Rehabilitation and nursing home admission after hospitalization in acute geriatric patients.

OBJECTIVES: This study explored the effect of multimorbidity, cognitive and physical impairment, and sociodemographic factors on the choice of allocation of geriatric patients at hospital discharge. DESIGN: Cross-sectional study SETTING AND PARTICIPANTS: Eight hundred thirty patients 65 years or older admitted into an acute geriatric ward in Italy were evaluated (1998-2000). MEASUREMENTS: Social characteristics before hospitalization, multimorbidity, physical functioning, and cognitive status were related to allocation of living place after hospitalization (home, rehabilitation unit, or nursing home). RESULTS: Most patients were discharged to their homes (85%); 7% of the younger patients (65-74 years) and 11% of the very old (75+ years) were referred to a rehabilitation unit, while only among the very old 4% were discharged to a nursing home. Worse functional status, longer hospitalization, and being affected by dementia and cerebrovascular diseases (CVD) were associated with the admission to both rehabilitation and nursing home. Cognitive impairment and multimorbidity played a role in discharge destination, but only in functionally impaired patients. Living alone before hospitalization was correlated only with being discharged to a rehabilitation unit. CONCLUSION: In geriatric patients, both medical and sociodemographic characteristics are key factors for referral to rehabilitation or nursing home at discharge.

How do older people experience their management of medicines?

AIM: The aim of this study was to describe how older people living at home in Stockholm, Sweden, experienced the management of their own medication regimen from their own perspective. BACKGROUND: Very old people tend to use more medicines, and without proper medication, many of them would not function well and would not be able to remain in their own homes. METHODS: This qualitative study involved audiotaped interviews with 25 very old persons. INCLUSION CRITERIA: aged >or=85 years, mini-mental state examination >or=24, living at home, taking medicines regularly. Data collected May-June 2005, analysed using content analysis. DESIGN: Descriptive study. RESULTS: Findings revealed that most participants managed their medicines by themselves and were very content with this. Older people who received some help with their medicines were also very pleased with that help. The most important components for older people were to have good cognitive ability, to be independent and to get support with their medicines from a close person as a back up. CONCLUSION: Our results indicate that most of the participants were very pleased with their medicine management, either on their own or they were able to get some help. There was, however, a need for assistance in delivering the medicines to their homes. RELEVANCE TO CLINICAL PRACTICE: Understanding how older people experience their management of medicines and to reveal the components which may affect them in this situation is important to improve nursing care. To observe the life of an older person as a whole is important in nursing care, so that the person's behaviour can be understood, as how older people manage to handle their medicines may have an impact on their autonomy and on health-care resource use.

Pain reporting by very old Swedish community dwellers: the role of cognition and function.

BACKGROUND AND AIMS: Pain is a common and unpleasant problem among elderly people and affects the possibility for them to remain living in their own homes. The aims of this study were therefore to report the prevalence of pain reporting and pain treatment, and their association with functional and cognitive status in a very old population. METHODS: Cross-sectional population-based study. Participants were 333, aged 84 years or older, living at home alone or with someone in Kungsholmen, in central Stockholm, Sweden. Information on pain was obtained from interviews. The Mini- Mental State Examination (MMSE) measured cognitive status and the index of basic Activities of Daily Living (ADL) functional status. Descriptive statistics were used to describe the population and logistic regression models to investigate factors associated with pain reporting and pain treatment. RESULTS: The prevalence of pain was 46%, and the prevalence of pain treatment 71%. Results from logistic regression analysis including all variables in the model showed that pain reporting was not associated with age, gender or living conditions. However, pain reporting was correlated with cognitive and functional status. There was no association between pain treatment and age, gender, living conditions, cognitive or functional status. CONCLUSIONS: Pain is common among the oldest old. Our results indicate that cognitive and functional status affect pain reporting. Poor cognitive status was associated with less pain reporting, whereas poor functional status was associated with more pain reporting.

Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery.

BACKGROUND AND AIMS: To identify pre-operative risk factors for delirium in patients undergoing elective cardiac surgery, using clearly defined diagnostic criteria for delirium, and a thorough clinical assessment. METHODS: The incidence of post-operative delirium in 107 patients >or=60 years undergoing elective cardiac surgery was calculated. None of the patients included suffered from dementia. Pre-operative cognitive function in all patients was assessed using the Mini Mental State Examination (MMSE) and post-operative delirium was diagnosed using the Confusion Assessment Method (CAM). Post-operative clinical and cognitive assessments were carried out for all patients. RESULTS: Twenty-five patients (23.4%) developed delirium post-operatively. Clinical parameters, including age, gender, co-morbidities, medications, and peri-operative parameters, were similar in patients with and without post-operative delirium. Patients with pre-operative subjective memory complaints and lower MMSE scores, undergoing valve operation or valve + coronary artery bypass grafting (CABG), exhibited an increased risk of developing post-operative delirium. Additionally, delirious patients had a significant decline in post-operative MMSE score compared with the non-delirious ones. CONCLUSIONS: The main pre-operative risk factors for post-operative delirium after elective cardiac operations were subjective memory complaints, mild cognitive impairment, and type of cardiac surgery, such as valve procedures. This study suggests that cognitive evaluation should be included in pre-operative assessment.

Rethinking the dementia diagnoses in a population-based study: what is Alzheimer's disease and what is vascular dementia?. A study from the kungsholmen project.

OBJECTIVE: To explore the hypothesis that older adults often are affected by more than one disease, making the differential diagnosis between Alzheimer's disease (AD) and vascular dementia (VaD) difficult. METHODS: Incident dementia cases (n = 308) from a population-based longitudinal study of people 75+ years were investigated. The DSM-III-R criteria were used for the clinical diagnosis of dementia. Data on vascular disorders (hypertension, cerebrovascular and ischemic heart diseases, heart failure, atrial fibrillation, diabetes) as well as type of onset/course of dementia were used retrospectively to reclassify dementias. RESULTS: Only 47% of the AD cases were reclassified as pure AD without any vascular disorder. Among subjects with AD and with a vascular component, cerebrovascular disease was the most common (41%). Only 25% of VaD were reclassified as pure VaD. Further, 26% of the pure AD subjects developed a vascular disorder in the following 3 years. CONCLUSIONS: Both vascular and degenerative mechanisms may often contribute to the expression of dementia among the elderly. Most of the AD cases have vascular involvements, and pure dementia types in very old subjects constitute only a minority of dementia cases.

Factors influencing the handling of medicines among very old people living at home in an urban area.

BACKGROUND AND AIMS: Elderly people in Sweden live longer in their own homes, some of them with good health, and others with chronic conditions that require medical treatment. Thus, the aim of this study was to investigate factors influencing elderly people's handling of their medicines. METHODS: Cross-sectional population-based study. Participants were 333, aged 84+ years, living in their own homes. Information on regular drug use was obtained from interviews. Descriptive statistics were used to describe the population, and logistic regression models were used to investigate the factors associated with receiving help in handling medicines. The Mini-Mental State Examination (MMSE) measured cognitive status, and the basic Activities of Daily Living (ADL) assessed functional status. RESULTS: Most participants were women living alone. 88% of this population took medicines on a regular basis and 23% of them received help with medicine handling. Using logistic regression models controlling for sociodemographic variables, cognitive and functional status, female (OR=2.8, 95% CI=1.2-6.5) was the only variable associated with regular use of medicines. Older age and functional disability in ADL increased the risk of receiving help with medicines, while higher cognitive status decreased the odds of receiving help. The only factor related to receiving help from a family member was living alone (OR=0.05; 95% CI=0.01-0.40). CONCLUSIONS: This study indicates that cognitive and functional problems require increased help with handling medicines. These results stress the need for ongoing vigilance of, and support for, people with this high-risk profile.

A population-based study on well-being in the very old: the role of cardiovascular diseases and drugs.

Cardiovascular diseases constitute the most common health problems in very old people. Consequently, cardiovascular drugs are the medicines that are most frequently used by elderly subjects. Although many studies have examined the physiological effect and adverse reactions of these drugs, knowledge on their effect on emotional well-being is missing. The present study aims to examine the association between cardiovascular diseases and their medical treatment on the emotional well-being of very old people. We investigated a representative group of elderly subjects gathered from a population-based study (n=235). Participants were 84 years or older and cognitively intact (mini-mental state examination (MMSE) > or =24 points). Well-being was assessed with the positive and negative affect schedule (PANAS), measuring different mood categories. Cardiovascular diseases were diagnosed following the International Classification of Diseases. In this population the prevalence of cardiovascular diseases was high (62%). Multivariate regression analysis showed that while being affected by a cardiovascular disease did not affect the emotional well-being of the subjects (PANAS-PA, p=0.171; PANAS-NA, p=0.209), the use of some cardiovascular drugs showed an association. Cardiac glycosides (p=0.006) and nitrates (p=0.008) were associated with increased negative feelings. Due to high prevalence of cardiovascular diseases and use of cardiovascular medicines, this finding has relevance on the quality of life of elderly people. However, due to the nature of this study we cannot assess cause-effect relationship of this positive association. Therefore, the present findings suggest that there is a need for clinical studies in this increasing and limited studied age group.

Poor mental and physical health differentially contributes to disability in hospitalized geriatric patients of different ages.

OBJECTIVE: To evaluate the relationship between depressive symptoms, cognition and somatic diseases on functional status of geriatric patients at hospital discharge. METHOD: Patients 65+ years consecutively admitted to the acute care geriatric ward of the Internal Medicine Department I, Civil Hospital of Brescia, Italy, from February 1998 to December 2000 (n = 830) were examined. Functional disability was defined as need of physical assistance in at least one of the basic Activities of Daily Living (ADL). The Greenfield Index of Disease Severity (IDS) and the Geriatric Index of Comorbidity (GIC) were used to measure number and severity of diseases. The Mini-Mental State Examination (MMSE) assessed cognitive status and the Geriatric Depression Scale (GDS) measured depressive symptoms. RESULTS: Prevalence of functional disability at discharge was 29.3% in the younger age group (65-74 years) and 55.2% in the older age group (75+ years). Using logistic regression models, older age, poorer cognitive status, and depressive symptoms were independently associated with functional disability in the younger and older age group, respectively. Additionally cognitive impairment and depressive symptoms showed an additive association with disability, especially in younger patients, while comorbidity was correlated with functional status only in the oldest old, in particular among those who were cognitively impaired. CONCLUSION: Functional disability after acute hospitalization is highly prevalent in geriatric patients. Depressive symptoms, comorbidity, and cognitive impairment often coexist, interact and are differentially associated with function depending on age. Considering that depressive symptoms are a modifiable problem, their detection in hospital settings may help clinicians in targeting subjects at high risk of functional disability.

Women are more disabled in basic activities of daily living than men only in very advanced ages: a study on disability, morbidity, and mortality from the Kungsholmen Project.

OBJECTIVE: We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population. METHODS: All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status. RESULTS: After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years). CONCLUSION: We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.

Rate of cognitive decline in preclinical Alzheimer's disease: the role of comorbidity.

We investigated the influence of individual-difference variables implicated as risk factors for Alzheimer's disease (AD) or known to be related to cognitive performance in normal aging (e.g., age, sex, years of education, previous and recent diseases, apolipoprotein E status, social network, and substance use) on rate of cognitive change from preclinical to clinical AD. With the use of data from a population-based study, 230 persons who were nondemented at baseline and diagnosed with AD at a 3-year follow-up were examined with the Mini-Mental State Examination (MMSE). Of all predictor variables examined, only number of diseases resulting in hospital admission during the follow-up period made an independent contribution to rate of MMSE change. These results suggest that many variables affecting the onset of the degenerative process as well as cognitive functioning in normal aging exert little influence on rate of cognitive change in preclinical AD. This may reflect the fact that the emerging dementia disease overshadows the role of these variables for cognitive functioning. A possible exception to this pattern is that an increasing number of concomitant health conditions may exacerbate the rate of cognitive decline during the final portion of the preclinical phase in AD.

Gender and rural-urban differences in reported health status by older people in Bangladesh.

The study aims to (i) describe regional variation and gender differences in health status of older people (60 years and older) in Bangladesh, indicated by self-reported health problems and functional ability; (ii) explore influence of socio-economic factors on health status of older people. In a cross-sectional study in rural and urban Bangladesh, 696 older persons were asked about their health problems and ability to manage activities of daily living (ADL). More than 95% of older people reported health problems. Approximately 80% of elderly women in both the regions reported having four or more health problems compared with 42% and 63% elderly men in the urban and rural regions, respectively. More women (urban: 55%; rural: 36%) than men (urban: 32%; rural: 22%) also reported difficulties with ADL. Irrespective of age, sex and area of residence, those reporting greater number of health problems were more likely to report difficulty with at least one ADL task. Reporting pattern of specific health problems varied between urban and rural regions. Socio-economic indicators were found to have little influence on reporting of health problems, particularly in the rural region. Observed regional difference may be related to the influence of social and environmental factors, and level of awareness concerning certain health conditions.

The magnitude of dementia occurrence in the world.

In this study, the worldwide occurrence of dementia in 2000 and during the period 1950-2050 was estimated. The calculations were based on worldwide demographics of the elderly and age-specific prevalence and incidence values of dementia, estimated from a meta-analysis. In a sensitivity analysis, different prevalence sources were used. The worldwide number of persons with dementia in 2000 was estimated at about 25 million persons. Almost half of the demented persons (46%) lived in Asia, 30% in Europe, and 12% in North America. Fifty-two percent lived in less developed regions. About 6.1% of the population 65 years of age and older suffered from dementia (about 0.5% of the worldwide population) and 59% were female. The number of new cases of dementia in 2000 was estimated to be 4.6 million. The forecast indicated a considerable increase in the number of demented elderly from 25 million in the year 2000 to 63 million in 2030 (41 million in less developed regions) and to 114 million in 2050 (84 million in less developed regions). In conclusion, the majority of demented elders live in less developed regions, and this proportion will increase considerably in the future.

The impact of somatic and cognitive disorders on the functional status of the elderly.

To estimate the relative effects of coexisting nondementia illnesses on the probability of functional disability, depending on the presence of cognitive impairment or dementia, we used data from the baseline case-control assessment of a longitudinal study of aging and dementia. Our study included 668 subjects (345 nondemented, 98 cognitively impaired, and 225 demented), aged 75 and older. Demented subjects had greater disability prevalence on all specific instrumental activities of daily living (IADL) and activities of daily living (ADL) items than cognitively impaired subjects who, in turn, had greater disability than nondemented subjects. Somatic illnesses were found to be associated with particular tasks in item specific models; decreasing MMSE was strongly associated with the probability of IADL and ADL disability, which increased dramatically in the presence of somatic illnesses among cognitively impaired as well as demented subjects. Attention to illnesses among cognitively impaired and demented people may shed light on remediable factors crucial to their daily functioning.

Dementing disorders in the elderly: evolution of disease severity over 7 years.

The goal of this study was to describe the evolution of dementia severity in a very old dementia population. We investigated a representative group of demented subjects gathered from a population-based study (n = 223). Changes in cognition, functioning, and performance on global scales were followed over a period of 7 years. At baseline, 19% of the demented subjects were found to be severely impaired according to the Clinical Dementia Rating scale, 41% according to the Mini-Mental State Examination score, and 31% according to Katz activities of daily living scale. After 7 years these proportions were 78%, 93%, and 68%, respectively. The probability of surviving 3 years, 5 years, and 7 years after baseline examination was 48%, 28%, and 15%, respectively. Over a 7-year follow-up period, subjects suffering from questionable-mild dementia had a mean survival of 3.9 years (95% confidence interval 3.3-4.5), whereas subjects with severe dementia survived on average 2.9 years (95% confidence interval 2.5-3.2). Male gender, lower education, and poor cognitive and functional status were associated with shorter survival in milder cases, whereas the only factors that predicted shorter survival in more severe cases were older age and poor functional status. Long-term survivors in dementia are not rare, and as the absolute number of demented people is increasing, expanding our knowledge of these persons is of high public health importance.