Hosam K. Kamel

Utilizing Pain Assessment Scales Increases the Frequency of Diagnosing Pain Among Elderly Nursing Home Residents

To study the effect of utilizing a combination of three easily-administered pain assessment instruments on the frequency of diagnosing pain among elderly nursing home residents, a cross-sectional study was conducted at two academic skilled nursing facilities: an 899-bed facility in Long Island, New York, and a 201-bed facility in Maryland Heights, Missouri. A total of 305 randomly selected elderly (>or= 60 years) subjects were enrolled in this study. The study involved medical records abstracting and patient interviews. Pain was assessed in 150 (49%) subjects using the question Do you have pain? (Group 1). In the remaining 155 (51%) subjects (Group 2), pain was assessed using three pain assessment instruments: the visual analog scale, the behavior (faces) scale, and the pain descriptive scale. The overall frequency of diagnosing pain was greater in the subjects in Group 2 compared to the subjects in Group 1 (30% vs. 15%, P < 0.01). Using the three pain assessment scales greatly increased the frequency of diagnosing pain among the old-old (>or= 85 years) residents (32% Group 2 vs. 6% Group 1, P < 0.001). The frequency of diagnosing pain among cognitively impaired residents showed a similar trend (16% Group 2 vs. 10% Group 1, P = 0.2). These data indicate that using three easily-administered pain assessment scales increased the frequency of diagnosing pain among nursing home residents.

Hormone Replacement Therapy and Fractures in Older Adults

Estrogen deficiency in women is associated with accelerated bone loss, and estrogen replacement therapy has been proven to be effective in preventing osteoporosis and fractures in postmenopausal women. The introduction of selective estrogen receptor modulators that have an estrogen‐like effect on the skeleton but have a different pattern of effects on other tissues may have an important role in the management of osteoporosis in women in the near future. In men, androgen deficiency has been shown to be associated with osteoporosis. Although androgen replacement in hypogonadal men may decrease bone resorption and increase bone mass, long‐term placebo‐controlled trials are needed to better define the benefits and risks of such therapy before it can be recommended. Sex hormone deficiency is linked to the development of osteoporosis in both women and men. In women, hormonal replacement by estrogen or the newly developed selective estrogen receptor modulators may prevent the development of osteoporosis and its related fractures. In men, there is early evidence that testosterone replacement therapy may enhance bone mass in hypogonadal men.

The Activities of Daily Vision Scale: A Useful Tool to Assess Fall Risk in Older Adults with Vision Impairment

OBJECTIVE: To evaluate the validity of the Activities of Daily Vision Scale (ADVS) as a tool to assess fall risk in older adults with vision impairment.

INAPPROPRIATE USE OF THERAPEUTIC DIETS IN THE NURSING HOME

left globus pallidus, and left caudate. Olanzepine (10 mg qhs) and trazodone (50 mg bid) significantly decreased his sweepstakes participation. His wife was instructed to change to an unlisted phone number and interrupt his calls. She purchased a post office box for mail delivery, discontinued 4th class mail, and cancelled his credit cards. Patient No. 2 was a 76-year-old hypertensive, diabetic man who had depleted his financial resources participating in sweepstakes. He was convinced that he had won 6 million dollars in a Readers Digest Sweepstakes and spent all of his waking hours on these contests. Other symptoms included memory impairment and delusions of theft and persecution. He believed that people were vandalizing his apartment for his sweepstakes winnings, and he wrote United Parcel Service warning that “bad police” were after his winnings. His MMSE score was 23/30, and he had deficits in delayed recall, naming, word list generation, constructions, and abstractions. There was flattening of the right nasolabial fold, pathologically brisk reflexes, and positive grasp reflexes. The MRI revealed T2 hyperintensities in the right centrum semiovale, left parietooccipital white matter, posterior limb of the left internal capsule, and the left cerebellar hemisphere. Haloperidol (2 mg qd) decreased both his sweepstakes participation and his paranoid ideation. Patient No. 3, a 74-year-old hypertensive man, spent his days on sweepstakes and lotteries, studying the entry forms and placing entries. He received 30 or more magazines and checked his mail multiple times per day for sweepstakes information. When asked if the sweepstakes could be a swindle, he claimed that he was “on to it now” and knew that he would win. During the previous 3 years, the patient had become progressively forgetful and suspicious that his family was interfering with his sweepstakes. His MMSE score was 22/30, and he had deficits in delayed recall, word list generation, constructions, abstractions, and alternating programs. He had saccadic smooth pursuit and a left Babinski response. The MRI showed confluent increased T2 hyperintensities in the periventricular white matter, corpus callosum, and globus pallidi bilaterally. Olanzepine (10 mg qd) decreased his sweepstakes preoccupation. Older people are susceptible to sweepstakes participation.’ Many sweepstakes promotions include deceptive practices such as falsely insinuating that participants have already won big prizes and misrepresenting their odds of winning. These contests, lotteries, and schemes may pose an even greater risk for those with dementia. Our three patients had increased participation in sweepstakes as a result of vascular dementia. In addition to impaired decision-making and impulse control, they had impaired memory for their experience and a delusional belief in winning. Not only could they not remember their losses or profit from negative feedback, but they believed falsely that the sweepstakes were specifically aimed at them and that they were winners. This

Dehydroepiandrosterone and Pregnenolone

Steroid hormones play a multifactorial role in human physiology. They facilitate coordinative processes that enable neural, endocrine, immune, and metabolic systems, separately or collectively, to operate in solving problems of survival and reproduction. Both pregnenolone and dehydroepiandrosterone (DHEA) are key hormones early in the pathway of steroid hormones biosynthesis (Fig. 1). Actually, pregnenolone is the precursor of all the known steroid hormones, and its formation from cholesterol via the action of cytochrome P450scc, is the rate limiting step in steroid hormone formation. DHEA and its sulfated conjugate, dehydroepiandrosterone sulfate (DHEAS), on the other hand, serve as precursors for both androgenic and estrogenic steroids, and are the most abundant steroid hormones in the human body. The plasma levels of both DHEA and pregnenolone have been shown to decline progressively with advancing age. Furthermore, based on multiple animal and human studies, there is now accumulating evidence to suggest a potential role for both these hormones in the prevention of multiple morbidities associated with the aging process. This chapter reviews the biological roles of DHEA and pregnenolone and draws implications for their possible role as antiaging agents.

Frequency of Ophthalmic Assessments among Elderly Whites and African Americans with Eye Disease and Impact on Visual Function

Objectives: To study the difference in patterns of utilization of eye‐care services among white and African American senior citizens with eye disease and its impact on visual function. Methods: This study involved cross‐sectional assessments of visual function using the Activities of Daily Vision Scale (ADVS), as well as retrospective self‐recall of history of eye disease and frequency of ophthalmic assessments. Participants included 99 consecutive elderly patients with history of eye disease who were attending the outpatient medical clinics at Nassau University Medical Center, a community teaching hospital in Long Island, New York. Results: White Americans constituted 52% of the study sample and African Americans constituted the remaining 48%. African American subjects were less likely than whites to report visiting an eye specialist over the previous 5 years (69% versus 88%, P<0.05). African American subjects who reported undergoing ophthalmic assessments over the past 5 years showed a trend of having higher ADVS scores (indicating better visual function) compared with those who did not report such history (86±12 versus 79±15, P=0.098). On the other hand, reporting such history had no apparent relation to the ADVS scores in whites. Conclusions: African American elderly ambulatory medical patients with eye disease were less likely than their white counterparts to report use of eye‐care services. The use of eye‐care services in African American but not white subjects was linked to better visual function as assessed by the ADVS.

Endocrinology and Aging

In 1889 C.E. Brown-Sequard, a noted French scientist, claimed that a water-soluble extract of dog testes gave him an “astonishing degree of rejuvenation” and improved his long-standing problems with impotence.1 Although we now know that there was minimal testosterone or other sex steroids in this water-soluble extract, the link between hormones and aging was clearly postulated. Over the past century our understanding of hormonal changes with age and the effect of hormonal repletion in elderly individuals has increased dramatically. It is now well established that aging is associated with a host of changes in the endocrine system (Table 20.1). At present, it is not completely clear whether these age-related changes aggravate the alterations in various biologic functions that accompany aging or are compensatory events that minimize tissue damage and conserve organ vitality. This chapter reviews the age-related changes in the endocrine system.