Successful intervention to mitigate an acetylcholinesterase inhibitor-induced rhinorrhea prescribing cascade: a case report.

WHAT IS KNOWN AND OBJECTIVE: A prescribing cascade if often treated by discontinuing both medications. We describe an intervention to mitigate a prescribing cascade while continuing a clinically necessary medication without negatively impacting the patient. CASE SUMMARY: A 77-year-old women experienced probable acetylcholinesterase inhibitor-induced rhinorrhea and subsequently self-medicated with diphenhydramine which lead to worsening cognitive function. We reduced the dose of the acetylcholinesterase inhibitor and discontinued the diphenhydramine. The symptoms of rhinorrhea were subsequently reduced without negatively impacting cognition. WHAT IS NEW AND CONCLUSION: This was the first published prescribing cascade intervention that did not require discontinuation of both medications, which may be emulated in future prescribing cascade cases.

Cardiometabolic risks during anabolic hormone supplementation in older men.

OBJECTIVE: To determine the cardiometabolic risks of testosterone and growth hormone (GH) replacement therapy to youthful levels during aging. DESIGN AND METHODS: A double-masked, partially placebo controlled study in 112 men 65-90 years-old was conducted. Transdermal testosterone (5 g vs. 10 g/day) using a Leydig Cell Clamp and subcutaneous recombinant GH (rhGH) (0 vs. 3 vs. 5 µg/kg/day) were administered for 16-weeks. Measurements included testosterone and IGF-1 levels, body composition by DEXA, and cardiometabolic risk factors (upper body fat, blood pressure, insulin sensitivity, fasting triglycerides, HDL-cholesterol, and serum adiponectin) at baseline and after 16 weeks of treatment. RESULTS: Some cardiometabolic factors improved (total and trunk fat, triglycerides, HDL-cholesterol) and others worsened (systolic blood pressure, insulin sensitivity index [QUICKI], adiponectin). Cardiometabolic risk composite scores (CRCSs) improved (-0.69 ± 1.55, P < 0.001). In multivariate analyses, QUICKI, triglycerides, and HDL-cholesterol contributed 33%, 16%, and 14% of the variance in CRCS, respectively. Pathway analyses indicated that changes in fat and lean mass were related to individual cardiometabolic variables and CRCS in a complex manner. Changes in BMI, reflecting composite effects of changes in fat and lean mass, were more robustly associated with cardiometabolic risks than changes in fat mass or LBM individually. CONCLUSIONS: Testosterone and rhGH administration was associated with diverse changes in individual cardiometabolic risk factors, but in aggregate appeared not to worsen cardiometabolic risk in healthy older men after 4-months. The long-term effects of these and similar anabolic therapies on cardiovascular events should be investigated in populations with greater functional limitations along with important health disabilities including upper body obesity and other cardiometabolic risks.

Predicting mortality in nursing home residents with lower respiratory tract infection: The Missouri LRI Study.

CONTEXT: Lower respiratory tract infection (LRI) is a leading cause of mortality and hospitalization in nursing home residents. Treatment decisions may be aided by a clinical prediction rule that identifies residents at low and high risk of mortality. OBJECTIVE: To identify patient characteristics predictive of 30-day mortality in nursing home residents with an LRI. DESIGN, SETTING, AND PATIENTS: Prospective cohort study of 1406 episodes of LRI in 1044 residents of 36 nursing homes in central Missouri and the St Louis, Mo, area between August 15, 1995, and September 30, 1998. MAIN OUTCOME MEASURE: Thirty-day all-cause mortality. RESULTS: Thirty-day mortality was 14.7% (n = 207). In a logistic analysis, using generalized estimating equations to adjust for clustering, we developed an 8-variable model to predict 30-day mortality, including serum urea nitrogen, white blood cell count, body mass index, pulse rate, activities of daily living status, absolute lymphocyte count of less than 800/microL (0.8 x 10(9)/L), male sex, and deterioration in mood over 90 days. In validation testing, the model exhibited reasonable discrimination (c =.76) and calibration (nonsignificant Hosmer-Lemeshow goodness-of-fit statistic, P =.54). A point score based on this model's variables fit to the entire data set closely matched observed mortality. Fifty-two percent of residents had low (score of 0-4) or relatively low (score of 5-6) predicted 30-day mortality, with 2.2% and 6.2% actual mortality, respectively. CONCLUSIONS: Our model distinguishes nursing home residents at relatively low risk for mortality due to LRI. If independently validated, our findings could help physicians identify nursing home residents in need of different therapeutic approaches for LRI.

Clinical findings associated with radiographic pneumonia in nursing home residents.

OBJECTIVE: Subtle presentation and the frequent lack of on-site physicians complicate the diagnosis of pneumonia in nursing home residents. We sought to identify clinical findings (signs, symptoms, and simple laboratory studies) associated with radiographic pneumonia in sick nursing home residents. STUDY DESIGN: This was a prospective cohort study. POPULATION: The residents of 36 nursing homes in central Missouri and the St. Louis area with signs or symptoms suggesting a lower respiratory infection were included. OUTCOME MEASURED: We compared evaluation findings by project nurses with findings reported from chest radiographs. RESULTS: Among 2334 episodes of illness in 1474 nursing home residents, 45% of the radiograph reports suggested pneumonia (possible=12%; probable or definite = 33%). In 80% of pneumonia episodes, subjects had 3 or fewer respiratory or general symptoms. Eight variables were significant independent predictors of pneumonia (increased pulse, respiratory rate =30, temperature =38 degrees C, somnolence or decreased alertness, presence of acute confusion, lung crackles on auscultation, absence of wheezes, and increased white blood count). A simple score (range = -1 to 8) on the basis of these variables identified 33% of subjects (score > or =3) with more than 50% probability of pneumonia and an additional 24% (score of 2) with 44% probability of pneumonia. CONCLUSIONS: Pneumonia in nursing home residents is usually associated with few symptoms. Nonetheless, a simple clinical prediction rule can identify residents at very high risk of pneumonia. If validated in other studies, physicians could consider treating such residents without obtaining a chest radiograph.

Development of a test of physical performance for the nursing home setting.

PURPOSE: This study was undertaken to develop a performance-based instrument to measure a range of function present among nursing home (NH) residents and to establish the reliability and validity of the measures. DESIGN AND METHODS: Fourteen items integral to daily life in a NH setting were administered to 95 NH residents with sufficient cognitive ability to follow a one-step command at baseline, 1 week later, and 6 months later. Intraclass correlation coefficients and Cronbach's coefficient alpha were calculated for reliability estimates. The Minimum Data Set (MDS), Katz, and Multidimensional Observational Scale for Elderly Subjects (MOSES) were used to establish concurrent validity. Factor analysis, correlation matrices, and other objective criteria were used for item reduction. RESULTS: Test-retest reliability for items ranged between.73 and.93. Factor analysis and correlations between Nursing Home Physical Performance Test (NHPPT) items and scales with measures of activities of daily living (ADL) suggest that the NHPPT taps aspects of gross motor function (Factor 1) and fine motor coordination and task sequencing (Factor 2) required for ADL function and mobility. The NHPPT may also tap aspects of ADL function and mobility not measured by the MDS (r = -.72-.75), MOSES (r = -.82-.84), or Katz (r = -.75-.77) scales. Effect sizes based on mean change scores were larger for the NHPPT scales (.38-.53) than for the other functional scales (.27-.33). IMPLICATIONS: The NHPPT is a reliable performance-based instrument that discriminates among frail NH residents. Further studies are necessary to assess the value of this instrument for prediction and monitoring of functional status in the NH.

Bone mineral density response to estrogen replacement in frail elderly women: a randomized controlled trial.

CONTEXT: Although hormone replacement therapy (HRT) is an established approach for osteoporosis prevention, little is known about the osteoprotective effects of HRT in frail elderly women. OBJECTIVE: To determine whether HRT increases bone mineral density (BMD) in frail elderly women. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled trial conducted in a US university-based research center from September 1995 to August 2000. PARTICIPANTS: Sixty-seven women aged 75 years or older with mild-to-moderate physical frailty. INTERVENTION: Participants were randomly assigned to receive conjugated estrogens, 0.625 mg/d, plus trimonthly medroxyprogesterone acetate, 5 mg/d for 13 days (n = 45), or matching placebo (n = 22), for 9 months. MAIN OUTCOME MEASURES: The primary outcome measure was 9-month change in BMD of the lumbar spine and hip, measured by dual-energy x-ray absorptiometry. Secondary outcomes were changes in markers of bone turnover. RESULTS: Based on intention-to-treat analyses, HRT resulted in significantly larger increases in BMD of the lumbar spine than placebo (mean change, 4.3% vs 0.4%; between-group difference, 3.9%; 95% confidence interval [CI], 3.5%-4.3%) and total hip (mean change, 1.7% vs -0.1%; between-group difference, 1.8%; 95% CI, 1.5%-2.1%). Compared with placebo, HRT resulted in significant decreases in serum bone-specific alkaline phosphatase levels (mean change, -24% vs 6%; between-group difference, -30%; 95% CI, -26% to -33%) and urine N-telopeptide levels (mean change, -48% vs 4%; between-group difference, -52%; 95% CI, -47% to -55%). CONCLUSIONS: In physically frail elderly women, 9 months of HRT significantly increased BMD compared with placebo in clinically important skeletal regions. Further studies are needed to determine whether these osteogenic effects of HRT in elderly women are associated with a reduction in osteoporotic fractures.

Effects of HRT and exercise training on insulin action, glucose tolerance, and body composition in older women.

The independent and combined effects of exercise training and hormone replacement therapy (HRT) on body composition, fat distribution, glucose tolerance, and insulin action were studied in postmenopausal women, aged 68 +/- 5 yr, assigned to control (n = 19), exercise (n = 18), HRT (n = 15), and exercise + HRT (n = 16) groups. The exercise consisted of 2 mo of flexibility exercises followed by 9 mo of endurance exercise. HRT was conjugated estrogens 0.625 mg/day and trimonthly medroxyprogesterone acetate 5 mg/day for 13 days. Total and regional body composition were measured by dual-energy X-ray absorptiometry. Serum glucose and insulin responses were measured during a 2-h oral glucose tolerance test. There were significant main effects of exercise on reductions in total and regional (trunk, arms, legs) fat mass, increase in leg fat-free mass, and improvements in glucose tolerance and insulin action. There were significant main effects of HRT on the reduction of total fat mass (HRT, -3.0 +/- 4.0 kg; no HRT, -1.3 +/- 2.6 kg), with a strong trend for reductions in trunk and leg fat mass (both P = 0.07). There was also a significant improvement in insulin action in response to HRT. These results suggest that there are independent and additive effects of exercise training and HRT on the reduction in fat mass and improvement in insulin action in postmenopausal women; the effect of HRT on insulin action may be mediated, in part, through changes in central adiposity.

Effects of hormone replacement therapy on serum lipids in elderly women. a randomized, placebo-controlled trial.

BACKGROUND: Coronary heart disease (CHD) is the leading cause of death among older women. In observational studies, the incidence of CHD has been reduced in postmenopausal women who take hormone replacement therapy (HRT). A low serum level of high-density lipoprotein (HDL) cholesterol is one of the risk factors predictive of death from CHD. OBJECTIVE: To determine the effects of HRT on serum lipid and lipoprotein levels in elderly women. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: University research center. PARTICIPANTS: 59 sedentary women 75 years of age or older. INTERVENTION: Participants were assigned to 9 months of oral therapy with placebo or conjugated estrogens, 0.625 mg/d, plus trimonthly medroxyprogesterone acetate, 5 mg/d for 13 days. MEASUREMENTS: Serum lipid and lipoprotein levels. RESULTS: After 9 months of treatment, women in the HRT group compared with women in the placebo group had decreased low-density lipoprotein cholesterol levels (mean change [+/-SD], -0.47 +/- 0.69 mmol/L [-18.2 +/- 26.5 mg/dL] vs. -0.06 +/- 0.32 mmol/L [-2.2 +/- 12.2 mg/dL], respectively; between-group difference, 0.41 mmol/L [95% CI, 0.09 to 0.74 mmol/L], 16 mg/dL [95% CI, 3.5 to 28.5 mg/dL]; P = 0.01) and increased HDL cholesterol levels (mean change, 0.21 +/- 0.27 mmol/L [8.1 +/- 10.5 mg/dL] vs. 0.06 +/- 0.11 mmol/L [2.4 +/- 4.3 mg/dL], respectively; between-group difference, 0.15 mmol/L [CI, 0.008 to 0.29 mmol/L], 5.7 mg/dL [CI, 0.8 to 10.6 mg/dL]; P = 0.02). The observed changes were independent of age at menopause onset, baseline lipid values, body weight, waist circumference, percentage body fat, and peak aerobic power. CONCLUSIONS: In women 75 years of age or older, HRT improved the lipoprotein profile to the extent observed previously in younger postmenopausal women. Further studies are needed to evaluate whether these effects protect against CHD in this population.

Effects of hormone replacement therapy on cognitive performance in elderly women.

OBJECTIVE: To determine the effects of 9 months of hormone replacement therapy (HRT) on cognitive performance in women aged 75 years and older. METHODS: A 9-month randomized, double-blinded, placebo-controlled parallel trial. Fifty-two elderly postmenopausal women (age range 75-91 years) without known contraindications to HRT or evidence of dementia or depression were enrolled. Participants were randomly assigned in a 1:2 ratio to placebo or conjugated estrogens at 0.625 mg/d plus trimonthly medroxyprogesterone acetate at 5 mg/d for 13 days (HRT). Main outcome measures were change from baseline and rate of change from baseline for the following psychometric tests: Verbal Fluency Test, Weschler Paired Associate Learning and 20 min Delayed Recall, Trailmaking A and B Tests, Cancellation Random Letter and Random Form Tests. RESULTS: At baseline, women in the HRT group reported a younger age of onset of menopause and a higher prevalence of hysterectomy, but otherwise did not differ from women in the placebo group. After 9 months of treatment, there were no significant group differences for any of the cognitive performance measures. The lack of an observed group-by-time difference for all cognitive tests remained after controlling for age of onset of menopause, education, and previous hysterectomy. CONCLUSIONS: Although conclusions are limited by small sample size and the relatively short duration of treatment, results suggest that 9 months of estrogen replacement in combination with trimonthly progestin does not improve cognitive performance in women over 75 years who do not have dementia or depression.

Frail older women's participation in a trial of hormone replacement therapy: perceived benefits and concerns.

OBJECTIVE: The aim of this study was to identify the reasons that were important to frail older women's decisions to participate or not participate in a clinical trial of hormone replacement therapy (HRT). DESIGN: We conducted a cross-sectional study of a community-based sample of physically frail women > or = 75 years old, who were recruited to participate in an intervention trial of HRT. Participants were randomized 2:1 to either HRT or placebo, respectively. Questionnaires measured participants' reasons for participation and nonparticipants' reasons for declining. Five-point scaled responses to questionnaire items ranged from least to most important or least to most concerned. RESULTS: Sixty-nine women participated (84% white, 16% African American) in the trial. Nonparticipants (n = 41) were older, on average, than participants (83.8+/-4.2 vs. 82.2+/-3.6 years; p = 0.04). Important reasons for participation were reducing risk for Alzheimer's disease and osteoporosis, having more energy, improving self-care ability, and benefiting other women. Fear of cancer from postmenopausal estrogen was the predominant concern of 46% of nonparticipants and 78% of participants (p = 0.08). Recommendation against participation or use of estrogen by a woman's personal physician was the most prevalent additional reason given for nonparticipation. CONCLUSIONS: Disease prevention and improving self-care abilities were most important to participants. Fear of cancer was not a greater concern for nonparticipants than for participants. The role of the physician in older women's decision-making about use of postmenopausal estrogen seems to be important.

Low-intensity exercise as a modifier of physical frailty in older adults.

OBJECTIVE: To examine the effects of a 3-month low-intensity exercise program on physical frailty. DESIGN: Randomized clinical trial. SETTING: Regional tertiary-care hospital and academic medical center with an outpatient rehabilitation fitness center. PARTICIPANTS: Eighty-four physically frail older adults (mean age, 83 +/- 4 yrs). INTERVENTION: Three-month low-intensity supervised exercise (n = 48) versus unsupervised home-based flexibility activities (n = 36). MAIN OUTCOME MEASURES: Physical performance test, measures of balance, strength, flexibility, coordination, speed of reaction, peripheral sensation. RESULTS: Significant improvement was made by the exercise group on our primary indicator of frailty, a physical performance test (PPT) (29 +/- 4 vs 31 +/- 4 out of a possible 36 points), as well as many of the risk factors previously identified as contributors to frailty; eg, reductions in flexibility, strength, gait speed, and poor balance. Although the home exercise control group showed increases in range of motion, the improvements in flexibility did not translate into improvements in physical performance capacity as assessed by the PPT. CONCLUSIONS: Our results suggest that physical frailty is modifiable with a program of modest activities that can be performed by virtually all older adults. They also indicate that exercise programs consisting primarily of flexibility activities are not likely to reverse or attenuate physical frailty. Although results suggest that frailty is modifiable, it is not likely to be eliminated with exercise, and efforts should be directed toward preventing the condition.

Physical and performance measures for the identification of mild to moderate frailty.

BACKGROUND: The relative importance and association of factors contributing to physical frailty in elderly persons are unclear. METHODS: Physical measures of upper and lower extremity strength, range of motion, balance, coordination, sensation, and gait were evaluated in relation to scores obtained on a 36-point physical performance test (PPT) in 107 elderly subjects. RESULTS: Scores on the PPT were significantly associated with the measures of strength and balance, gait, several range of motion values, and sensation. Subjects were also grouped according to score on the PPT as not frail (32-36 points), mildly frail (25-31 points), or moderately frail (17-24 points). ANOVA followed by Bonferroni post hoc analyses were used to examine the relationships of physical measures to this index of frailty. Balance measures, an obstacle course, the Berg scale, the full tandem portion of the Romberg test, and fast gait speed were significantly different among the three groups. Multiple stepwise regression analyses indicated that the strongest combination of variables, explaining 73% of all the variance in the PPT, included obstacle course performance, hip abduction strength, the semitandem portion of the Romberg test, and coordination (pegboard). CONCLUSIONS: Results provide further insight into the relative importance of factors that contribute to frailty and factors that should be considered in treatment planning for the remediation of physical frailty in old adults.

Effects of 10 days of endurance exercise training on the suppression of whole body and regional lipolysis by insulin.

The aim of this study was to evaluate in premenopausal women (10 sedentary obese women) the effects of 10 days of exercise on the suppression of whole body and regional lipolysis by insulin. Lipolysis was determined using 2H5-glycerol infusion and microdialysis of sc adipose tissue during a two-stage hyperinsulinemic-euglycemic clamp [10 (LO) and 20 (MO) mU/m x min]. Microdialysis probes were positioned in abdominal and femoral sc adipose tissue to monitor interstitial glycerol and blood flow. Basal plasma glycerol was 86.7 +/-17.0 and 100.3 +/- 19.8 micromol/L before and after training, respectively (P < 0.05). Plasma glycerol was suppressed to a greater extent after [to 47 +/- 5% (LO) and 42 +/- 5% (MO) of basal] than before [to 62 +/- 8% (LO) and 55 +/- 8% (MO) of basal] training. The rate of appearance of glycerol was suppressed to 49 +/- 7% and 40 +/- 5% of basal during LO and to 38 +/- 5% and 30 +/- 4% of basal during MO (P < 0.05) before and after training, respectively. There were no differences in the suppression of lipolysis in abdominal as well as femoral sc adipose tissue as evidenced by similar reductions in dialysate glycerol levels before and after training in each of these tissues. The results indicate that the antilipolytic response to insulin can be improved through endurance exercise training. Intraabdominal adipose tissue or skeletal muscle may be the site of improved antilipolytic response to insulin after training, as improvement was not evident in abdominal or femoral sc adipose tissue.

Suppression of whole body and regional lipolysis by insulin: effects of obesity and exercise.

The aim of this study was to evaluate in premenopausal women (six endurance-trained nonobese, six sedentary nonobese, and five sedentary obese) the suppression of whole body and regional lipolysis by insulin. Lipolysis was determined using 2H5-glycerol infusion and microdialysis of sc adipose tissue (AT) during a two-stage [6-10 (low; LO) and 12-20 (moderate; MOD) mU/m x min] hyperinsulinemic-euglycemic clamp. Microdialysis probes were positioned in abdominal and femoral sc AT to monitor interstitial glycerol and nutritive blood flow. Basal plasma glycerol was 102 +/- 9, 52 +/- 6, and 143 +/- 30 micromol/L in endurance-trained nonobese, sedentary nonobese, and sedentary obese, respectively (P < 0.05, sedentary nonobese < endurance-trained nonobese, sedentary obese). The plasma glycerol concentration was decreased (P < 0.05) to a greater extent in endurance-trained nonobese and sedentary nonobese [both to approximately 50% (LO) and approximately 45% (MOD) of basal] than in sedentary obese [to 72% (LO) and 63% (MOD) of basal]. The rate of appearance of glycerol was suppressed to 36 +/- 7%, 44 +/- 10%, and 62 +/- 7% of basal during LO in endurance-trained nonobese, sedentary nonobese, and sedentary obese, respectively (P < 0.05, endurance-trained nonobese < sedentary obese), and to 34 +/- 3%, 36 +/- 5%, and 53 +/- 8% of basal during MOD, respectively (P < 0.05, endurance-trained nonobese < sedentary obese). There were no between-group differences in the suppression of lipolysis in abdominal sc AT, as evidenced by similar reductions in dialysate glycerol levels [all to approximately 65% (LO) and approximately 55% (MOD) of basal]. Femoral dialysate glycerol was reduced (P < 0.05) more in sedentary nonobese and endurance-trained nonobese (to approximately 75% of basal) than in sedentary obese (to 90% of basal) during LO, but to a similar extent (to approximately 60% of basal) in all groups during MOD. The results indicate that the sedentary obese women had whole body resistance to the suppression of lipolysis by insulin. Intraabdominal AT may be the site of resistance, as resistance was not evident in abdominal or femoral sc AT.

Leptin response to insulin in humans is related to the lipolytic state of abdominal subcutaneous fat.

Insulin-induced leptinemia in humans appears to be blunted by insulin resistance. We therefore examined the relationship between insulin action and plasma leptin by monitoring regional and whole body lipolysis and plasma leptin levels in 15 premenopausal women (body fat range, 14-59%) during a two-stage euglycemic clamp (insulin was infused 90 min each at 6-10 and 12-20 mU/m2 x min). Microdialysis probes were placed in abdominal and femoral sc adipose tissue. Subjects were given a primed, constant infusion of a stable isotope tracer (2H5-glycerol), and plasma glycerol isotope enrichments were analyzed by mass spectrometry to determine glycerol kinetics. Although there was no mean change in plasma leptin during the clamp (baseline, 16.6 +/- 4.5 ng/mL; final, 16.3 +/- 4.3 ng/mL), there was large interindividual variability in the changes in plasma leptin (range, -18% to +19%). Changes in plasma leptin during the clamp stages were correlated with abdominal dialysate glycerol concentrations (r = -0.44; P < 0.05), but not femoral dialysate glycerol concentrations (r = -0.15), the rate of appearance of glycerol in plasma (r = 0.005), or plasma insulin levels (r = 0.16). The results suggest that insulin-induced changes in plasma leptin are more related to the lipolytic state (i.e. low leptin response when lipolysis is high) of abdominal sc adipose tissue than that of other fat depots.

The relation between psychometric test performance and physical performance in older adults.

BACKGROUND: The relationship between cognitive function and physical disability in nondemented older adults is not well characterized. The purpose of this study was to determine the relationship between performance on psychometric measures and a modified Physical Performance Test (modified PPT) in older men and women. METHODS: One hundred twenty-five men and women aged 75 years and older, who were enrolled in randomized, controlled trials of exercise or hormone replacement therapy, were recruited from the community-at-large and from congregate living sites. Measures obtained included Trailmaking A and B tests, Cancellation Random Figure tests, Weschler Associate Learning and 20-minute Delayed Recall, Verbal Fluency test, a modified PPT, and self-reports about performance of activities of daily living, medication use, and hospitalization in the previous year. RESULTS: Simple regression analysis demonstrated that speed of performance on the Trailmaking B and Cancellation Random Figure tests was significantly associated with total modified PPT score (r = .29, p < .001 and r = .36,p < .001, respectively). A factor analysis of the psychometric test battery demonstrated that two factors, a cognitive speed factor and a memory factor, accounted for 55% of the variance in cognitive test performance. Hierarchical multiple regression analyses demonstrated that age, number of medications, and the cognitive speed factor were independent predictors of total modified PPT score. CONCLUSIONS: Cognitive processing speed is a significant component of physical frailty in this population, although it accounts for a small percentage of variance on a standardized physical performance test.

Peak aerobic power is an important component of physical performance in older women.

BACKGROUND: The purpose of this study was to determine the relationship between peak aerobic power (VO2peak) and performance on a modified Physical Performance Test (modified PPT) in older women. METHODS: One hundred one women aged 75 years and older seeking enrollment in randomized, controlled trials of exercise and/or hormone replacement therapy were recruited from the community-at-large and from congregate living sites. Measures obtained included VO2peak, a modified PPT, and self-reports about performance of activities of daily living. RESULTS: Simple regression analysis demonstrated that VO2peak was associated with total PPT score (r =.53, p <.001), gait speed (r =.44, p <.001), time to arise from a chair five times (r =.43, p = <.001), and time to climb one flight of stairs (r =.36, p =.007). Multiple regression analysis revealed that the relationships between VO2peak and total modified PPT score, gait speed, chair rise time, and time to climb one flight of stairs were independent of age. CONCLUSIONS: Peak aerobic power is a significant independent predictor of performance on a standardized test of physical function in older women and is an important component of physical frailty in this population.

Effects of endurance exercise and hormone replacement therapy on serum lipids in older women.

OBJECTIVE: To determine the effects of 11 months of exercise training and hormone replacement therapy (HRT), alone or in combination, on serum lipids and lipoproteins, in postmenopausal women. DESIGN: Controlled, prospective, 11-month clinical trial. Healthy postmenopausal women (n = 71, age range 60-72 yrs) were assigned to four groups in a 2 X 2 design (control, exercise, HRT, exercise + HRT). SETTING: Large, midwestern urban community; subjects were recruited from the community-at-large. The exercise program was conducted at a university exercise facility. INTERVENTIONS: HRT consisted of conjugated estrogens at 0.625 mg/day and trimonthly medroxyprogesterone acetate 5 mg/day for 13 days. Exercise consisted of 2 months of low intensity exercise followed by 9 months of vigorous exercise for 45 min/day, 3 or more days/week, at 65-85% of maximal heart rate. MEASUREMENTS: Maximal aerobic power (VO2max), resting blood pressure, body composition, serum lipids and lipoproteins, and dietary intake at baseline and after 11 months. MAIN RESULTS: At the end of 11 months, subjects in the exercise group had decrease total cholesterol (TC; P < .01) and LDL-cholesterol (LDL-C; P < .05), but there was no change in HDL-cholesterol (HDL-C) or triglycerides. Women in the HRT group had decreased LDL-C (P < .001) and increased HDL-C (P < .01) and triglycerides (P < .01), but there was no change in TC. Exercise + HRT subjects had decreased TC (P < .05) and LDL-C (P < .001), and increased HDL-C (P < .001); exercise prevented the HRT-related increase in triglycerides. CONCLUSIONS: Endurance exercise training and HRT have independent and complimentary effects on serum lipids profiles in healthy postmenopausal women. Such effects are likely to reduce the risk of cardiovascular morbidity in this population.

Diltiazem-induced psychosis and a possible diltiazem-lithium interaction.

Calcium channel blockers are being used increasingly for a variety of cardiovascular problems. Diltiazem hydrochloride, a benzothiazepine derivative, has been reported to have a low incidence of adverse side effects. We report a case of acute psychosis associated with the use of diltiazem in a patient receiving lithium carbonate therapy. Both diltiazem hydrochloride and lithium carbonate have calcium antagonist effects in the central nervous system, and we review their mechanisms of action. A possible synergistic drug interaction between diltiazem and lithium is reported.