Effect of walking distance on 8-year incident depressive symptoms in elderly men with and without chronic disease: the Honolulu-Asia Aging Study.

OBJECTIVES: To determine the effect of walking on incident depressive symptoms in elderly Japanese-American men with and without chronic disease. DESIGN: Prospective cohort study. SETTING: The Honolulu-Asia Aging Study. PARTICIPANTS: Japanese-American men aged 71 to 93 at baseline. MEASUREMENTS: Physical activity was assessed according to self-reported distance walked per day. Depressive symptoms were measured using an 11-question version of the Centers for Epidemiologic Studies Depression Scale (CES-D 11) at the fourth examination (n=3,196) and at the seventh examination 8 years later (1999/00, n=1,417). Presence of incident depressive symptoms was defined as a CES-D 11 score of 9 or greater or taking antidepressants at Examination 7. Subjects with prevalent depressive symptoms at baseline were excluded. RESULTS: Age-adjusted 8-year incident depressive symptoms were 13.6%, 7.6%, and 8.5% for low (<0.25 miles/day), intermediate (0.25-1.5 miles/day), and high (>1.5 miles/day) walking groups at baseline (P=0.008). Multiple logistic regression analyses, adjusted for age, education, marital status, cardiovascular risk factors, prevalent diseases, and functional impairment, showed that those in the intermediate and highest walking groups had significantly lower odds of developing 8-year incident depressive symptoms (odds ratio (OR)=0.52, 95% confidence interval (CI)=0.32-0.83, P=.006 and OR=0.61, 95% CI= 0.39-0.97, P=.04, respectively). Analysis found that this association was significant only in participants without chronic diseases (coronary heart disease, cerebrovascular accident, cancer, Parkinson's disease, dementia, or cognitive impairment) at baseline. CONCLUSION: Daily physical activity (≥0.25 mile/day) is significantly associated with lower risk of 8-year incident depressive symptoms in elderly Japanese-American men without chronic disease at baseline.

Strength and influence of geriatrics departments in academic health centers.

The United States is establishing new medical schools and increasing class size by 30% in response to the predicted increased needs of the baby boom generation, which will retire soon and live longer than prior generations. Society in general and the medical profession in particular are ill equipped to care for the special needs of the elderly. Since the early 1980s, departments of geriatric medicine have been developed in the United States. However, the prevailing U.S. system for the training of physicians in geriatrics is through sections, divisions, or institutes. This article reviews the advantages and disadvantages of departments of geriatrics, using case examples from three (University of Oklahoma College of Medicine, Florida State University College of Medicine, and University of Hawaii at Mãnoa John A. Burns School of Medicine) of the extant 11 medical schools in the United States with departments of geriatrics. Commonalities among the three departments include a seat at the planning table in academic life, equal treatment and collaboration with other departments in academic and research program development, and direct access to key decision makers and opportunities for negotiation for funds. Each department has outreach to all undergraduate medical students through its training program. All three departments were launched through the investment of significant resources obtained both internally and externally. The challenge for the future will be to definitively demonstrate the efficacy of the department model versus the more prevalent section, division, and institute approach to training physicians to care for the elderly.

Assessment of pain in older Asian Americans with cancer.

This cross-sectional study focused on pain assessment in a group of older Asian Americans with cancer. Thirty-six participants and their primary nurses were interviewed, and pain intensity was measured using 3 different scales: the Numeric pain intensity 0-10 scale, the Faces expression scale, and Visual analog scale (VAS). Overall, 56% of participants reported pain. Younger age (65-75 years old) was significantly associated with higher pain intensity (p < 0.05). High correlation was found between the participants' and their nurses' pain intensity ratings (r = 0.69, p < 0.0001). High correlation was also found among different pain intensity scales, with a Spearman correlation coefficient ranging from 0.89 to 0.96 (p < 0.0001), suggesting that they are reliable measures in this population.

Cardiovascular risk in women with non-specific chest pain (from the Women's Health Initiative Hormone Trials).

Women discharged with diagnoses of nonspecific chest pain (NSCP) may be at increased risk for subsequent coronary artery disease (CAD) events. The influence of hormone therapy on NSCP is unknown. The Women's Health Initiative (WHI) enrolled postmenopausal women aged 50 to 79 years. The duration of follow-up was 7.1 years in the WHI Estrogen-Alone trial (E-Alone) and 5.6 years in the WHI Estrogen Plus Progestin trial (E+P). After excluding women with previous cardiovascular disease, 9,427 women in E-Alone and 15,105 women in E+P were included in this analysis. NSCP, defined as having a primary hospital discharge diagnosis of NSCP by International Classification of Diseases, Ninth Revision, code, was reported in 322 women in E-Alone and 249 in E+P. Risks for subsequent CAD events were estimated using intent-to-treat Cox proportional-hazards models stratified by clinic and adjusted for age and other risk factors. In the fully adjusted models of the combined trials, women with NSCP had a twofold greater risk for subsequent nonfatal CAD events, including nonfatal myocardial infarction (2.3% vs 1.7%, hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.11 to 3.98), revascularization (3.5% vs 2.6%, HR 1.99, 95% CI 1.20 to 3.30), and hospitalized angina (3.7% vs 2.3%, HR 2.39, 95% CI 1.46 to 3.92). Hormone therapy did not appear to have a significant effect on either the incidence of NSCP hospitalizations (E-Alone: HR 1.04, 95% CI 0.81 to 1.32; E+P: HR 0.78, 95% CI 0.59 to 1.02) or the risk for a subsequent CAD event. In conclusion, a hospitalization for NSCP doubles the risk for a subsequent CAD event in postmenopausal women over the next 5 to 7 years and identifies them as candidates for aggressive risk factor treatment.

The impact of curricular changes on the geriatrics knowledge, attitudes and skills of medical students.

We redesigned our medical school's Problem-Based Learning (PBL) curriculum to include a substantial increase in required geriatrics content. Innovations included new PBL health care problems and standardized patients (SPs) throughout the first three years and a new required four-week, fourth-year rotation. We used data from the AAMC Medical School Graduation Questionnaire, the UCLA Geriatrics Knowledge Test and Attitudes Survey and a Geriatrics SP Examination to measure self-efficacy, geriatrics specific knowledge, attitudes and clinical skills before and after these curricular changes. Positive effects on students' self-efficacy, knowledge and skills were demonstrated. Scores on the attitude scale were high before and after implementation. The demonstration of improved educational outcomes will help to validate our curricular changes and guide their future development.

Utility of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for dementia in a Japanese-American population.

Ethnic diversity among older patients in Hawai'i is common; yet few data exist concerning the applicability of cognitive testing instruments in non-Caucasian populations. This project aimed to determine the specificity and sensitivity of the IQCODE for the detection of cognitive impairment in a Japanese-American population. Results confirm that the IQCODE is a valuable tool for primary care physicians to detect impairment in this population.

Elderly women diagnosed with nonspecific chest pain may be at increased cardiovascular risk.

BACKGROUND: Women are more likely than men to have nonspecific chest pain (NSCP) symptoms. The long-term outcomes in women discharged with a diagnosis of NSCP are unknown. METHODS: The Women's Health Initiative Observational Study enrolled postmenopausal women aged 50-79 years. After excluding those with prior cardiovascular disease (CVD), 83,622 women were studied. NSCP cases were defined as having an initial primary hospital discharge diagnosis of NSCP (ICD-9 codes 786.50, 786.51, 786.59) without a prior diagnosis of coronary heart disease (CHD). Risks of subsequent CHD events were estimated from Cox proportional hazard ratio (HR) models stratified by clinic and adjusted for baseline age, cardiovascular risk factors, and hormone use. RESULTS: Over an average of 8 years of follow-up, 11% (230 of 2,092) of women with NSCP experienced a cardiovascular event compared with 9.5% (7,724 of 81,530) who did not. Compared with women without a hospitalization for NSCP during follow-up, those with NSCP had a greater than 2-fold higher risk of a subsequent hospitalization for clinically diagnosed angina (HR 2.18, 95% CI 1.66-2.86) and at least a 1.5-fold higher risk of nonfatal myocardial infarction (MI) (HR 1.59, 1.10-2.31), revascularization (HR 1.67, 1.28-2.20), and congestive heart failure (HR 1.75, 1.27-2.41). Women with NSCP who subsequently experienced a CHD event were more likely to be over age 65 or to have cardiovascular risk factors. CONCLUSIONS: Older women discharged with a diagnosis of NSCP may be at increased risk of CHD morbidity. Further research is needed to replicate these findings in other populations.

Plantation work and risk of Parkinson disease in a population-based longitudinal study.

CONTEXT: Parkinson disease (PD) has an unknown cause; however, convincing evidence is emerging that indicates pesticides can selectively injure the dopaminergic system in laboratory animals. Retrospective studies in humans demonstrate a link between exposure to agricultural lifestyle factors and PD. OBJECTIVE: To determine whether working on a plantation in Hawaii and exposure to pesticides are associated with an increased risk of PD decades later. DESIGN AND SETTING: Prospective cohort study based on the island of Oahu, Hawaii, with 30 years of follow-up. Years of work on a plantation were assessed by questionnaire at study enrollment in 1965. Self-reported information on pesticide exposure was collected at a separate examination 6 years later. PARTICIPANTS: Participants were 7986 Japanese American men born between 1900 and 1919 who were enrolled in the longitudinal Honolulu Heart Program. MAIN OUTCOME MEASURES: Incident PD was determined by medical record review or by an examination conducted by a study neurologist at a later date. RESULTS: During follow-up, 116 men developed PD. Age-adjusted incidence increased significantly among men who worked more than 10 years on a plantation. The relative risk of PD was 1.0 (95% confidence interval, 0.6-1.6), 1.7 (95% confidence interval, 0.8-3.7), and 1.9 (95% confidence interval, 1.0-3.5) for men who worked on a plantation 1 to 10 years, 11 to 20 years, and more than 20 years compared with men who never did plantation work (P =.006, test for trend). Age-adjusted incidence of PD was higher in men exposed to pesticides than in men not exposed to pesticides although this was not statistically significant (P =.10, test for trend). CONCLUSION: These longitudinal observations regarding plantation work in Hawaii support case-control studies suggesting that exposure to pesticides increases the risk of PD.

Self-reported driving, cognitive status, and physician awareness of cognitive impairment.

OBJECTIVES: To assess self-reported driving rates in older people and correlate these data with cognitive status and physician recognition of cognitive impairment. DESIGN: Cross-sectional study. SETTING: A multiphysician private practice clinic in a primarily Asian-American community of Honolulu, Hawaii. PARTICIPANTS: Two hundred ninety-seven ambulatory patients aged 65 and older. MEASUREMENTS: Cognitive function was assessed by physician interview using the Cognitive Abilities Screening Instrument (CASI) and proxy informant data. Subjects' self-reported driving status. Outpatient medical records were reviewed. RESULTS: Sixty percent of the studied population reported that they currently drove. This rate decreased from 73.3% (148/202) for subjects with good CASI performance (CASI 282) to 37.5% (21/56) for subjects with intermediate CASI performance (CASI 74-81.9) and further to 23.7% (9/38)for subjects with poor CASI performance (CASI <74). Further analysis of drivers with intermediate and poor CASI performance scores revealed that almost none of their physicians recognized that these drivers had cognitive problems(4.8% (1/21) of drivers with intermediate CASI performance and 11.1% (1/9) of drivers with poor CASI performance). CONCLUSION: In this convenience sample of older drivers, driving rates dropped precipitously with poorer performance on cognitive tests, yet a significant percentage of individuals with intermediate or poor cognitive test performance reported that they currently drove. This poor performance was often unrecognized by their physicians. Low recognition rates could affect physicians' interventions to curb unsafe driving.

The phrase: "no ifs, ands, or buts" and cognitive testing. Lessons from an Asian-American community.

This study assessed the clinical utility of repeating the phrase "No ifs, ands, or buts" for cognitive testing in Hawaii. 242 subjects were screened; 25 (10%) had cognitive impairment. 68% of all subjects were unable to say the phrase "No ifs, ands, or buts" (83% of cognitively impaired and 67% of cognitively intact, p = 0.122). Specificity for cognitive impairment was poor.

The American Diabetes Association and World Health Organization classifications for diabetes: their impact on diabetes prevalence and total and cardiovascular disease mortality in elderly Japanese-American men.

OBJECTIVE: To compare the prevalence of diabetes according to the American Diabetes Association (ADA) and World Health Organization (WHO) classifications in a sample of elderly Japanese-American men; to examine the association with total and cardiovascular mortality by diabetes status using both classifications; and to determine whether the fasting or 2-h glucose measurement is a stronger predictor of adverse outcomes. RESEARCH DESIGN AND METHODS: Examinations given from 1991 to 1993 in the Honolulu Heart Program were used as baseline for these analyses. Subjects were 71-93 years of age at that time and were followed for total and cardiovascular disease mortality for up to 7 years. RESULTS: A total of approximately 66% of individuals who had diabetes by WHO criteria were missed when the ADA definition was used. The relative risks of total and cardiovascular mortality for those with versus those without diabetes were similar for both definitions; however, when fasting and postload glucose measures were analyzed as continuous variables, the 2-h measurement was a superior predictor and was independent of fasting glucose. In contrast, fasting glucose was not an independent predictor of these outcomes in the presence of the 2-h measurement. CONCLUSIONS: The prevalence of glucose metabolism abnormalities was very high among elderly Japanese-American men. The WHO classification was superior to the ADA classification in identification of subjects at high risk for adverse outcomes. Therefore, we conclude that the 2-h glucose measurement is valuable and should be retained in epidemiologic studies.