Heidi K. White

A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults

The Internet (electronic mail and the World Wide Web) may provide new opportunities for communication that can help older adults avoid social isolation. This randomized controlled trial assessed the psychosocial impact of providing Internet access to older adults over a five-month period. One hundred volunteers from four congregate housing sites and two nursing facilities were randomly assigned to receive Internet training or to a wait list control group. The pre & post measures included the UCLA Loneliness scale, modified CES Depression scale, a measure of locus of control, computer attitudes, number of confidants, and overall quality of life. Participants received nine hours of small group training in six sessions over two weeks. Computers were available for continued use over five months and the trainer was available two hours/week for questions. At the end of the trial, 60% of the intervention group continued to use the Internet on a weekly basis. Although there was a trend toward decreased loneliness and depression in intervention subjects compared to controls, there were no statistically significant changes from baseline to the end of trial between groups. Among Internet users ( n = 29) in the intervention group there were trends toward less loneliness, less depression, more positive attitudes toward computers, and more confidants than among intervention recipients who were not regular users ( n = 19) of this technology. Most elderly participants in this trial learned to use the Internet and the majority continued to use it on a weekly basis. The psychosocial impact of Internet use in this sample suggested trends in a positive direction. Further research is needed to determine more precisely, which older adults, residing in which environmental contexts are more likely than others to benefit from this rapidly expanding information and communication link.

The association of weight change in Alzheimer's disease with severity of disease and mortality : A longitudinal analysis

OBJECTIVE: To describe weight loss in relation to the severity of Alzheimers disease (AD), to identify confounders that might account for weight loss, and to investigate the association of weight change with mortality.

Four-week nicotine skin patch treatment effects on cognitive performance in Alzheimer's disease.

Rationale: Acute nicotine injections have been found to improve attentional performance in patients with Alzheimer’s disease (AD), but little is known about chronic nicotine effects. Objective: The present study was undertaken to evaluate the clinical and neuropsychological effects of chronic transdermal nicotine in Alzheimer’s disease subjects over a 4-week period. Methods: The double-blind, placebo controlled, cross-over study consisted of two 4-week periods separated by a 2-week washout period. Patients wore the nicotine patch (Nicotrol®) for 16 h a day at the following doses: 5 mg/day during week 1, 10 mg/day during weeks 2 and 3 and 5 mg/day during week 4. The eight subjects had mild to moderate AD and were otherwise healthy. Results: Nicotine significantly improved attentional performance as measured by the Conners’ continuous performance test (CPT). There was a significant reduction in errors of omission on the CPT which continued throughout the period of chronic nicotine administration. The variability of hit reaction time (reaction time for correct responses) on the CPT was also significantly reduced by chronic nicotine. Nicotine did not improve performance on other tests measuring motor and memory function. Conclusions: The sustained improvement in attention found in this study with nicotine dermal patches is encouraging. However, the lack of detected effects of nicotine treatment on other cognitive and behavioral domains in this study leaves questions concerning the clinical impact of nicotinic treatment in Alzheimer’s disease. The modest size of this study limited statistical power which may have been needed to detect more subtle but clinically significant cognitive effects. Higher doses of nicotine, other nicotinic ligands or combination treatment of nicotine with other therapies may be efficacious for producing broader therapeutic effects.

Surfing the Net in Later Life: A Review of the Literature and Pilot Study of Computer Use and Quality of Life

The Internet offers new opportunities for communication that can help older adults avoid social isolation. Although elders may need more time and assistance in learning computer systems, many are embracing this new technology. There is growing potential not only for recreation and communication through the Internet but also the delivery of services. This study examines the feasibility of providing Internet and electronic mail access to older adults in a retirement community and the extent to which this improves psychosocial well-being. In contrast to members of a comparison group, a trend toward decreased loneliness was observed among participants. In addition, the number of computer-related problems decreased and use of the applications increased throughout the study. These preliminary results support the feasibility of implementing computer-based interventions with the potential of improving psychosocial well-being among older adults.

Weight Change in Alzheimer's Disease

PURPOSE: To determine the natural history of weight change and the occurrence of clinically significant weight loss in subjects with Alzheimers disease (AD).

Nicotine Treatment of Mild Cognitive Impairment: a 6-Month Double-Blind Pilot Clinical Trial

Objective: To preliminarily assess the safety and efficacy of transdermal nicotine therapy on cognitive performance and clinical status in subjects with mild cognitive impairment (MCI). Methods: Nonsmoking subjects with amnestic MCI were randomized to transdermal nicotine (15 mg per day or placebo) for 6 months. Primary outcome variables were attentional improvement assessed with Connors Continuous Performance Test (CPT), clinical improvement as measured by clinical global impression, and safety measures. Secondary measures included computerized cognitive testing and patient and observer ratings. Results: Of 74 subjects enrolled, 39 were randomized to nicotine and 35 to placebo. 67 subjects completed (34 nicotine, 33 placebo). The primary cognitive outcome measure (CPT) showed a significant nicotine-induced improvement. There was no statistically significant effect on clinician-rated global improvement. The secondary outcome measures showed significant nicotine-associated improvements in attention, memory, and psychomotor speed, and improvements were seen in patient/informant ratings of cognitive impairment. Safety and tolerability for transdermal nicotine were excellent. Conclusion: This study demonstrated that transdermal nicotine can be safely administered to nonsmoking subjects with MCI over 6 months with improvement in primary and secondary cognitive measures of attention, memory, and mental processing, but not in ratings of clinician-rated global impression. We conclude that this initial study provides evidence for nicotine-induced cognitive improvement in subjects with MCI; however, whether these effects are clinically important will require larger studies. Classification of evidence: This study provides Class I evidence that 6 months of transdermal nicotine (15 mg/day) improves cognitive test performance, but not clinical global impression of change, in nonsmoking subjects with amnestic MCI.

Effects of an oral growth hormone secretagogue in older adults

CONTEXT GH secretion declines with age, possibly contributing to reduced muscle mass, strength, and function. GH secretagogues (GHS) may increase muscle mass and physical performance. OBJECTIVES/DESIGN We conducted a randomized, double-masked, placebo-controlled, multicenter study to investigate the hormonal, body composition, and physical performance effects and the safety of the orally active GHS capromorelin in older adults with mild functional limitation. INTERVENTION/PARTICIPANTS: A total of 395 men and women aged 65-84 yr were randomized for an intended 2 yr of treatment to four dosing groups (10 mg three times/week, 3 mg twice a day, 10 mg each night, and 10 mg twice a day) or placebo. Although the study was terminated early according to predetermined treatment effect criteria, 315 subjects completed 6 months of treatment, and 284 completed 12 months. RESULTS A sustained dose-related rise in IGF-I concentrations occurred in all active treatment groups. Each capromorelin dose prompted a rise in peak nocturnal GH, which was greatest with the least frequent dosing. At 6 months, body weight increased 1.4 kg in subjects receiving capromorelin and decreased 0.2 kg in those receiving placebo (P = 0.006). Lean body mass increased 1.4 vs. 0.3 kg (P = 0.001), and tandem walk improved by 0.9 sec (P = 0.02) in the pooled treatment vs. placebo groups. By 12 months, stair climb also improved (P = 0.04). Adverse events included fatigue, insomnia, and small increases in fasting glucose, glycosylated hemoglobin, and indices of insulin resistance. CONCLUSIONS In healthy older adults at risk for functional decline, administration of the oral GHS capromorelin may improve body composition and physical function.

A 6-Month Observational Study of the Relationship Between Weight Loss and Behavioral Symptoms in Institutionalized Alzheimer's Disease Subjects

OBJECTIVE Weight loss is a common occurrence in Alzheimers disease (AD). This study was undertaken to investigate the relationship between weight loss and behavioral symptoms in institutionalized AD subjects. DESIGN Observational study. SETTING Two facilities that included assisted living and nursing care. PARTICIPANTS Residents with probable or possible AD (n = 32). MEASUREMENTS Weight was measured monthly. At baseline, month 3, and month 6, a knowledgeable staff member provided information that included the Neuropsychiatric Inventory: Nursing Home Version (NPI-NH, ie, a measure of behavioral symptoms) and a questionnaire regarding eating habits, food intake, and appetite. Two-day calorie counts were done and accelerometers were worn to monitor physical activity. RESULTS At baseline, the mean body mass index (BMI) was 24.0 (standard deviation, 3.5) with 12 subjects exhibiting a BMI <22. BMI was negatively associated with the baseline NPI-NH total score (Spearman Correlation Coefficient -0.52, P <0.01), which indicates that subjects with low BMIs were more likely to have higher frequency and severity of behavioral problems. Individual behavior scores for agitation/aggression (-0.40, P <0.05), depression (-0.31, P = 0.08), irritability/lability (-0.47, P <0.01), aberrant motor behavior (ie, pacing, -0.42, P <0.05), nighttime behavior (-0.37, P = 0.05), and appetite/eating (-0.48, P <0.01) at baseline were negatively correlated with baseline BMI. Behaviors not correlated with BMI were delusions, hallucinations, elation, apathy, and disinhibition. Although this was a small sample followed for a relatively short time period, change in specific NPI-NH scores from baseline to month 6 were correlated with the change in weight over the 6-month period. Both agitation/aggression (-0.37, P = 0.05) and disinhibition (-0.45, P <0.05) showed negative correlation with weight change, which indicates an association between changes in these behaviors and weight loss. There were no significant differences between those who lost weight (n = 13) and those who did not (n = 19) on baseline variables, which included age, comorbidity, functional status, and NPI-NH. However, those who lost weight had a significantly higher BMI at baseline than those who gained weight. CONCLUSIONS These preliminary results suggest that behavioral disturbances play a role in low body weight and weight loss in AD subjects.

Difficult Behaviors in Long-term Care Patients With Dementia

Difficult behaviors are relatively common challenges that can occur throughout the natural progression of dementia, but are particularly common in the mid to late stages of disease. These behaviors can be challenging to manage in nursing and assisted care facilities, and can cause distress to the caregivers and to the patients themselves. Our ability to manage these symptoms can have a profound effect on the patients quality of life. This article reviews the appropriate assessment of behavioral and psychological symptoms of dementia (BPSD) and the literature supporting various nonpharmacologic and pharmacologic treatments. Nonpharmacologic approaches should be the initial focus for treatment of most BPSD, but should these prove inadequate, a variety of medications are available with varying degrees of clinical research to support their use in ameliorating BPSD.

A LONGITUDINAL ANALYSIS OF WEIGHT CHANGE IN ALZHEIMER'S DISEASE

To the Editor: In a recent issue of U.S. News and World Report (August 12, 1996), an article entitled “America’s Best Hospitals” provides rankings that reflect ‘quality of care’ in several specialties, including geriatrics. The rankings for geriatrics are based on reputational score, hospital-wide mortality rate, whether the hospital is a member of the Council of Teaching Hospitals, the breadth of community services offered, the availability of technology in geriatrics, the ratio of fulltime RNs to beds, the number of postdischarge services, and the number of geriatric services. We have several concerns regarding the use of such criteria for measuring quality of care for older people. Reputational score is likely to bias in favor of tertiary care centers with high profiles in clinical research. Hospital-wide mortality rate bears little relationship to quality of care of older people, in our experience, but rather measures average age and acuity of illness in the population served. The ‘more is better’ emphasis on the number of distinct community, discharge, and geriatric services offered is disturbing. Our experience is that having a large number of such services is often inefficient and confusing, leading to many older patients falling through the cracks. In our community, a move toward ‘one-stop shopping’ for community, discharge AND geriatric services has improved continuity of care while reducing drastically the number of services. The ratio of fulltime RNs to beds is likely to be much higher at procedurally oriented hospitals with large ICUs. Apart from access to a portable bladder ultrasound, we are unaware of other available technology in geriatrics that is likely to result in better care for older people. There are alternative criteria which, in our opinion, are better measures of the quality of geriatric care provided. Diagnosis-specific readmission rates (i.e., for CHF) have been shown to decline with multidisciplinary geriatric care programs.’ Falls prevention programs have similarly been shown to be cost-effective at preventing falls-related admissions in older adults.2 The frequency of neuroleptic use during nonpsychiatric admissions may also be a good measure of quality of geriatric care, as recent declines in neuroleptic use in nursing homes would suggest.3 Simultaneous use of two benzodiazepines was noted in 2.5% of older persons in a recent French study of all acute hospital admissions, and this could also be considered a marker for quality of care.4 We hope that the American Geriatrics Society will be more active in suggesting more appropriate criteria for determining “America’s Best Geriatric Hospitals” in the future,