agreement between traditional neglect tests and the corresponding virtual reality test were between 0.47-0.85. Usability was assessed by a questionnaire; 77% reported that the VR-DiSTRO was 'easy' to use. Eighty-eight percent reported that they felt 'focused', 'pleased' or 'alert'. No patient had adverse symptoms. The test session took 15 min.

CONCLUSIONS

The VR-DiSTRO quickly and with a high accuracy identified visuospatial neglect in patients with stroke in this construct validation. The usability among elderly patients with stroke was high. This VR-test battery has the potential to become an important screening instrument for neglect and a valuable adjunct to the neuropsychological assessment.

Physical activity in middle-aged women and hip fracture risk: the UFO study

In a population-based case-control study, we demonstrate that middle-aged women who were active with walking or in different physical spare time activities were at lower risk of later sustaining a hip fracture compared to more sedentary women.

INTRODUCTION

In middle-aged women participating in the Umeå Fracture and Osteoporosis (UFO) study, we investigated whether physical activity is associated with a subsequent decreased risk of sustaining a hip fracture.

METHODS

The UFO study is a nested case-control study investigating associations between bone markers, lifestyle, and osteoporotic fractures. We identified 81 female hip fracture cases that had reported lifestyle data before they sustained their fracture. Each case was compared with two female controls who were identified from the same cohort and matched for age and week of reporting data, yielding a total cohort of 237 subjects. Mean age at baseline was 57.2 ± 5.0 years, and mean age at fracture was 65.4 ± 6.4 years.

RESULTS

Conditional logistic regression analysis with adjustments for height, weight, smoking, and menopausal status showed that subjects who were regularly active with walking or had a moderate or high frequency of physical spare time activities (i.e. berry/mushroom picking and snow shovelling) were at reduced risk of sustaining a hip fracture (OR 0.14; 95% CI; 0.05-0.53 for walking and OR 0.19; 95% CI; 0.08-0.46, OR 0.17, 95% CI; 0.05-0.64 for moderate and high frequency of spare time activities, respectively) compared to more sedentary women.

CONCLUSION

An active lifestyle in middle age seems to reduce the risk of future hip fracture. Possible mechanisms may include improved muscle strength, coordination, and balance resulting in a decreased risk of falling and perhaps also direct skeletal benefits.

Renal concentrating capacity in long-term lithium treatment and after withdrawal of lithium

The urinary concentrating capacity was estimated with the DDAVP test in 87 patients receiving lithium therapy, which was discontinued in all patients. The test was repeated three and eight weeks after withdrawal of lithium in 75 patients and one year after withdrawal in 27 patients. Of the 87 patients, 52 were also treated with neuroleptics, which treatment was continued throughout the study. Two control groups, consisting of 30 patients receiving only neuroleptics and 30 healthy subjects, were studied on one occasion with the DDAVP test. Lithium-treated patients had significantly lower concentrating capacity and higher serum creatinine than healthy subjects at all examinations. Small but statistically significant correlations were found between urinary osmolality and total dose of lithium, between urinary osmolality and duration of lithium treatment, between the highest serum lithium concentration recorded and urinary osmolality after withdrawal of lithium and between the daily dose of lithium and urinary osmolality, while patients were still on lithium. The concentrating capacity improved significantly during the first two months after withdrawal of lithium, but not later. One year after withdrawal of lithium, 17 of 27 patients still had a concentrating capacity below 800 mOsm/kg. Patients receiving lithium and neuroleptics had lower concentrating capacity than patients treated with lithium alone, and patients treated with neuroleptics alone had lower concentrating capacity than healthy subjects.

ECG changes during lithium therapy. A prospective study

The influence of long-term lithium treatment on the ECG was investigated in 53 consecutive patients. An ECG was recorded prior to and 4 and 12 months after institution of lithium therapy. The most frequently observed change during treatment was flattening or inversion of the T wave. Heart rate decreased and P-Q interval increased slightly during therapy. There was no change in the S-T segment or the Q-T interval corrected for heart rate. Our data indicate that well monitored lithium treatment of patients with serum lithium concentrations of about 0.6 mmol/l does not cause serious ECG abnormalities. In the absence of symptoms or signs of heart disease, routine monitoring of ECG is not necessary during lithium treatment.

Renal function and morphology in long-term lithium and combined lithium-neuroleptic treatment

Ten patients on long-term lithium therapy and ten on lithium and neuroleptics (combination therapy) were examined with renal biopsy and tests of renal function. Patients on combination therapy had more pronounced histopathological changes and lower concentrating capacity than patients on lithium alone. Patients on combination therapy had received a larger total dose of lithium and had had higher maximum serum lithium levels than patients on lithium alone. Patients with large daily urine volumes had a low concentrating capacity. There was a negative correlation between degree of histopathological lesions and urinary concentrating capacity. Estimation of urinary concentrating capacity seems to be of value for the assessment of renal lesions in lithium treatment.

Hypoglycemia in Alzheimer's disease

Glucose tolerance tests (GTT) were performed on patients with a) dementia of Alzheimer type, b) distal gangrene, c) cerebrovascular disease, and d) on non-diabetic controls. Fasting blood sugar was significantly lower and the areas under the GTT curves were significantly smaller in the dementia group than in the other three groups. It is discussed whether Alzheimer's disease is a generalized disease not only confined to brain tissue and whether the reduced blood glucose levels could impair the brain transmitter levels.

Changes in blood glucose and insulin secretion in patients with senile dementia of Alzheimer type

A retrospective study of 839 hospital records with various dementia diagnoses showed that 63 cases had a diagnosis of diabetes mellitus as well. None of these were found in the group of patients with senile dementia of Alzheimer type (SDAT). Oral glucose tolerance tests (OGTT) were performed in patients with SDAT, multiinfarct dementia (MID), cerebrovascular disease (CVD), hospitalized control patients (Chosp) and healthy elderly persons (Celd). Fasting blood sugar was significantly lower and the areas under the OGTT curves were significantly smaller in the SDAT group than in the CVD and the Chosp group. SDAT patients had higher insulin levels than Celd during the OGTT and on a statistically significant level 90 min after ingestion of sugar. Our findings suggest that SDAT and diabetes mellitus may not co-exist and that patients with SDAT have decreased blood sugar concentrations and elevated serum insulin levels. It is discussed whether this is an effect of the transmitter deficiencies in SDAT or may serve to explain these deficiencies.

PCR-generated linear DNA fragments utilized as a hantavirus DNA vaccine

The field of DNA vaccines has grown rapidly, and since most such vaccines involve the inoculation of large circular DNA molecules previously propagated in bacteria, several inconveniences (e.g. the presence of antibiotic resistance genes, impurities from bacterial cultures or inefficient uptake of the large and bulky plasmid DNA molecules to the nucleus) are debated. In this study, we have explored the possibility of using smaller and more flexible PCR-generated linear DNA fragments instead. Phosphorothioate (PTO)-modified primers were used successfully to protect the PCR-generated DNA fragments from exonuclease degradation, and by using a nuclear localization signal-peptide to target the linear DNA to the nucleus the immune response against the encoded antigen was further improved. This approach was tested in cell culture using a sensitive reporter system and in vivo with DNA encoding the amino-terminus of the Puumala hantavirus nucleocapsid protein. Our results indicate that linear DNA fragments have a great potential as a genetic vaccine and phosphorothioate modification in combination with a nuclear localization signal peptide increase the stability and targets the linear DNA molecules to the nucleus resulting in an improved biological response examined both in vitro and in vivo.

Sleep Apnea, Delirium, Depressed Mood, Cognition, and ADL Ability After Stroke

OBJECTIVES

The incidence of sleep apnea and stroke increases with age. The aim of this study was to investigate the presence of sleep apnea after stroke and its relationship to delirium, depressed mood, cognitive functioning, ability to perform activities of daily living (ADLs), and psychiatric and behavior symptoms.

DESIGN

Cross-sectional study.

SETTING

Geriatric stroke rehabilitation unit.

PARTICIPANTS

133 patients (78 women and 55 men, mean age 77.1 +/- 7.7 years) consecutively admitted to a geriatric stroke rehabilitation unit.

MEASUREMENTS

All patients underwent overnight respiratory sleep recordings at 23 +/- 7 days (range 11 to 41 days) after suffering a stroke. The patients were assessed using the Organic Brain Syndrome Scale, Montgomery-Asberg-Depression-Rating Scale, Mini-Mental State Examination (MMSE), and Barthel-ADL Index. Sleep apnea was defined as an apnea-hypopnea index (AHI) of 10 or more.

RESULTS

The median of the AHI for the studied sample (N = 133) was 13 (range 0-79; interquartile range 6-28). Fifty-nine percent fulfilled the criteria for sleep apnea; 52% with first-ever stroke had sleep apnea. More patients with sleep apnea than without were delirious, depressed, or more ADL-dependent. Sleep apnea patients also had a higher frequency of ischemic heart disease and had more often suffered from an earlier cerebral infarction. Multivariate analysis showed that obesity, low ADL scores, ischemic heart disease, and depressed mood were independently associated with sleep apnea. Low ADL scores, apnea-related hypoxemia, body mass index < or = 27, and impaired vision were independently associated with delirium. The presence of sleep apnea was not associated with any specific type of stroke or location of the brain lesion.

CONCLUSIONS

Sleep apnea is common in stroke patients and is associated with delirium, depressed mood, latency in reaction and in response to verbal stimuli, and impaired ADL ability. We suggest a trial investigating whether delirium, depressed mood, and ADL ability improve with nasal continuous positive airway pressure treatment of sleep apnea in stroke patients.

Factors relating to the use of physical restraints in geriatric care settings

Physical restraints are commonly used on older persons living in geriatric care settings. The aim of this study was to investigate the influence of environmental and organizational variations and resident and staff characteristics on restraint prevalence. In this cross-sectional study of 33 nursing home wards and 12 group living units for old persons with dementia in two municipalities in northern Sweden, 540 residents (mean age 82) and 529 staff members were evaluated for resident and staff characteristics and organizational and environmental variables. The proportion of residents with impaired mobility function, the number of behavioral disturbances, and nursing staff's attitudes towards use of restraints were the strongest discriminators between restraint-free wards and wards that used restraints. A classification function analysis showed that these three variables could correctly classify the wards as restraint-free, low-use, and high-use wards in 63.6% of the cases, with the highest figures for restraint-free wards (91%). This study has shown that the use of physical restraints is strongly connected with residents' functional status and nursing staffs' attitudes toward their use.

Delirium before and after operation for femoral neck fracture

OBJECTIVES

The aim of this study was to investigate the differences between preoperative and postoperative delirium regarding predisposing, precipitating factors and outcome in older patients admitted to hospital with femoral neck fractures.

DESIGN

A prospective clinical assessment of patients treated for femoral neck fractures.

SETTING

Department of orthopedic surgery at Umeå University Hospital, Sweden.

PARTICIPANTS

One hundred one patients, age 65 and older admitted to the hospital for treatment of femoral neck fractures.

MEASUREMENTS

The Organic Brain Syndrome (OBS) Scale.

RESULTS

Thirty patients (29.7%) were delirious before surgery and another 19 (18.8%) developed delirium postoperatively. Of those who were delirious preoperatively, all but one remained delirious postoperatively. The majority of those delirious before surgery were demented, had been treated with drugs with anticholinergic properties (mainly neuroleptics), had had previous episodes of delirium, and had fallen indoors. Patients who developed postoperative delirium had perioperative falls in blood pressure and had more postoperative complications such as infections. Male patients were more often delirious both preoperatively and postoperatively. Patients with preoperative delirium were more often discharged to institutional care and had poorer walking ability both on discharge and after 6 months than did patients with postoperative delirium only.

CONCLUSIONS

Because preoperative and postoperative delirium are associated with different risk factors it is necessary to devise different strategies for their prevention.

Nasal continuous positive airway pressure in stroke patients with sleep apnoea: a randomized treatment study

The authors have investigated whether treatment of sleep apnoea with nasal continuous positive airway pressure (nCPAP) improves depressive symptoms, personal activities of daily living (ADL), cognitive functioning and delirium in patients that have suffered a stroke. Sixty-three patients consecutively admitted to a stroke rehabilitation unit 2-4 weeks after a stroke, with an apnoea/hypopnoea index > or =15, were randomized to either nCPAP treatment (n=33) or a control group (n=30). Four patients dropped out after randomization. Both groups were assessed at baseline and after 7 and 28 nights using the Montgomery-Asberg Depression Rating Scale (MADRS), Barthel-ADL index, and the Mini-Mental State Examination (MMSE) scale. Compared to the control group, depressive symptoms (MADRS total score) improved in patients randomized to nCPAP treatment (p=0.004). No significant treatment effect was found with regard to delirium, MMSE or Barthel-ADL index. Delirium and low cognitive level (MMSE score) explained poor compliance with nCPAP. Depressive symptoms are reduced through nasal continuous positive airway pressure treatment in patients with severe stroke and sleep apnoea. Compliance with nasal continuous positive airway pressure treatment is a problem in stroke patients, especially when delirium and severe cognitive impairment occur.

Inpatient care quality: analyzing Swedish hospitals with stroke as a tracer

Mortality statistics are an important source of information concerning variations in time and place, identification of risk factors and the evaluation of treatment programs. In this study, a new death certificate was completed "blind" on the basis of hospital records from the last episode of care, across a random sample of 1,376 cases. The results showed that the overlap between the official register's underlying cause of death and that of a panel was 72 per cent at the three-digit level. The official underlying cause of death from cerebrovascular diseases (CVD) was 72 cases in this sample, while 93 were deemed to have CVD by a panel. Additionally, of the 1,233 cases originally reported as non-CVD, the panel deemed non-CVD to be the true underlying cause in 1,176 cases. The paper concludes that CVD was most often correctly reported as the underlying cause of death in the investigated ages up to 75 years but plain differences were found between specialities and in different hospital size.

Modifying the cellular transport of DNA-based vaccines alters the immune response to hantavirus nucleocapsid protein

Puumala virus is a member of the hantavirus genus (family Bunyaviridae) and is one of the causative agents of hemorrhagic fever with renal syndrome (HFRS) in Europe. A genetic vaccination approach was conducted to investigate if the immune response could be modulated using different cellular secretion and/or localisation signals, and the immune responses were analysed in BALB/c mice and in a bank vole infectious model. Rodents vaccinated with DNA constructs encoding the antigen fused to an amino-terminal secretion signal raised significantly higher antibody levels when compared to using constructs lacking secretion signals. Furthermore, the ratios of the IgG subclasses (IgG2a/IgG1) were raised by the use of cellular localisation signals, indicating a more pronounced Th1-type of immune response. The majority of the mice, or bank voles, immunised with DNA encoding a secreted form of the antigen showed a positive lymphoproliferative response and were protected against challenge with Puumala virus (strain Kazan-wt).

Geriatric-based versus general wards for older acute medical patients: a randomized comparison of outcomes and use of resources

BACKGROUND

The effects of residence in an acute geriatrics-based ward (AGW) with emphasis on early rehabilitation and discharge planning for older patients with acute medical illnesses were assessed. Outcome and use of resources were compared with those of patients treated in general medical wards (MWs). A per-protocol rather than intention-to-treat analysis was performed.

METHODS

A randomized trial with 3-months follow-up. A total of 190 patients aged 70 years and older were randomized to an acute geriatrics-based ward, and 223 patients were randomized to general medical wards.

RESULTS

The two groups were comparable at inclusion. However, after care in the AGW, 71% of patients could be discharged directly home compared with 64% of those treated in MWs (relative risk 1.17; 95% CI, 0.93-1.49). The length of stay was shorter in the AGW (mean 5.9 vs 7.3 days; P = .002). The proportion of patients in geriatric or other hospital wards or in nursing homes did not differ, but the proportion of AGW patients in sheltered living tended to be lower (P = .085). At the follow-up, case fatality, ADL function, psychological well-being, need for daily personal assistance, drug consumption, need for readmission to hospital, and total health care costs after discharge did not differ between the two groups. Poor global outcome was observed in 37% of AGW and 34% of MW patients.

CONCLUSIONS

A geriatric approach with greater emphasis on early rehabilitation and discharge planning in the AGW shortened the length of hospital stay and may have reduced the need for long-term institutional living. This occurred despite patients in an acute geriatric ward not having better medical or functional outcome than older acute patients treated in general medical wards.

Clinical profile of delirium in older patients

OBJECTIVE

To examine the prevalence, psychiatric and behavior symptoms, differing symptom profiles, and diurnal variations of delirium in older patients.

DESIGN

A descriptive, point prevalence study with a cross-sectional design.

SETTING

One ordinary county hospital (n = 148), three nursing homes (n = 202), five old people's homes (n = 196), and home medical care patients (n = 171) in parts of a hospital catchment area in Mid-Sweden.

PARTICIPANTS

A total of 717 patients 75 years of age and older were observed and assessed for the prevalence of delirium. Women accounted for 66.4% of the studied population, and the mean age for both sexes was 83.7 years.

MEASUREMENTS

All patients were examined using the OBS (Organic Brain Syndrome) scale, and delirium was diagnosed according to DSM-III-R.

RESULTS

Delirium was diagnosed in 315 of 717 (43.9%) patients, and 135 of 315 (42.9%) of the delirious patients had dementia. Thirty-seven percent of the patients with delirium were delirious in the afternoon, evening, or at night, and 47% of the delirious patients had morning delirium. The delirious patients presented a wide variety of psychiatric symptoms. More than half the patients exhibiting anxiety, psychomotor slowing, depressed mood, and irritability. Nearly 26% were classified as having hypoactive, 22% as having hyperactive, and 42% as having mixed delirium, whereas 11% had neither hypo- nor hyperactive delirium. Seventy-seven percent were classified as having delirium with pronounced emotional and 43% with pronounced psychotic symptoms.

CONCLUSIONS

This study shows that patients with delirium have very different clinical profiles. This might indicate a need for different treatment strategies for patients with different types of delirium.

Epidemiology of delirium

Delirium is one of the most frequent symptoms of disease in the elderly. A large variation of incidence and prevalence data is reported probably due to different patient populations and inconsistent diagnostic criteria. In medical and surgical elderly inpatients recent studies report a prevalence rate of approximately 15% and in postoperative patients the incidence and prevalence rates vary greatly, 7-52%, depending on patient population and clinical setting. In nursing homes the prevalence is even higher and delirium is often combined with dementia. Data supports the statement that delirium is most often found in hospitalized somatically ill elderly patients. As a consequence of the rising number of elderly in hospitals we have to expect an increase in the prevalence and incidence of delirium.

Optimising the signal peptide for glycosyl phosphatidylinositol modification of human acetylcholinesterase using mutational analysis and peptide-quantitative structure-activity relationships

Glycosyl phosphatidylinositol (GPI)-modified proteins have a C-terminal signal peptide (GPIsp) that mediates the addition of a GPI-anchor to an amino acid residue at the cleavage and modification site (omega-site). Within the GPIsp, a stretch of hydrophilic amino acid residues are found which constitutes the spacer region that separates the omega-site residue from a hydrophobic C-terminus. Deletions and insertions into the spacer region of human acetylcholinesterase (AChE) show that the length of this spacer region is very important for efficient GPI-modification. Surprisingly, the natural length of the spacer region in human AChE was not optimal for the highest degree of GPI modification. The importance of the two adjacent residues downstream of the omega-site, the omega+1 and omega+2 residues, was investigated by peptide-quantitative structure-activity relationships (Peptide-QSAR). A model was made that predicts the efficiency of the GPI modification when these residues are substituted with others, and suggests important features for these residues. The most preferred omega+1 and omega+2 residues, predicted by the model, in combination with an ideal spacer length resulted in an optimised GPIsp. This mutant protein is more efficiently GPI-modified than any mutant AChE tested thus far.

Physical restraints in geriatric care. Knowledge, attitudes and use

The aim of the present study was to investigate the use of physical restraints in institutional elder care and staff knowledge about and attitudes toward the use of these restraints. Poor knowledge and negative attitudes toward the use of restraints were found among staff. Significant differences between various staff categories were found concerning knowledge about the use of restraints; nurse aids had the lowest and physicians the highest scores on the knowledge test. Nurse aids demonstrated the least negative attitudes (were most prone to use restraints) and physicians the most negative. Furthermore, there was a significant relation between attitudes and knowledge, i.e. staff with poor knowledge also demonstrated the least negative attitudes toward the use of restraints. Despite these negative attitudes among staff, we found a large proportion of restrained patients in the institutions investigated. Twenty-nine percent of the patients at the investigated clinics were physically restrained. The most common reason given was that restraints were used to prevent falls. No documentation of the observed use of restraints was found in any of the restrained patients' hospital records.

Prevalence of dementia, delirium and psychiatric symptoms in various care settings for the elderly

A prevalence study of psychiatric symptoms was performed in parts of a hospital catchment area in Mid-Sweden. In total 717 patients, aged 75 years and above, who were receiving care in an emergency hospital, three nursing homes, five old people's homes and two home medical care districts were included. All patients were examined using the OBS-scale (Organic Brain Syndrome Scale). Anxiety (51%), psychomotor slowing (45%), delirium (44%), depressed mood (41%), irritability (40%) and dementia (33%) were the most prevalent psychiatric symptoms or diagnoses in the sample but there were wide differences between the four care settings. The present study shows that the prevalence of dementia, delirium and psychiatric symptoms is high in all types of care settings for the elderly. It also demonstrates the need for psychiatric medical and nursing competence in all types of care for the elderly.

Physical restraints in geriatric care in Sweden: prevalence and patient characteristics

OBJECTIVE

Physical restraints are used frequently in geriatric care to promote the safety of frail older patients. This study investigated the prevalence of the use of physical restraints in geriatric care and the way in which patient characteristics are related to the use of physical restraints.

DESIGN

A point prevalence study of patients cared for in various types of geriatric settings.

SETTING

Eight nursing homes, 15 old people's homes, a somatic geriatric clinic, and a psychogeriatric clinic in a health care district in northern Sweden.

PARTICIPANTS

A total of 1325 patients, mean age 82 years, 64% of whom were women.

MEASUREMENTS

The Multi-Dimensional Dementia Assessment Scale (MDDAS) was used to measure motor function, vision, hearing, speech, ADLs, behavioral symptoms, psychiatric symptoms, use of psychoactive drugs, and the physical and psychological workload of the staff. In addition, questions concerning the use of physical restraints were added to the instrument.

RESULTS

Twenty-four percent of the patients were physically restrained. The highest prevalence was found in nursing homes and psychogeriatric care. Physical restraints were found to relate most strongly to cognitive impairment, impaired ADLs, and speech and walking ability. Ninety-four percent of the restrained patients were cognitively impaired. Other variables relating to the use of physical restraints were psychiatric symptoms and behavioral disturbances.

CONCLUSIONS

This study has shown that physical restraints are used frequently in geriatric care in Sweden and that cognitive and physical impairments relate very closely to the use of physical restraints.

Incidence and clinical characterization of unprovoked seizures in adults: a prospective population-based study

In a population-based prospective study of epileptic seizures in adult s aged > 17 years, we identified 563 patients with possible seizures in a period of 34 months. Seizures were unprovoked in 160 patients, an incidence of 56 in 100,000 person-years. There was no difference in incidence between sexes. Age-specific incidences of unprovoked seizures increased sharply in men from age 60 years and in women from age 70 years. The incidence of unprovoked seizures in those aged > 65 years was 139 (men 166, women 116). The cumulative incidence of unprovoked seizures between the ages of 17 and 84 years was 4.6%. The proportion with an identified presumptive cause for unprovoked seizures increased with advancing age. A presumed etiology was identified in 77% of persons aged > 60 years. Stroke was the most common etiology, detected in 30% (incidence 16) and in 45% at ages > 60 years. Tumors were detected in 11% (incidence 6) and Alzheimer's disease was detected in 7% (incidence 4). Eighteen percent of patients were demented. Unprovoked seizures were partial in 68% of cases (incidence 38), and generalized in 16% (incidence 9). Another 13% of patients had generalized seizures, but seizure onset was not witnessed (incidence 7). In 16%, there was a delay of > 1 year from the first unprovoked seizure to initial diagnosis.

Residues in Torpedo californica acetylcholinesterase necessary for processing to a glycosyl phosphatidylinositol-anchored form

Acetylcholinesterase from Torpedo californica (TcAChE) can be found as a glycosyl phosphatidylinositol (GPI)-anchored, membrane associated form. The C-terminal amino-acid sequence of the precursor protein resembles the signal peptide sequence found in proteins and enzymes destined for GPI-modification. Characteristics of such a signal peptide are a relatively polar stretch of amino acids, separating a cleavage- and modification-site (omega-site) residue from a hydrophobic C-terminus. We have introduced mutations, both at putative omega-sites and in the hydrophobic region, and analysed their effects on GPI-anchoring of TcAChE. Our results show that substitution of all three Ser residues in the region Ser542-Ser544 prevents GPI-modification and membrane anchoring. Individual substitution of each of these residues resulted in no or only a minor effect on the modification. We therefore conclude that more than one residue within this sequence can be utilised as the omega-site. Our analyses of double substitutions indicated that Ser543 and Ser544 are the preferred residues for GPI-modification. Moreover, the hydrophobic region is shown to be essential for GPI-anchoring of TcAChE.

Falls leading to femoral neck fractures in lucid older people

OBJECTIVE

To analyze the mechanisms of falls that result in femoral neck fractures among lucid older people.

DESIGN

A cross-sectional study.

SETTING

An orthopedic university hospital department.

PARTICIPANTS

A consecutive series of 123 lucid patients, 65 years of age or more, who were admitted for femoral neck fractures.

MEASUREMENTS

On admission, the subjects were interviewed about fracture accident characteristics, and falling mechanisms were classified. An arterial blood gas sample was taken from each patient soon after admission. Based on data regarding drug consumption and social and medical characteristics, a fall-risk index was calculated for each subject.

RESULTS

It was ascertained that 95% of the fractures were caused by falls and < 2% were spontaneous. Most accidents (68%) took place indoors, 47% of the falls were classified as extrinsic, 24% as intrinsic, 7% as nonbipedal, and 22% remained unclassified. Almost all outdoor falls were extrinsic; however, intrinsic falls were as common as extrinsic falls indoors (P < .001). Extrinsic fallers presented a significantly lower fall-risk index score than subjects with fractures caused by intrinsic, nonbipedal, and unclassifiable falls. A large proportion of subjects (24%) wre hypoxemic (pO2 < 8 kPa) on admission, and patients who sustained fractures at night had lower oxygen tension than that of daytime fallers (P = .006).

CONCLUSIONS

Accidental falls are the primary cause of femoral neck fractures. Preventive actions should be directed toward intrinsic, as well as extrinsic, risk factors for falls. Hypoxemia might be a risk factor for falls, especially those falls that occur at night.

Epidemiology and treatment of post-stroke depression

Depression is a common and serious complication after stroke. According to epidemiological studies, at least 30% of stroke patients experience depression, both early and late after stroke. However, in clinical practice only a minority of the patients are diagnosed and even fewer are treated. There are several studies confirming the magnitude of the problem but the main conclusion which can be drawn from the few treatment studies published is that tricyclic antidepressants cannot be recommended for the treatment of post-stroke depression, mainly because of the high frequency of contraindications and adverse effects. Until now there has only been 1 double-blind, placebo-controlled treatment study from which some general conclusions can be drawn. The study evaluated a selective serotonin reuptake inhibitor (citalopram) and concluded that the drug was well tolerated and effective for the treatment of post-stroke depression. However, when treatment was initiated very early, both the treatment group and the placebo group improved equally during the first 7 weeks after stroke. This finding could indicate diagnosis difficulties during the first few weeks after stroke. A recent study, although small, comparing the combination of drugs with either noradrenergic (desipramine plus mianserin) or noradrenergic and serotonergic effects (imipramine plus mianserin) for post-stroke depression, indicated that drugs with the dual effect may be more effective. Many more double-blind placebo-controlled treatment studies and studies comparing the efficacy and adverse effects of various antidepressants in patients with post-stroke depression need to be conducted. According to 3 small studies, electroconvulsive therapy (ECT) seems to be quite well tolerated and therefore ECT may also be considered in the treatment of post-stroke depression. Future studies should also address the long term efficacy of treatment for post-stroke depression.

Abnormalities in adrenal androgens, but not of glucocorticoids, in early Alzheimer's disease

In an attempt to evaluate possible adrenal abnormalities in Alzheimer's disease (AD), prestimulus levels and ACTH-stimulated serum levels of steroid hormones, corticosteroid-binding globulin (CBG), and insulin-like growth factor I (IGF-I) were measured in 18 patients with early AD (8 men, 10 women; 74.6 +/- 6.5 years, mean +/- SD) and 19 healthy controls (10 men, 9 women; 74.2 +/- 7.6 years, mean +/- SD). Steroid hormone levels were measured before and after an intravenous bolus injection of 250 micrograms ACTH. AD per se had an independent influence on hormone levels when evaluated in MANOVA models. AD patients had significantly higher prestimulus levels of dehydroepiandrosterone and androstenedione (p = .04 and p = .003, respectively) with accentuated differences after ACTH (p = .02 and p < .001 for peak responses, respectively). Serum levels of cortisol, CBG, free cortisol, 17 alpha-hydroxyprogesterone (17 alpha-OHP), and IGF-I did not differ between groups. These abnormalities may have implications for neuronal degeneration as well as for behavioural symptoms in AD.

Residues important for folding and dimerisation of recombinant Torpedo californica acetylcholinesterase

The three-dimensional crystal structure of the glycosyl phosphatidylinositol (GPI)-modified form of Torpedo acetylcholinesterase reveals the participation of Arg-44 and Glu-92 in a salt bridge and a hydrogen bond between Asp-93 and Tyr-96. To investigate the biological significance of these interactions, we have made amino acid replacements in this form of AChE: R44E, R44K, E92Q, E92L, D93N, and D93V. None of the introduced mutations affected the production of the acetylcholinesterase polypeptide significantly. However, the mutations introduced at position 92, as well as the D93V and R44E mutations, resulted in a total loss of surface located, active acetylcholinesterase. Replacement of Asp-93 with Asn resulted in a reduced amount of active enzyme. This mutant enzyme was indistinguishable from the wild-type enzyme regarding catalytic constants, but was more sensitive to thermal inactivation. The results show that the salt bridge and hydrogen bond involving residues Arg-44, Glu-92, and Asp-93 have important structural roles and are needed for correct folding, required for transport to the cell surface of TcAChE. The GPI-modified form of acetylcholinesterase is a disulfide bonded dimer. Cys-537 is shown to be required for the formation of the intersubunit disulfide bond in the dimer. Replacement with Ser resulted in the production of an enzyme, that migrates as a monomer upon non-reducing SDS-PAGE and has a lower stability compared to the dimeric wild-type enzyme.

Physical health and cognitive ability among married long-term-care patients and among their spouses--a comparison between home care and nursing home care

The purpose of this study was to establish whether physical health and cognitive function in married long-term patients or in their spouses determines why some patients are cared for in home care while others reside in nursing homes. Out of 38 married couples with a sick spouse cared for in a nursing home, 23 couples were studied; out of 34 couples with a sick spouse cared for in home care, 22 patients and 25 spouses were studied. The results showed no significant differences in physical health score either between the two groups of patients, or between the two groups of spouses. Both home-care patients and nursing home patients had low cognitive function scores, but nursing home patients had significantly lower scores. A multivariate analysis showed that physical health and cognitive function explained only 20% of patients' residence. Between the two groups of spouses there was no difference in cognitive function score. The conclusion is that physical health status and cognitive function explain only to a small extent why married long-term care patients are cared for in nursing homes or in home care.

A comparative study of the social conditions of spouses of long term patients cared for either in nursing homes or home care

In order to study the social conditions of spouses of patients suffering from long term illnesses structured interviews were performed. The interviewees were divided into two groups: spouses of persons with chronic conditions cared for at home and spouses of patients cared for in nursing homes. Each group consisted of 27 spouses and there were no differences in physical health score, Mini mental score or ability to manage primary Activities of Daily Living functions between the groups. Home care spouses paid fewer visits to children, had fewer friends and paid fewer visits to friends and they also had time for hobbies or interests significantly more seldom (reading, visits to church) than nursing home spouses. There were no significant differences between the groups concerning sex, socio-economic class, housing conditions and amount of home health services. Their contact with children and their feelings of loneliness were reported to be the same.

Drug consumption during the last decade among persons born in 1902 in Umeå, Sweden. A longitudinal population study

A population study of drug consumption among people born in 1902 was performed in Umeå, Sweden. The cohort was followed between 79 and 88 years of age. The number of persons in the study varied between 124 and 72. Mean consumption increased from 2.5 to 5.2 drugs per man and from 3.3 to 5.3 per woman. The main correlate of this increase was shown to be the aging individuals' greater morbidity. Cardiovascular preparations, analgesics, psychoactive substances and drugs used to alleviate gastrointestinal symptoms were the most common. At the age of 88 years, 45 to 55% of the individuals used drugs belonging to each one of these drug groups. Furthermore, during the 9 years of study there was a substantial increase in use of these drug groups except for the cardiovascular agents, of which the consumption was constant. The proportion of subjects on regular drugs increased from 82% at 79 years to 95% at 88 years of age. Benzodiazepines were, at 88 years, used by almost 40% of the population; at the same age, 43% were using laxatives and 37% diuretics. Paracetamol (acetaminophen) was the most common analgesic used. Total consumption of drugs prescribed for hypertension decreased considerably, from 23 to 10%, despite an increase in the use of loop diuretics and vasodilating agents.

Serum dehydroepiandrosterone sulfate in Alzheimer's disease and in multi-infarct dementia

Circulating levels of dehydroepiandrosterone sulfate (DHEAS) and cortisol were studied in 86 patients with dementia; 45 with Alzheimer's disease and 41 with multi-infarct dementia. Compared to an elderly control group, after adjustment for age and sex, patients with Alzheimer's disease were found to have lower serum levels of DHEAS. We found a covariation between serum albumin and DHEAS levels, which may be of importance regarding peripheral hormone concentration in patients with dementia. These findings may provide evidence for a role of DHEAS in amnestic disorder in humans, either reflecting or contributing to the course of dementing diseases.

Underdiagnosis and poor documentation of acute confusional states in elderly hip fracture patients

STUDY OBJECTIVE

To determine the accuracy of diagnosis and documentation of acute confusional states (ACS) in the medical records of patients with hip fracture.

DESIGN

The diagnosis of ACS in two prospective clinical studies was compared to its diagnosis in the medical records of the same patients on the same hospitalization. In order to determine if the simultaneous prospective study influences the diagnostic and documentary practices evidenced in the medical records, a further comparison was done by reviewing medical records of two series of patients seen some years prior to the prospective studies.

SETTING

Patients with femoral neck fractures treated at a department of orthopedic surgery in a university hospital and one retrospective control sample from a department of general surgery in a county hospital.

SUBJECTS

Two prospective samples of patients 65 years and older treated for femoral neck fractures (n = 111 and n = 57, respectively) and two earlier retrospective samples (n = 66 and n = 68, respectively).

MEASUREMENTS AND MAIN RESULTS

All comparisons showed that both physicians and nurses diagnosed ACS unsatisfactorily and documented the patients' mental status poorly. The analysis of the two retrospective medical record control samples gave the same results. Neither the physicians nor the nurses used any kind of diagnostic instrument to detect cognitive disorders in the patients.

CONCLUSIONS

ACS is a common and severe complication in elderly people treated for femoral neck fractures. Acute confusional states have, by definition, one or more causes that can often be identified and treated. Poor assessment and documentation is a threat to the patients as a correct diagnosis of ACS is a prerequisite for further assessment of its underlying causes and the consequent necessary medical and nursing care.

A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures

The aim of this study was to evaluate the effect of a geriatric-anesthesiologic intervention program for the prevention and treatment of acute confusional states (ACS) in elderly patients treated for femoral neck fractures. The intervention program was based on the results of previous prospective studies in similar patient populations. The outcome of the intervention, comprising 103 patients, was compared with that of an earlier study comprising 111 patients. The intervention program consisted of pre- and post-operative geriatric assessments, oxygen therapy, early surgery, prevention and treatment of peri-operative blood pressure falls and treatment of post-operative complications. The incidence of ACS was lower, 47.6%, in the intervention study compared with 61.3% (P less than 0.05) in the control study. Furthermore, the ACS that occurred in the intervention study was less severe and of shorter duration than that in the control study. The incidence of post-operative decubital ulcers, severe falls, and urinary retention was also lower. The mean duration of orthopedic ward stay was 17.4 days in the control study and 11.6 days in the intervention study (P less than 0.001). It can be concluded that the intervention program reduced the incidence, severity, and duration of ACS which resulted in a shortened orthopedic ward stay.

Alzheimer's disease: paired helical filament immunoreactivity in cerebrospinal fluid

A competitive enzyme-linked immunosorbent assay with high sensitivity has been developed for measuring ubiquitin reactivity of paired helical filaments (PHF). Using the assay, ubiquitin immunoreactivity was estimated in the cerebrospinal fluid (CSF) of 44 patients who had been clinically diagnosed as having Alzheimer's disease (AD) and of 38 control patients, including 20 neurological cases. Monoclonal antibody (mAb) 5-25 to isolated paired helical filaments was used. This mAb recognizes amino acids 64-76 of ubiquitin. The levels of ubiquitin immunoreactivity measured in CSF (twice diluted) were significantly higher in the AD (p less than 0.001) than in the control group. In only a minority of instances were values for ubiquitin levels the same in AD and control groups: on PHF-coated plates, immunoreactivity values for 77% of the AD CSF specimens were higher than those for 92% of the controls, and on ubiquitin-coated plates, values for 85% of the AD CSF specimens were higher than those for 88% of the controls. On immunoblots of both AD and control CSF, mAb 5-25 stained a series of protein bands. The free ubiquitin that is also present in the CSF was not labeled. No striking differences were detected in the immunoblot pattern of AD and control CSF. This study demonstrates the presence of quantitative differences in the conjugated ubiquitin in AD and control CSF.

Development of psychogeriatric medicine in Sweden

Psychogeriatric medicine is a young discipline in Sweden as well as in other parts of the world. Patients with psychogeriatric diseases, however, have been cared for in different ways during the centuries. When Christianity was established in Sweden, the view toward the helpless and poor changed radically. The institutions that were built, however, so-called Houses of the Holy Spirit, housed all kinds of poor and sick people as well as mentally ill elderly persons. During the 17th and 18th centuries, hospitals consisted of large units for the care of the poor elderly, children, and physically and mentally ill people. In 1763 it was established that the local communities should be responsible for the social care, and the State be responsible for mental and somatic care of both young and old people. Further, it was decided that the big hospitals should be mental hospitals reserved for all patients with mental disturbances, young and old.

Antibodies in serum of patients with Alzheimer's disease cause immunolysis of cholinergic nerve terminals from the rat cerebral cortex

A blind study showing that serum from patients with Alzheimer's disease causes immunolysis of mammalian brain synaptosomes is reported. Control, aged-matched, sera were largely without effect. The immunolysis was directed mainly against cholinergic synaptosomes. The data support the hypothesis that autoimmune mechanisms may operate in the pathogenesis of Alzheimer's disease.

Evidence for the presence of antibodies to cholinergic neurons in the serum of patients with Alzheimer's disease

A blind study showing that serum from patients with Alzheimer's disease causes immunolysis of mammalian brain synaptosomes is reported. Control, aged-matched, sera were largely without effect. The immunolysis was directed mainly against cholinergic synaptosomes. The data presented support the hypothesis that autoimmune mechanisms may operate in the pathogenesis of Alzheimer's disease.

Acute confusional states in elderly patients treated for femoral neck fracture

The aims of this study were to estimate the incidence of acute confusional state (ACS), its predisposing factors and consequences in 111 consecutive patients operated for fractured neck of the femur. The incidence of ACS was 61 percent and the predicting factors were old age and dementia. Drugs with anticholinergic effect, depression, and previous stroke were factors that seemed to be associated with the development of ACS. Ninety-two percent of the patients who had severe perioperative blood pressure drops developed ACS. The consequences of ACS were prolonged ward-stay at the orthopedic department, a greater need for long-term care after discharge, and poor walking ability at discharge and six months after surgery. The confused patients also had more complications, such as urinary problems, feeding problems and decubital ulcers, as compared with the nonconfused patients.

Postoperative confusion after anesthesia in elderly patients with femoral neck fractures

Fifty-seven patients, all over the age of 64, with femoral neck fracture were randomized to receive epidural or halothane anesthesia to see if the anesthetic technique influenced the incidence of postoperative confusion. All patients were lucid on admission. Using the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III) as criteria for confusion, we found that 44% of the patients developed confusion that correlated closely to a history of mental depression (P less than 0.01) and to the use of drugs with anticholinergic effect (P less than 0.005). There was no difference in the incidence of confusion between the two anesthetic groups. In patients given halothane, however, early postoperative hypoxemia was associated with confusion (P less than 0.05). Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times. It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique.

Iontophoretic study of adrenergic and cholinergic skin vessel reactivity in normal ageing and Alzheimer's disease

Iontophoresis was used to evaluate the peripheral reactivity of phenylephrine (alpha 1-agonist), isoproterenol (beta-agonist) and metacholine (cholinergic agonist) in patients with Alzheimer's disease (AD). The cutaneous responses--erythema and blanching--were visually recorded. Healthy personnel, medical students and patients with various dermatoses served as controls. A reduced response towards the adrenergic agonists was seen in AD. The reduced sensitivity was highly significant for the beta-agonist isoproterenol (p less than 0.001), in contradistinction the metacholine response did not differ between AD and age-matched controls. Furthermore, increasing age did not seem to significantly influence the cutaneous responses in mentally healthy controls. Thus, a reduced peripheral adrenergic reactivity was observed in the patients suffering from AD.

Age dependence of tissue plasminogen activator concentrations in plasma, as studied by an improved enzyme-linked immunosorbent assay

A procedure for improving the specificity of enzyme-linked immunosorbent assays (ELISA) was devised, based on addition of antigen-specific or non-immune immunoglobulins to the citrated plasma sample and defining the difference in assay response between these two mixtures as the antigen-specific part of the response. When applied to measurement of tissue plasminogen activator (t-PA; EC 3.4.21.31) antigen in plasma, this procedure resulted in elimination of the overestimates obtained in a large proportion (10-20%) of patients' samples when assayed according to the conventional ELISA technique. Basal t-PA concentrations in plasma were found to be highly age-dependent, normal values being about 3 micrograms/L for adults near 30 years of age and about 10 micrograms/L for those over 60. Patients with gallbladder stone disease had increased mass concentrations of t-PA in plasma, even when corrected for the age effect; patients with multi-infarct dementia did not.

Age dependence of tissue plasminogen activator concentrations in plasma, as studied by an improved enzyme-linked immunosorbent assay

A procedure for improving the specificity of enzyme-linked immunosorbent assays (ELISA) was devised, based on addition of antigen-specific or non-immune immunoglobulins to the citrated plasma sample and defining the difference in assay response between these two mixtures as the antigen-specific part of the response. When applied to measurement of tissue plasminogen activator (t-PA; EC 3.4.21.31) antigen in plasma, this procedure resulted in elimination of the overestimates obtained in a large proportion (10-20%) of patients' samples when assayed according to the conventional ELISA technique. Basal t-PA concentrations in plasma were found to be highly age-dependent, normal values being about 3 micrograms/L for adults near 30 years of age and about 10 micrograms/L for those over 60. Patients with gallbladder stone disease had increased mass concentrations of t-PA in plasma, even when corrected for the age effect; patients with multi-infarct dementia did not.