Edmund H. Duthie

Delirium Severity and Psychomotor Types: Their Relationship with Outcomes after Hip Fracture Repair

OBJECTIVES: To validate the Memorial Delirium Assessment Scale (MDAS) as a measure of delirium severity in a cohort of patients aged 65 and older; to examine the association between severity of delirium and patient outcomes; and to examine the association between psychomotor variants of delirium and each of those outcomes.

Efficacy of an Influenza Hemagglutinin‐Diphtheria Toxoid Conjugate Vaccine in Elderly Nursing Home Subjects During an Influenza Outbreak

To compare the efficacy of an influenza hemagglutinin‐diphtheria toxoid conjugate vaccine with the commercially available influenza hemagglutinin‐subunit vaccine in preventing influenza in older adults living in a nursing home.

Role of Hormones in the Pathogenesis and Management of Sarcopenia

There is growing evidence to indicate that age-related declines in growth hormone (GH), insulin-like growth factor (IGF)-1, and androgen and estrogen production play a role in the pathogenesis of sarcopenia (an age-related decline in muscle mass and quality). Although GH supplementation has been reported to increase lean body mass in elderly individuals, the high incidence of adverse effects combined with a very high cost has limited the applicability of this form of therapy. The assessment of an alternative approach to enhance the GH/IGF-1 axis in the elderly by using GH-releasing hormone and other secretagogues is currently under way and is showing some promise. Testosterone replacement therapy may increase muscle mass and strength and decrease body fat in hypogonadal elderly men. Long-term randomised, controlled trials are needed, however, to better define the risk-benefit ratio of this form of therapy before it can be recommended. Available data are currently insufficient to decide what role estrogen replacement therapy may play in the management of sarcopenia.Therefore, although the evidence linking age-related hormonal changes to the development of sarcopenia is rapidly growing, it is still too early to determine the clinical utility of hormonal supplementation in the management of sarcopenia.

Association of Dehydroepiandrosterone Sulfate, Body Composition, and Physical Fitness in Independent Community-Dwelling Older Men and Women

OBJECTIVES: To determine the association of dehydroepiandrosterone sulfate (DHEAS), body composition, and physical fitness in independent community‐dwelling men and women aged 60 to 80 years.

Running Elevates Plasma β-Endorphin Immunoreactivity and ACTH in Untrained Human Subjects

Abstract Twenty minutes of submaximal treadmill running was associated with an elevation in plasma levels of β-endorphin immunoreactivity (P < 0.02). This increase was greater in men (14.9 ± 3.4 fmole/ml) than women (2.6 ± 1.2 fmole/ml) (P < 0.05). Plasma levels of ACTH and growth hormone also increased after running. ACTH increased more in men (7.8 ± 1.1 fmole/ml) than in women (1.1 ± 0.44 fmole/ml) (P < 0.02). There was a similar growth hormone response in both sexes. No correlation can at this time be made with levels in the central nervous system. Changes in plasma levels of β-endorphin immunoreactivity may be responsible for some of the euphoria and analgesia anecdotally associated with running.

Augmentation of influenza antibody response in elderly men by thymosin alpha one. A double-blind placebo-controlled clinical study.

Influenza remains a major cause of illness and death in elderly people despite current vaccination programs. One factor is an immunization failure rate in the elderly that may be as high as 50%. To test whether administration of thymosin α 1 would result in greater antibody production, we administered it (900 μg/m2 subcutaneously twice weekly for eight doses) in conjunction with the 1986 trivalent influenza vaccine. Ninety men (65—99 years old, mean age 77.3 years) were randomized double‐blind to receive thymosin α1, or placebo by the same schedule; the sera from 85 of these men were acceptable for analysis. The two groups were similar with respect to underlying disease, medications, and age. No toxicity was observed in either group. Antibody response rate was defined as a four‐fold rise in antibody titer over 3—6 weeks following vaccination and was measured by an enzyme‐linked immunosorbent assay (ELISA). Analysis was performed on treatment groups and subgroups divided by the mean age: the older group consisted of subjects aged 77 years and older, and the younger group those aged from 65—76 years. Baseline and change in absolute antibody levels were compared by t test and using age as a continuous variable by multiple regression analysis. The response was greater in the thymosin α1 treatment group at 6 weeks compared to the placebo group (P = .023), and this difference in absolute amount of antibody produced could be attributed to the greater response to vaccine in the older thymosin α1 treated subjects (P = .039) as no difference was observed between the younger treatment groups, or between the older thymosin α1 treated subjects and the younger subjects. The ability of elderly men receiving thymosin α1 treatment to produce antibody to vaccine similar to their younger counterparts may be of clinical importance.

Prevalence survey of infections and their predisposing factors at a hospital-based nursing home care unit.

A prevalence survey was performed at a Veterans Administration nursing home care unit to detect the frequency, demographics, features, and potential risk factors associated with infections, compare different methods for calculating infection rates, and compare prevalence data with routine physician reporting of infections during a one‐month period. In 176 evaluable residents, 22 nursing home‐acquired infections were detected, with rates of 12.5% by infections per residents at risk, and 4.6% by infections per 1000 resident‐days. Fifty percent of these infections (11 of 22) involved the urinary tract, seven of which were associated with indwelling catheters. Factors potentially associated with increased overall infection rates included immobility (P < .02), acute‐care hospitalization in the 28 days preceding the study (P < .01), and antibiotics given preceding the infection (P < .001). An indwelling urinary catheter (P < .01) potentially was associated with an increased urinary tract infection rate. During the concurrent period, routine physician reporting of infection detected four of the 22 infections (18%) that were identified by the survey. These findings suggest that physician reporting of infection underestimates infection risk as compared with conventional surveillance practices, and that hospital‐based care units may have infection problems more similar to acute‐care hospitals than to community nursing homes. Identification of potential risk factors is critical in planning preventive practices based on institution‐specific needs.

Predictors of Lean Body Mass and Total Adipose Mass in Community-Dwelling Elderly Men and Women

As part of an ongoing longitudinal study, we analyzed cross-sectional data to identify the predictors of lean body mass (LBM) and total adipose mass (TAM) in community-dwelling elderly men and women. Body composition analysis was done using dual energy x-ray absorptiometry. A total 262 subjects (118 women and 144 men), 60 to 80 years of age, from the urban and suburban communities of southeastern Wisconsin were studied. In women, the age (r = -.18), body mass index (BMI) (r = .43), and waist-to-hip ratio (WHR) (r = .30), and in men, BMI (r = .45) and insulin-like growth factor-1 (IGF-1) (r = .32) were identified as predictors (P < .05) of LBM. In women, the BMI (r = .87), WHR (r = .21), and functional work capacity (VO2 max) (r = -.47), and in men, the BMI (r = .83), WHR (r = .52), dehydroepiandrosterone sulfate (DHEAS) (r = -.27), total testosterone (TT) (r = -.35), free testosterone (FT) (r = -.23), physical activity (LTE) (r = -.32), and VO2 peak (r = -.59) were identified as predictors of TAM. After partialling out age in addition to the predictors identified earlier, the VO2 peak was identified as a predictor (P < .05) of LBM in both women and men, and TT, FT, and LTE as predictors (P < .05) of LBM in men. We conclude that the BMI, WHR, and VO2 peak influences LBM and TAM in both women and men. Additionally, in men LBM and TAM is influenced by hormone profile.

Bacterial infections in a hospital-based skilled nursing facility.

The incidence of bacterial infections occurring in 132 residents in a Veterans Administration hospital-based nursing home care unit (VA NHCU) was studied retrospectively over a 1 yr period. There were a total of 35 non-Foley-catheter-related bacterial infections documented during this time, occurring in 21 residents. Of these infections, 14 were pulmonary, 18 urinary and 3 of the integument. Of the 23 residents having indwelling urinary catheters, 47.8% became clinically symptomatic due to a urinary infection at least one time during the year. Thirty-six per cent of these infections were due to Pseudomonas aeruginosa and 48% were due to E. coli and Proteus mirabilis. Eighteen of 23 residents (78.3%) with Foley catheters had more than one predominant organism cultured from their urine during the year, making the practice of monthly cultures not very useful in considering treatment. If one grouped all urinary tract infections on the NHCU, the major pathogens were Pseudomonas (19.5%), Klebsiella (17.1%). Proteus (17.1%) and E. coli (14.6%). Documented pulmonary infections were predominantly due to Streptococcus pneumonia (50.0%) and Hemophilus influenza (35.7%). Our data suggest that the location of the institutional setting must be considered in caring for the elderly resident in a skilled nursing facility. Future plans to establish hospital based nursing home units must consider the benefits resulting from easy access to acute health care and educational programs against problems of hospital bacterial flora.

The Underuse of Therapy in the Secondary Prevention of Hip Fractures

There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.