Noel H. Ballentine

Unawareness of cognitive deficit (cognitive anosognosia) in probable AD and control subjects

Objective: To develop a quantitative method of assessing cognitive anosognosia in six cognitive and two noncognitive domains. Methods: Control (n = 32) and probable Alzheimer disease (pAD) (n = 14) subjects self-estimated memory, attention, generative behavior, naming, visuospatial skill, limb praxis, mood, and uncorrected vision, both before and after these abilities were assessed. Based on this estimate and their performance the authors calculated an anosognosia ratio (AR) by dividing the difference between estimated and actual performance by an estimated and actual performance sum. With perfect awareness, AR = 0. Overestimating abilities would yield a positive AR (≤1); underestimation would yield a negative AR (≥−1). Results: Relative to controls, pAD subjects demonstrated anosognosia. Pre-testing (off-line), pAD subjects overestimated their visuospatial skill; post-testing (on-line), pAD subjects overestimated their memory. Control subjects also made self-rating errors, underestimating their attention pre-testing and overestimating limb praxis and vision post-testing. Conclusions: This anosognosia assessment method may allow more detailed examination of distorted self-awareness. These results suggest that screening for anosognosia in probable Alzheimer disease (pAD) should include self-estimates of visuospatial function, and that, in pAD, it may be useful to assess anosognosia for amnesia both before and after memory testing.

Polypharmacy in the elderly: maximizing benefit, minimizing harm.

The purpose of this article is to define our current understanding of appropriate prescribing and outline the potential hazards of overprescribing, while acknowledging the benefits of modern pharmacologic treatment. Finally, we discuss practical strategies to attempt to achieve optimal prescribing patterns for the elderly. Polypharmacy, as well as inappropriate prescribing, for the elderly is a major problem and a challenge that contributes to costs, adverse drug events, confusion, compliance issues, and errors in management. A systematic approach to drug monitoring is an important aspect of appropriate prescribing. Attention to prescribing of medications, consistent review of medication lists, and reevaluation of indications and outcomes of prescribing are essential to ensure that polypharmacy is minimized and safety for patients is maximized. This article acts as a practical review for caregivers in multiple practice situations including acute care hospitals, outpatient settings, long-term care, and home care.

Light Therapy for Seniors in Long Term Care

OBJECTIVES To investigate the effects of light therapy on cognition, depression, sleep, and circadian rhythms in a general, nonselected population of seniors living in a long term care facility. DESIGN A double-blind, placebo-controlled trial. SETTING The experiment took place at a long term care facility in Pennsylvania. PARTICIPANTS Study participants (15 treatment, 13 placebo) were residents receiving either personal care or skilled nursing care. INTERVENTION Treatment consisted of approximately 400 lux of blue light administered for 30 minutes per day, Monday through Friday, for 4 weeks. The placebo was approximately 75 lux of red light generated from the same device. MEASUREMENTS Behavioral assessments were made using the MicroCog Assessment of Cognitive Functioning, Geriatric Depression Scale, and Profile of Mood States. Daytime sleepiness was evaluated using the Epworth Sleepiness Scale. RESULTS Three of the 4 composite scores from the MicroCog as well as the mean Tension/Anxiety score from the Profile of Mood States showed a significant treatment versus placebo effect. CONCLUSION Blue light treatment led to significant cognitive improvements compared with placebo red light and may be a promising environmental intervention to reduce cognitive symptoms in elderly, long-term care residents.

Is strength training associated with mortality benefits? A 15 year cohort study of US older adults

BACKGROUND The relationship between strength training (ST) behavior and mortality remains understudied in large, national samples, although smaller studies have observed that greater amounts of muscle strength are associated with lower risks of death. We aimed to understand the association between meeting ST guidelines and future mortality in an older US adult population. METHODS Data were analyzed from the 1997-2001 National Health Interview Survey (NHIS) linked to death certificate data in the National Death Index. The main independent variable was guideline-concordant ST (i.e. twice each week) and dependent variable was all-cause mortality. Covariates identified in the literature and included in our analysis were demographics, past medical history, and other health behaviors (including other physical activity). Given our aim to understand outcomes in older adults, analyses were limited to adults age 65years and older. Multivariate analysis was conducted using multiple logistic regression analysis. RESULTS During the study period, 9.6% of NHIS adults age 65 and older (N=30,162) reported doing guideline-concordant ST and 31.6% died. Older adults who reported guideline-concordant ST had 46% lower odds of all-cause mortality than those who did not (adjusted odds ratio: 0.64; 95% CI: 0.57, 0.70; p<0.001). The association between ST and death remained after adjustment for past medical history and health behaviors. CONCLUSIONS Although a minority of older US adults met ST recommendations, guideline-concordant ST is significantly associated with decreased overall mortality. All-cause mortality may be significantly reduced through the identification of and engagement in guideline-concordant ST interventions by older adults.

Coding and documentation: Medicare severity diagnosis‐related groups and present‐on‐admission documentation

Effective October 1, 2007, the Centers for Medicare and Medicaid Services has changed its methodology for determining the diagnosis-related group for hospitalized patients. In an effort to more accurately reflect severity of illness, the 538 diagnosis-related groups have been converted to 745 new Medicare severity diagnosis-related groups. In addition, selected hospital-acquired complications not identified as present on admission will no longer be reimbursed. The changes will have profound effects on reimbursement for hospitalizations. To minimize financial losses under the new rules, hospitals and physicians will have to devote significant resources and attention to improved documentation. This article will discuss the new payment system, the physicians role in ensuring that all clinically important diagnoses are captured by coding specialists, and strategies that can be employed to respond proactively to the challenge.

Is exercise used as medicine? Association of meeting strength training guidelines and functional limitations among older US adults

OBJECTIVE To determine the association between meeting strength training guidelines (≥2 times per week) and the presence of functional limitations among older adults. METHODS This cross-sectional study used data from older adult participants (N=6763) of the National Health Interview Survey conducted in 2011 in the United States. RESULTS Overall, 16.1% of older adults reported meeting strength training guidelines. For each of nine functional limitations, those with the limitation were less likely to meet strength training recommendations than those without the limitation. For example, 20.0% of those who reported no difficulty walking one-quarter mile met strength training guidelines, versus only 10.1% of those who reported difficulty (p<.001). In sum, 21.7% of those with no limitations (33.7% of sample) met strength training guidelines, versus only 15.9% of those reporting 1-4 limitations (38.5% of sample) and 9.8% of those reporting 5-9 limitations (27.8% of sample) (p<.001). CONCLUSION Strength training is uncommon among older adults and even less common among those who need it the most. The potential for strength training to improve the publics health is therefore substantial, as those who have the most to gain from strength training participate the least.

Treatment of poison ivy/oak allergic contact dermatitis with an extract of jewelweed☆

BACKGROUND Jewelweed (Impatiens biflora) is a plant which has been used for centuries for the treatment of poison ivy/oak allergic contact dermatitis. Numerous claims for its effectiveness exist in the lay press, and over-the-counter medicaments containing jewelweed are reputed to be an effective remedy for poison ivy/oak dermatitis. Despite these claims, few scientific studies testing the effectiveness of jewelweed have been performed. OBJECTIVE Our objective in this pilot study was to test the efficacy of an extract of jewelweed in the treatment of experimentally induced allergic contact dermatitis to poison ivy/oak. METHODS A randomized, double-blinded, paired comparison investigation was performed. Ten adult volunteers were patch tested to urushiol, the allergenic resin in poison ivy/oak. For each volunteer, one patch test site was treated with an extract prepared from the fresh stems of jewelweed; the remaining site was treated with distilled water to serve as a control. Sites were examined on days 2, 3, 7, and 9 with reactions graded on a numerical scale. RESULTS All subjects developed dermatitis at each patch test site. There was no statistically significant difference in the objective scores at the sites treated with jewelweed extract versus the distilled water control sites. CONCLUSION This study demonstrated that an extract of jewelweed was not effective in the treatment of poison ivy/oak allergic contact dermatitis.

Validity of the Brief Inpatient Screen for Intimate Partner Violence Among Adult Women

Background: Identifying intimate partner violence in healthcare settings is becoming the standard of care. The Brief Inpatient Screen was designed to assess recent emotional, physical, and sexual abuse in a general inpatient medical-surgical setting and compared to the Composite Abuse Scale. Methods: Researchers matched “cases” (inpatients screening Brief Inpatient Screen-positive) to up to four “controls” (inpatients screening Brief Inpatient Screen-negative). Forty-six female hospital inpatients ages 18–64 years completed a self-administered survey. The sensitivity and specificity of the Brief Inpatient Screen and its subscales were compared to the Composite Abuse Scale. Researchers examined the performance of the Brief Inpatient Screen when used as a verbal screen versus an anonymous written screen. Results: Twelve of 46 participants (26%) had a positive screen. Compared to the Composite Abuse Scale, the overall sensitivity and specificity of the verbal Brief Inpatient Screen were 52.6% (95% CI 28.9–75.6) and 92.6% (95% CI 75.7–99.1), respectively. The written Brief Inpatient Screen showed improved sensitivity overall (68.4%, 95% CI 43.5–87.4) for the most severe intimate partner violence. Subscale analysis revealed greater sensitivity for emotional and severe combined intimate partner violence. Conclusions: The verbal Brief Inpatient Screen, when compared to the Composite Abuse Scale, was limited in its ability to identify intimate partner violence. An anonymous written format improved sensitivity. Future research should optimize intimate partner violence screening among inpatients.

Working to Increase Stability through Exercise (WISE): Study protocol for a pragmatic randomized controlled trial of a coached exercise program to reduce serious fall-related injuries

Approximately one-third of older adults fall each year and fall-related injuries are a leading cause of death and disability among this rapidly expanding age group. Despite the availability of bisphosphonates to reduce fractures, concerns over side effects have dramatically reduced use, suggesting that other treatment options are needed. Though many smaller studies have shown that physical activity programs can reduce falls, no study has been adequately powered to detect a reduction in fall-related injuries. We present the design of a three-year randomized controlled clinical trial of 1130 adults age 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The main aim is to determine the impact of a community-based multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers (or delivered via DVD) and accompanied by coaching and oversight, by telephone and in-person, by a fitness professional. The main outcome measure is serious fall-related injuries. Secondary outcomes include health care utilization, bone and muscle mass, loneliness, health-related quality of life and mood. The study represents the first large clinical trial of a comprehensive physical activity program to reduce secondary injuries among patients with a history of fragility fracture.