John Meuleman

Exercise training in the debilitated aged: Strength and functional outcomes

OBJECTIVE Resistance and endurance training result in gains in fitness in the aged. It is unclear whether the debilitated elderly can perform moderate-intensity training and whether such training results in short-term improvements in strength, endurance, and function in this population. DESIGN Randomized, controlled trial. SETTINGS AND PATIENTS Subjects were from a Veterans Affairs nursing home and rehabilitation unit and a community nursing home. They were older than 60 yrs with impairment in at least one physical activity of daily living. Seventy-eight subjects volunteered and 58 (mean age, 75 yrs; 9 women, 49 men) completed the intervention and initial posttest. Only one subject withdrew because of injury or disinterest. INTERVENTION Thrice-weekly resistance training (using an isokinetic dynamometer) and twice-weekly endurance training for 4 to 8 weeks. MAIN OUTCOMES Isometric strength in dominant arm and leg, heart rate response to timed endurance test, and activities of daily living score. RESULTS The mean change in isometric strength across the muscle movements tested was 32.8% in the training group and 10.2% in the control group (difference, 22.6%; 95% confidence interval, 6.2% to 39.0%). No change in heart rate during exercise was seen in the training group. Trained subjects tended to have a greater improvement in functional activity than control subjects, which was statistically significant (p = .04) for those subjects who at enrollment were most dysfunctional (i.e., activities of daily living score less than 13 [maximum score 26]). CONCLUSION This group of debilitated elderly patients effectively performed resistance training and increased their strength, with the most impaired gaining the most function. Few in the group could effectively perform endurance training.

The Immunologic Effects, Kinetics, and Use of Clucocorticosteroids

This article describes our current understanding of the immunologic effects of glucocorticosteroids and uses this information in an attempt to place the therapeutic dosing of glucocorticosteroids on a more rational basis.

Influence of pain and depression on fear of falling, mobility, and balance in older male veterans.

This study determined the extent to which pain and depression influenced changes in fear of falling, mobility, and balance in older veterans with mobility disorders. Data were reviewed from 95 consecutive patients (aged 60 to 95 yr) who attended the Geriatric Gait and Balance Disorders Clinic at the Malcom Randall Department of Veterans Affairs Medical Center between 1998 and 2000. All subjects performed an individualized exercise program and were assessed four times over 12 weeks with a standardized evaluation battery. We used separate hierarchical regression models to examine the influence of measures of bodily pain and depression on outcomes (Berg Balance Test, Dynamic Gait Index, and Falls Efficacy Scale). Approximately half of the patients attended all evaluation sessions. Attendance at follow-up visits was a significant predictor of improvement in all outcome measures. Pain was a significant predictor of a decrease in balance and mobility outcome scores but not fear of falling. Thus, completing the program increased the amount of improvement, while having pain decreased the amount of improvement. These data suggest that targeted interventions for pain and improving adherence to rehabilitation recommendations should be included in the rehabilitation of older veterans with balance or mobility disorders to maximize potential improvements in balance and mobility.

Influenza Vaccination and Warfarin Anticoagulation: A Comparison of Subcutaneous and Intramuscular Routes of Administration in Elderly Men

Study Objectives. To determine if subcutaneous administration of influenza vaccine is as immunogenic as the intramuscular route, and to evaluate the frequency of local adverse events associated with both routes in elderly anticoagulated men.

Drug Use among Functionally Active, Aged, Ambulatory People

BACKGROUND AND METHODS: Only a few pharmacoepidemiology studies have included very old subjects and most studies included both healthy and very ill people. Interpretation of data from these investigations is limited because of the mix of health status in the populations studied. We examined drug use in a group of active, relatively healthy, older people. Sixty-one attendees at a national convention, aged 76–96 years, volunteered to participate in a study on health status in a very old, ambulatory population. Medication histories, selected blood biochemistry analyses, a mental status examination, and other data were collected. RESULTS: The mean number of prescription and nonprescription drugs used per person was 2.02 and 1.85, respectively. More than a quarter of the sample population took no prescription medications and two-thirds used two or fewer prescription drugs. Sixteen percent of those taking prescription medications experienced adverse effects from their current drug regimens. Although falling was prevalent among our study subjects, there were similar drug-use patterns in those who did and who did not fall. CONCLUSIONS: In a group of relatively healthy and functional very old people, we found that drug use was not excessive, although adverse effects were still prevalent. In addition, most subjects were knowledgeable about their medications. These studies demonstrate that extreme age alone does not always result in sickness, frailty, and overuse of medications.

Importance of Assessment of Metered-Dose Inhaler Technique in the Elderly

An 85-year-old male with a history of hypertension and infrequent asthma, who had not smoked cigarettes for 40 years, presented to the emergency room (ER) in December 1991 because of shortness of breath. Nebulized albuterol was administered, with improvement in breathing. He was instructed to change his albuterol inhaler use from as needed to every 6 hours. After three more ER visits in the next month, theophylline was started, and he was given a tapering dose of prednisone followed by a triamcinolone inhaler in February 1992. Over the next 3 months he had four more ER visits for wheezing, which responded to nebulized albuterol. At a geriatrics clinic visit in May 1992, he was felt to have normal cognitive status, in keeping with his score of 29 out of 30 on the Folstein MiniMental Status Examination in 1990. In the clinic he demonstrated grossly incorrect technique in using his triamcinolone inhaler, so he was instructed in correct inhaler use and his ibuprofen was stopped out of concern that this was causing bronchospasm. Pulmonary function tests revealed a moderate obstructive ventilatory deficit with good response to bronchodilators. After five more ER visits, an ipratropium inhaler was added in July 1992. He visited the ER twice more; his theophylline dose was increased, he was placed on another course of prednisone, and on August 5, 1992, he was given a tube spacer to use with his MDls. He again came to the ER with wheezing on August 14, 1992. During a clinic visit on August 20, 1992 he was found to be using the spacer incorrectly. In addition, he was instructed to use the triamcinolone inhaler after the bronchodilator inhalers. Use of a home nebulizer was considered because of his difficult clinical course, which had included 16 ER visits and five courses of tapering prednisone over the preceding 9 months. The nebulizer proved unnecessary, however, as correct inhaler use resulted in much less shortness of breath and

Osteoporosis and the Elderly

Osteoporosis causes significant morbidity and some mortality among the elderly. Although increasing bone content should reduce the rate of osteoporotic fracture, attention should also be paid to other factors (such as falling). Loss of bone mass is a universal phenomenon with aging, and currently we are not able to use risk factor analysis to accurately predict which people are likely to suffer osteoporotic fracture. Bone densitometry cannot be recommended as a useful screening test in elderly patients. When deciding about treatment of osteoporosis in the elderly, it should be noted that few studies have included patients over 75 years of age and that prevention of bone loss is more effective than restoration of lost bone. Although high-dose calcium appears ineffective, patients ingesting low amounts of calcium should be counselled to increase their daily intake to at least 800 mg. Estrogens are very effective at preserving bone mass at least up to age 70 years, and their use is associated with a reduction in hip fractures. Vitamin D at a dose of 600 to 800 IU per day should be given to elderly subjects who do not get significant exposure of their skin to sunlight. Other specific recommendations regarding the prevention and treatment of osteoporosis await the results of further investigation.

A clinical, physiology and pharmacology evaluation of Orthostatic Hypotension in the elderly

Orthostatic hypotension is very common in the elderly. It increases morbidity and is an independant predictor of all cause mortality. It is defined as a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic blood pressure greater than 10 mm Hg within 3 minutes of standing. Symptoms include light headedness, weakness, blurred vision, fatigue and lethargy and falls. Most patients have orthostatic hypotension due to non neurogenic causes. Drugs like antihypertensives and tricyclic antidepressants are very common causes of orthostatic hypotension. Diagnosis is based on the history and a thorough clinical examination. Based on the history and physical examination, further testing of the heart, kidneys and autonomic nervous system may be required in selected patients. Non pharmacological methods like slow position change, increased fluid and sodium intake, compression stockings and elevation of head of the bed are the key to management of orthostatic hypotension. After these methods, pharmacological treatment with fludrocortisone and midodrine should be tried. Other drugs like desmopresin acetate, xamoterol, erythropoetin and ocreotide can be used as second line agents in selected patients.

Health status of veterans found ineligible for ongoing outpatient care

In patients declared ineligible for longitudinal outpatient care in the Veterans Administration (VA) health care system, it is unclear how health status changes after discharge from the VA or how many patients find a regular provider of care in the private sector. Among 65 patients declared ineligible for longitudinal care at the Gainesville VA Medical Center (GVAMC), 28 (43%) continued to use this facility as their primary source of general medical care. Patients who lived within 50 miles of GVAMC or had used this facility frequently in the past were more likely to return to GVAMC for their general care. In the 37 patients who no longer used GVAMC for general care, 42% could not identify a regular provider of care outside GVAMC nine months after their discharge from this facility. Thirty-six percent had not seen a non-VA physician during this time, and 44% felt their health had worsened since they were released from GVAMC. A large number of patients who are declared ineligible for longitudinal care in the VA system continue to use the VA system for primary care. Among those who stop using the VA, many do not receive any medical care or obtain a regular care provider within the first nine months after their release from the VA system.

Appropriateness of Iron Prescribing: A Retrospective Study

We retrospectively reviewed the charts of 120 patients who received an initial prescription of iron from a resident physician in internal medicine to determine how accurately house officers diagnose iron‐deficiency anemia before initiating iron therapy. Each patients laboratory records were reviewed for the 3‐month period before the prescription. Of the 120 patients, 77 (64%) did not have any iron tests performed to aid in the diagnosis of iron‐deficiency anemia. Forty‐three percent of those who had iron tests did not have the disorder by our criteria. Ferritin levels and iron profiles are often not measured in patients prescribed iron, and when they are, they are frequently misinterpreted by medical house officers. This can lead to inappropriate gastrointestinal procedures as well as inappropriate prescribing of iron.