Survival after percutaneous endoscopic gastrostomy: the role of dementia.

BACKGROUND: Percutaneous Endoscopic Gastrostomy (PEG) is a widely used technique for enteral feeding in nursing home patients. Several factors including malnutrition, hypoalbuminemia, older age, number of co-morbidities and cognitive impairment adversely affect survival. OBJECTIVE: This study evaluated the relative impact of age, serum albumin, number of co-morbid illnesses and dementia on survival in male nursing home patients who had undergone percutaneous endoscopic gastrostomy (PEG). DESIGN: In a retrospective study the hospital records of all North Chicago Veterans Affair (VA) male nursing home residents (n=88) who had PEG placed between 1990 through 2000 were reviewed. Of the 88 charts reviewed, 17 were eliminated from analysis due to incomplete data. Following data was examined: Age, serum albumin, number of co-morbid illnesses, presence of dementia, survival in years following PEG placement. RESULTS: Advancing age was associated with increasing probability of dementia and increased number of co-morbidities. Post PEG survival decreased with increasing age, with lower serum albumin, and increased number of co-morbidities. Age and serum albumin were strong predictors of survival in PEG recipients without the diagnosis of dementia. However, in PEG recipients with a diagnosis of dementia, age and serum albumin no longer predicted survival. Dementia appears to attenuate the effects of age and serum albumin on survival following PEG placement. CONCLUSION: In the presence of dementia, none of the usual predictors of survival in PEG recipients remain significant.

Postprandial systolic blood pressure and subsyndromal depression.

Changes in systolic blood pressure following the consumption of a standard meal were measured. We hypothesized that larger postprandial drops in systolic blood pressure would be associated with elevated subsyndromal depressive symptomatology. Following an overnight fast, individuals consumed a liquid meal. Blood pressure and pulse were measured preprandially and during the 90-min postprandial period. Several days later, individuals completed a test for depression. Men and women, patients and caregivers, aged 51 to 82 years, were recruited at an outpatient geriatric day care center. Measurements included systolic and diastolic blood pressures, pulse, and Zung Self-Rating Depression Scale. Results showed that the larger the drop in systolic blood pressure, the higher level of somatic depressive symptomatology. This is the first study to identify depressive symptomatology associated with postprandial systolic blood pressure. These results parallel those reported by Perlmuter and Greenberg (Experimental Aging Research, 22, 325-341, 1996) showing that orthostatic changes in systolic blood pressure were associated with elevated subsyndromal depression.

Learned illness behavior and adjustment to arthritis.

OBJECTIVE: To evaluate the effects of parents' avoidant illness behaviors on their adult children's adjustment to arthritis. METHODS: Men and women attending a rheumatology clinic completed arthritis health status questionnaires and described how their parents generally responded to their own minor illnesses. Some participants rated their parents as never avoiding routine activities when confronting minor illness and were assigned to the non-avoidant group. Participants in the avoidant group reported that their parents avoided routine activities in response to minor illness. Those in the mixed group rated one parent as avoidant and the other parent as non-avoidant. RESULTS: Relative to the non-avoidant group, participants in the avoidant group reported more behavioral restrictions, helplessness, and depression. All groups were similar with respect to disease severity. CONCLUSION: Even after the passage of several decades, early observations of parents' illness behaviors appear to affect adjustment to arthritis.

Do you mind standing?: cognitive changes in orthostasis.

This initial study examines cognitive function in individuals with asymptomatic orthostatic hypotension. Cerebral hypoperfusion accompanying repeated episodes of orthostatic hypotension may eventually produce some cerebral structural deterioration which, depending on foci, could compromise cognitive function. Subjects (aged 55 to 74 years) were relatively healthy women and men, the majority of whom were being treated for non-insulin-dependent diabetes mellitus. Blood pressure (BP) and pulse were measured under supine and upright posture. The difference between BP and pulse under supine and standing conditions indexed orthostatic hypotension. About 1 hr after evaluation of orthostatic hypotension, cognitive testing was performed with individuals comfortably seated. Results showed that, irrespective of possible confounders, including depression, decreased systolic BP in response to upright posture predicted slower reaction times and compromised serial list learning, although sparing immediate and working memory. Orthostatic hypotension, measurable in more than 4% of the elderly, is a hitherto unexplored source of cognitive decline.

Choice enhances performance in non-insulin dependent diabetics and controls.

Cognitive performance on a number of tasks is poorer in individuals with non-insulin dependent diabetes mellitus (NIDDM) than in age-matched nondiabetics. In this study, diabetic and nondiabetic individuals, 55-74 years of age, learned target words, half of which were self-chosen and the remainder assigned. To evaluate susceptibility to background interference, each target was accompanied by one or more unrelated background words. On a recognition test, susceptibility to background interference appeared to be greater in diabetic individuals. The allocation of processing resources to target and background stimuli was more uniform in diabetic than in nondiabetic individuals. While choice improved recognition of target and background words for both groups, its effectiveness was attenuated in NIDDM. Choice facilitates the differentiation of target from background stimuli--a process that may reduce interference from background stimuli.

Cognitive and affective disorders in elderly diabetics.

In non-insulin-dependent diabetes mellitus, performance of complex cognitive tasks requiring the storage and retrieval of new information is poorer than in age-matched controls. By contrast, performance of less demanding tasks such as immediate memory and simple reaction time is essentially equivalent for NIDDM patients and controls. This pattern parallels the cognitive change observed with normal aging, in which age differences are minimal on less demanding immediate memory tasks but older adults perform more poorly than young adults on secondary or long-term memory tasks. Age-related changes in cognitive performance have been attributed to a reduction in processing resources or working memory capacity. Although the explanation for NIDDM-related deficits remains to be identified, reduced glucose control and elevated levels of triglycerides appear to play some role in cognitive impairment. Non-insulin-dependent diabetes is associated not only with elevated levels of depression, but with an increased frequency of self-reported memory problems. Moreover, elevated levels of depression are associated with various indicators of neuropathy and with significant reductions in self-regulated control of glucose at the time of medical office visits. Diabetic patients may perceive less control over their lives as a result of the many restrictions associated with the disease. When provided with the opportunity to exercise control, however, performance on many cognitive tasks can be improved in NIDDM as well as in age-matched controls. This suggests that by providing NIDDM patients with opportunities to exercise increased control over their lives it may be possible to enhance motivation and to increase the likelihood of the patient's adopting more effective self-regulatory behaviors.

Effects of age and removable artificial dentition on taste.

Sodium chloride and sucrose gustatory recognition thresholds, suprathreshold taste intensity function, and sucrose suprathreshold taste preference in healthy adult males with removable artificial dentition were compared with persons having natural dentition. In addition, several inorganic salivary constituents were evaluated for their possible relationship with these modalities. The 75 participants studied were divided into two age and two dentition groups: less than 65 years versus 65 years and older; and natural dentition only versus either removable partial dentures or complete artificial dentition. Recognition threshold and suprathreshold psychophysical functions were assessed using aqueous solutions of sodium chloride and sucrose. Suprathreshold hedonic judgments were also determined for sucrose. Samples of stimulated parotid saliva were analyzed for sodium, potassium, and bicarbonate. As age increased, a statistically significant decrease was noted in the exponent of the psychophysical function for sodium chloride. A similar, but nonsignificant, trend was observed for sucrose, which was complicated by an interaction between age and dentition status. For sodium chloride, recognition thresholds tended to be higher for older persons with removable partial and complete dentures. However, no statistically significant effect was observed on the sucrose threshold or hedonic response as a result of dentition status. Analysis of several parotid saliva constituents showed no statistically significant effect caused by age or dentition status and correlations noted among the psychophysical measures appeared to be fortuitous.

Effects of dentition status and personality on masticatory performance and food acceptability.

Missing natural teeth have been associated with a reduced acceptability for the taste and texture of hard foods as well as with an increase in the perceived difficulty of chewing these foods. The present study examined the role of the personality variables extroversion and anxiety in modulating the relationship between dentition status, masticatory performance, taste preference, texture preference, and perceived ease of chewing of an easy-to-chew food (pot roast) and a more difficult-to-chew food (raw carrots). Healthy adult men, participants in the Veterans Administration Dental Longitudinal Study, were examined. Results indicated that with increased age there was a tendency for texture acceptability to increase for the easy-to-chew food. Masticatory and swallowing performance were diminished in persons with artificial dentition, and these individuals also perceived an increase in the difficulty of chewing raw carrots. There was a significant association of anxiety, but not extroversion, with masticatory and swallowing performance.

Triglyceride levels affect cognitive function in noninsulin-dependent diabetics.

Noninsulin-dependent diabetes mellitus (NIDDM) is associated with decrements in several cognitive functions. Among the variables that apparently contribute to the decline in cognitive performance is poor glucose control, as measured by hemoglobin A1c. Elevated levels of triglycerides in diabetics may also contribute to this cognitive decline through the increased incidence of atherosclerosis in these patients. The authors examined the relationship between triglycerides and cognitive performance in 246 NIDDM outpatients, aged 55-74 years. The relationship between triglyceride levels and performance on three cognitive tasks and on a test of reaction time was measured. Elevated levels of triglycerides were associated with significant decrements in performance on the digit symbol substitution test, digit span (backward) test, and on a reaction time measure. High levels of triglycerides, independent of chronic glucose control, appear to contribute to the decreased ability to perform short-term memory tasks in NIDDM.

Depression and diabetic neuropathy: a complex relationship.

In a group of 64 non-insulin-dependent diabetic females, a significant positive correlation between Zung self-rated depression scores and objective measurements of diabetic peripheral neuropathy was limited to those women with Zung scores greater than 50 (depressed group, n = 12). In the overall group, there was no significant linear or quadratic relationship between peripheral neuropathy and depression scores. The associations between depression, peripheral neuropathy, and diabetes are discussed.

Memory self-assessment and performance in aged diabetics and non-diabetics.

Non-insulin dependent diabetes in older adults is associated with elevated depression and a greater decline in certain aspects of cognitive functioning than is found with normal aging. This study sought to determine whether diabetics report more memory complaints in carrying out their daily activities, and if memory self-assessments are reflective of performance on laboratory tasks. Middle-aged (55-64 years) and old (65-74 years) diabetics and non-diabetic control subjects were studied. Results showed that both diabetes and increased age were associated with poorer performance on some cognitive tests as well as with more self-reported memory problems. When depression levels were statistically controlled, the diabetes variable was no longer a significant predictor of memory complaints. The usefulness of self-assessments as an adjunct to more objective cognitive test measures was discussed.

Age and diabetes related changes in verbal fluency.

Non-insulin-dependent diabetes mellitus is present in 7-10% of the aged. This disease appears to be associated with an acceleration of the aging process and results in compromised performance on learning and memory tasks. The present study used a verbal fluency test to examine semantic memory performance in two age groups (55-64 and 65-74 years) of diabetic subjects and controls. In addition, immediate and secondary memory were also examined using the digit symbol and digit span tests and a serial learning task. Results showed that digit symbol performance was poorer for older subjects and diabetics while serial learning was poorer only for diabetic subjects. However, the number of words generated on the verbal fluency test was similar for all groups. Qualitative analyses of the verbal output revealed that older subjects and diabetics produced the greatest number of previously recited words (repetitions). Repetitions may signal a failure to adequately monitor behavior which in turn could contribute to cognitive decline.

Non-insulin-dependent diabetes in older patients. Complications and risk factors.

Non-insulin-dependent diabetes mellitus is predominantly a disease of aging, with more than 70 percent of non-insulin-dependent (type II) diabetic patients older than 55 years of age. The prevalence of macrovascular, microvascular, and neurologic complications in outpatients with type II diabetes between the ages of 55 and 74 was compared with that in a similarly aged nondiabetic group of patients. The association between duration of diabetes, hypertension, age, and other putative risk factors that are prevalent in this elderly diabetic population and the occurrence of complications was explored. This cross-sectional survey confirmed a significant increase in retinopathy, neuropathy, impotence, and macrovascular complications in patients with type II diabetes. Within the diabetic population, duration of disease was associated with the occurrence of retinopathy and neuropathy, but not associated with such macrovascular complications as coronary artery disease. Gender, type of therapy, and previously identified risk factors for vascular disease such as hypertension had little impact on the prevalence of complications in this population. The notion that type II diabetes in the elderly represents "mild" diabetes with regard to complications must be discarded. Further identification of risk factors within this diabetic population may suggest therapeutic approaches that will prevent or ameliorate the development of complications.

Retinopathy in older type II diabetics. Association with glucose control.

Non-insulin-dependent (type II) diabetics over the age of 55 comprise most of the diabetic population and are at considerable risk for the development of both macrovascular and microvascular complications. We studied the prevalence of retinopathy and its association with putative risk factors for its development in an elderly (55- to 75-yr-old) population of type II diabetics. Our cross-sectional analysis revealed that duration of diabetes and hemoglobin A1c (HbA1c) concentration were the two major predictors of the presence of retinopathy. Duration effect was seen after 10 yr of diabetes, whereas HbA1c effect was linear over its entire range. Hypertension, which has been reported to be a risk factor for microvascular disease in younger diabetic patients, was not associated with retinopathy in the older type II population. Multiple logistic regression analysis revealed that both the duration of diabetes and HbA1c remained significant independent determinants of retinopathy even after taking age and blood pressure into account. Our results support an etiologic role for metabolic control in the development of retinopathy in the elderly type II population.

Decreased cognitive function in aging non-insulin-dependent diabetic patients.

A cross-sectional study was conducted to determine whether normal, age-related declines in cognitive function are accelerated in non-insulin-dependent (type II) diabetes mellitus. Study participants ranged in age from 55 to 74 years. Results indicate that cognitive function is inferior in the patients with type II diabetes compared with a comparably aged, nondiabetic control group. On the basis of a series of cognitive tests, it appears that the cognitive impairment is due to a deficiency in memory retrieval rather than to an attentional or encoding deficit. Cognitive performance is poorer in diabetic patients with peripheral neuropathy or elevated hemoglobin A1c levels. The apparent cognitive impairment in aging patients with type II diabetes may complicate adherence to medical regimens.

Processing sets of letters for order: Evidence from reaction time experiments.

In two experiments, subjects were required to impose different levels of organization on randomly ordered letters. In a between-subject design, the subject was to identify the letter in the set coming first in the alphabet or to reorganize the set into an alphabetic sequence. In a within-subject design, presentation of the letters was followed by an instruction to carry out the identification or reorganization task or to recite the letters in left-to-right order. Reaction time varied systematically with level of required organization, size of the presented set, and position and spacing of the letter set in the alphabet. The results are discussed in terms of two simple models.