Relationships of sex hormone levels to dependence in activities of daily living in the frail elderly.

OBJECTIVES: We undertook this nursing home study in order to determine the relationships between dependency in activities of daily living (ADL) and blood levels of estrone, testosterone, androstenedione, and dehydroepiandrosterone (DHEA). Little is known about this issue. METHODS: cross-sectional study of 370 nursing home residents. Hormone levels in blood specimens drawn in 1997 and 1998 were correlated with degree of ADL dependency recorded in medical charts. RESULTS: Because of multiple comparisons associations were deemed significant for P-values < or =0.017 for males and < or =0.0125 for females. In males, the following were inversely related: testosterone levels with dependency in transferring and eating; estrone with eating and a summary ADL index; and androstenedione with toileting and a summary ADL index (in all cases, r=-0.4; P=0.007-0.015). Inverse trends existed between testosterone levels and dependency in mobility and a summary ADL index; and androstenedione and eating (in all cases r=-0.3; P=0.030-0.055). Among females the following were directly related: estrone levels with dependence in mobility, toileting, transferring, and a summary ADL index; and DHEA with transferring and a summary ADL index (r=0.2-0.3, P=0.0001-0.01). Trends existed between estrone and eating, and DHEA and toileting (r=0.1-0.2, P=0.04). CONCLUSION: In male residents, higher sex hormone levels are associated with better ADL performance. Among females the opposite is true. While further studies are needed to elucidate these relationships, our results and recent findings of others suggest sex hormone actions in older women differ from those in younger populations. A possible stress-related mechanism is also presented.

Surrogate decision makers' attitudes towards tube feeding in the nursing home.

In the nursing home, a widely accepted medical practice is to recommend the initiation of long term tube feeding in residents with eating difficulties. However, frequently the nursing home resident has dementia, lacks decision-making capacity, and has no advance directives to guide the physician and the family member(s). Therefore, the family member or another surrogate decision maker has to make the difficult decision of whether or not to consent to the placement of a feeding tube. We surveyed 50 English speaking surrogates of nursing home residents who were on a feeding tube for at least 6 months. Each surrogate was contacted by telephone and was administered a 16-item structured questionnaire. Statistical analyses included frequency distributions, and the Wilcoxon signed rank test for two related samples. Most surrogates rated the residents' quality of life as poor or extremely poor. Yet, 78% of the surrogates perceived tube feeding to be beneficial, 62% would repeat their initial decision to initiate tube feeding, and 68% would not consider removal of the feeding tube. Their leading concerns were medical complications, tube feeding's impact on each resident's quality of life, and adequacy of nursing care. The surrogates were satisfied with their initial decision for the placement of a feeding tube despite their perception that there was no improvement in the quality of life of the residents. The surrogates may have viewed tube feeding as a life prolonging measure.

Elevated serum total and LDL cholesterol in very old patients with Alzheimer's disease.

The relationships of serum lipids with Alzheimer's disease (AD) and other dementias in very old patients are not clear. All residents of an academic nursing home were studied clinically for dementia and for serum lipids. All those autopsied over a 7.7-year period had apolipoprotein E (apoE) genotyping and detailed neuropathological examination. Those with pathologically defined criteria for AD (n = 84) were compared to all others who also had clinical dementia but did not show AD changes (n = 22). In contrast to most other reports of serum lipids in very old patients with AD, total cholesterol (TC) and low density lipoprotein cholesterol levels were each significantly higher for those with AD. The lipid-AD associations were progressively stronger with increasing pathological certainty of AD diagnosis. These relationships remained significant after adjustment for apoE genotype and for other known risk factors. The lipid-AD associations in a very old cohort, and prior evidence that elevated TC in middle life is a risk factor for later dementia, prompt consideration of factors associated with lipid metabolism in the development of Alzheimer's dementia.

The association of fecal impaction and urinary retention in elderly nursing home patients.

The objective of this study was to examine the association of fecal impaction and urinary retention in an elderly nursing home population. Two-hundred and three nursing home patients with urinary dysfunction (77% female, median age: 85 years (range: 61-104)) underwent an evaluation which included rectal examination, measurement of residual urine, and cystometric studies. Bivariate analyses indicated that fecal impaction was not associated with urinary retention. However, dependency in transfer was directly associated with fecal impaction (OR=2.91; P=0.004), and with urinary retention (OR=3.13; P=0.017). There was no association between detrusor underactivity and fecal impaction. When urinary retention and fecal impaction occurred in the same patient, detrusor overactivity was the most common cystometric finding. Rather than implicating an anatomic or neurologic link between poor bladder emptying and poor bowel emptying, a third factor (e.g. immobility) causing both urinary retention and fecal impaction should be sought.