Philip G. Weiler

The cardiovascular health study: Design and rationale

The Cardiovascular Health Study (CHS) is a population-based, longitudinal study of coronary heart disease and stroke in adults aged 65 years and older. The main objective of the study is to identify factors related to the onset and course of coronary heart disease and stroke. CHS is designed to determine the importance of conventional cardiovascular disease (CVD) risk factors in older adults, and to identify new risk factors in this age group, especially those that may be protective and modifiable. The study design called for enrollment of 1250 men and women in each of four communities: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania. Eligible participants were sampled from Medicare eligibility lists in each area. Extensive physical and laboratory evaluations were performed at baseline to identify the presence and severity of CVD risk factors such as hypertension, hypercholesterolemia and glucose intolerance; subclinical disease such as carotid artery atherosclerosis, left ventricular enlargement, and transient ischemia; and clinically overt CVD. These examinations in CHS permit evaluation of CVD risk factors in older adults, particularly in groups previously under-represented in epidemiologic studies, such as women and the very old. The first of two examination cycles began in June 1989. A second comprehensive examination will be repeated three years later. Periodic interim contacts are scheduled to ascertain and verify the incidence of CVD events, the frequency of recurrent events, and the sequellae of CVD.

Relation of cognitive status and abnormal behaviors in Alzheimer's disease.

Some studies suggest that abnormal behaviors are associated with increasing cognitive loss in Alzheimers disease (AD). Other studies do not show this association. We examined the relation of cognitive loss, represented by Folstein Mini‐Mental State Examination (MMSE) score, with abnormal behaviors in 680 patients with probable AD. Six behaviors were examined: agitation / anger, personality change, wandering, hallucinations / delusions, insomnia, and depression. All but depression were associated with declining MMSE score. The number of abnormal behaviors present in each patient was also related to declining MMSE score. Several other associations were also found: hallucinations / delusions were associated with age and race; agitation / anger was related to male gender; and wandering was associated with increased age. Although these data support the general notion that five of the six abnormal behaviors studied are more likely to occur with increasing cognitive loss, the correlations are small and it is suggested that other as yet unproven factors may play an as large or greater role than MMSE score in predicting such behaviors.

Cognitive impairment and hospital use.

BACKGROUND An increasing number of older people are at higher risk of developing Alzheimers Disease or another dementias. The resultant cognitive impairment has been well identified as one of the risk factors for nursing home placement but it has not been well studied as a risk for hospitalization. METHODS To study the association between cognitive impairment and hospital use, this study examined data from a randomly selected cohort of community dwelling California elderly (California Senior Survey). The cohort was followed for one year (N = 940). RESULTS Only about 17 percent of the study population was in the mildly or moderately/severe impaired category. Those participants with cognitive impairment were almost twice as likely as those without any impairment to be hospitalized and to be hospitalized for six days or more. CONCLUSIONS Although the cause of the cognitive impairment and hospitalization was not determined in this study, the data support the importance of cognitive impairment as a risk factor for hospital use even after controlling for age, ADL, IADL, and prior hospitalizations. The causes for this need to be further examined so the burden of such care can be reduced.

Assessment of disruptive behavior associated with dementia: The disruptive behavior rating scales

Disruptive behavior associated with dementia is a major clinical problem, but there has been limited methodology for assessing it. This study describes the development of a set of rating scales used to measure four dimensions of disruptive behavior that present frequent problems in patients with dementia: physical aggression, verbal aggression, agitation, and wandering. In addition, a total disruptive behavior scale is derived by averaging scores from these four scales. A sample of 16 patients in a skilled nursing facility was used to test interrater reliability and validity of this instrument. Interrater reliability was quite favorable for all scales. There was clear evidence for convergent validity of all scales except the verbal aggression scale, where a substantial correlation was found with one relevant external measure but not the other. There was also favorable evidence of discriminant validity for all scales except the verbal aggression scale. Psychometric properties of this instrument appear to be promising and indicate that it has potential utility for further research on causes and treatments for disruptive behavior in demented patients. ( J Geriatr Psychiatry Neurol 1989; 2:196-202).

Dietary Preference for Sweet Foods in Patients with Dementia

Using a telephone survey, patients with probable Alzheimers disease (n = 31) and vascular dementia (n = 14) were compared with elderly normal controls (n = 43) in preferences for different foods. Patients with Alzheimers disease had a greater preference than normal controls for relatively high‐fat, sweet foods and for high‐sugar, low‐fat foods, but did not significantly differ in preference for other foods, including those high in complex carbohydrates and protein. Vascular dementia patients showed a similar pattern, not significantly different from that for Alzheimers patients. Results did not consistently support a hypothesis that increased sweet preference is a nonspecific form of disinhibited behavior related to declining mental status, nor was a hypothesis relating sweet preference to serotonin activity within the brain consistently supported. Results provide preliminary evidence that craving for sweet food may be a significant part of the clinical syndrome of dementia, but further research is needed to delineate the psychological and biological mechanisms accounting for it.

Propranolol for the control of disruptive behavior in senile dementia

Six patients with senile dementia, exhibiting severe, disruptive behavior were effectively treated with propranolol in doses ranging from 80 mg per day to 560 mg per day. All six patients were given a trial of propranolol after conventional therapy had failed, and in all patients, the agitated behavior significantly improved. There were no adverse side effects requiring the discontinuation of the propranolol, and in all cases, the agitated behavior was controlled without inducing general sedation. Both the nursing home staff and the families were pleased with the therapeutic effects. Propranolol represents a possible alternative way of addressing the severe problem of agitated behavior in senile dementia patients.

Lymphocyte Beta-Adrenoreceptor Density in Patients with Unipolar Depression and Normal Controls

Values of binding maximum (Bmax) and dissociation constant (Kd) of (-)3-[125I]iodocyanopindolol (ICYP) were determined in beta-adrenergic receptors of membranes of peripheral lymphocytes in 32 patients with unipolar depression (DSM-III-R) and 31 normal controls. Results were analyzed by a two-way Analysis of Covariance method. A significant difference was noted for group assignment (patient versus control, p less than 0.05). Mean Bmax (fmol ICYP bound/mg lymphocyte membrane fraction total protein) of patients was 31.9 +/- 3.84 (SE) and controls 46.3 +/- 3.92 (SE). A significant interaction was found between group membership and gender (p less than 0.05). In the female patient group (n = 14), mean Bmax was 30.5 +/- 5.79 (SE); in female controls, mean Bmax was 56.0 +/- 5.15 (SE). Differences between male patients and male controls were not significant. Mean values of Kd (pmol/liter) showed a trend for patient values to be lower than control values [69.0 +/- 13.66 (SE) versus 108.5 +/- 14.42 (SE), respectively]. A significant inverse relationship was noted between lymphocyte beta-receptor Bmax and frequency of panic attacks during the depressive episode in 18 patients (p = 0.05). No relationship was found between values of Kd and frequency of panic attacks in these patients. Thus, preliminary evidence is provided for relationships among altered beta-adrenergic receptor binding, gender, and indices of panic-anxiety in unipolar depressed patients.

Health practices of the elderly poor.

The purpose of the present study was to describe the health practices of the elderly poor and to examine the association between specific health practices and subsequent hospital use. Data came from a sample of 931 Medicaid elderly living in California. Smoking, limited social networks, and lack of regular exercise significantly increased the odds of subsequent hospital utilization. Implications of these findings, which could benefit health promotion intervention and treatment programs for the elderly, were discussed.

AIDS as a cause of dementia in the elderly.

It has been recognized that AIDS can present initially as dementia without other neurological or clinical manifestations. In addition, HIV‐contaminated blood transfusions in the elderly seem to be underreported. Because of these findings, dementia in the elderly may be misdiagnosed as Alzheimers disease or other causes of senile dementia. This paper reports on one patient who presented with a diagnosis of Alzheimers disease and was later found to have AIDS.

GENDER AND ETHNIC DIFFERENCES IN THE HEALTH PRACTICES OF THE ELDERLY POOR

Gender and ethnic differences in personal health practices were examined with a sample of 1021 Medicaid recipients aged 65 years and older. Six different health practices were examined including smoking, drinking, weight control, exercise, and social networks. Although gender differences were noted with respect to all of the health practices examined, neither men nor women were consistently favored in adhering to desired health practices. Perhaps most importantly, women were more apt than men to refrain from smoking and drinking which have been strongly linked to major health consequences. Ethnicity was also a factor in all of the health practices examined. Whereas Hispanic and Black elderly were very similar to White elderly, Asian elderly generally adhered to more desired health practices than did either Whites, Blacks, or Hispanics. The implications of these findings could benefit health promotion programs for the elderly.