Robert J. Sullivan

Quantitative cerebral anatomy of the aging human brain A cross‐sectional study using magnetic resonance imaging

Seventy-six healthy adults underwent magnetic resonance imaging (1.5 T) to investigate the effects of age on regional cerebral volumes and on the frequency and severity of cortical atrophy, lateral ventricular enlargement, and subcortical hyperintensity. Increasing age was associated with (1) decreasing volumes of the cerebral hemispheres (0.23% per year), the frontal lobes (0.55% per year), the temporal lobes (0.28% per year), and the amygdalahippocampal complex (0.30% per year); (2) increasing volumes of the third ventricle (2.8% per year) and the lateral ventricles (3.2% per year); and (3) increasing odds of cortical atrophy (8.9% per year), lateral ventricular enlargement (7.7% per year), and subcortical hyperintensity in the deep white matter (6.3% per year) and the pons (8.1% per year). Many elderly subjects did not exhibit cortical atrophy or lateral ventricular enlargement, however, indicating that such changes are not inevitable consequences of advancing age. These data should provide a useful clinical context within which to interpret changes in regional brain size associated with “abnormal” aging.

Insomnia And The Eye Of The Beholder: Are There Clinical Markers Of Objective Sleep Disturbances Among Adults With And Without Insomnia Complaints?

Previous findings suggest that some who report insomnia sleep well, whereas some noncomplaining individuals sleep rather poorly. This study was conducted to determine if mood, anxiety, and sleep-related beliefs might relate to perceived sleep disturbance. Thirty-two women and 32 men (aged 40-79 years) with primary insomnia and an aged-matched sample of 61 normal sleepers (31 women, 30 men) completed 6 nocturnal sleep recordings, as well as the Beck Depression Inventory (BDI), the Trait portion of the State-Trait Anxiety Inventory (STAI-2), and the Dysfunctional Beliefs and Attitudes About Sleep Questionnaire. Sleep and interview data were used to subdivide the majority of the sample (n = 108) into objective normal sleepers and subjective insomnia sufferers who seemingly slept well and subjective normal sleepers and objective insomnia sufferers who slept poorly. The 2 subjective subgroups showed the most marked differences on most of the psychometric measures. The findings suggest that the psychological factors scrutinized in this study may mediate sleep satisfaction and/or predict objective sleep difficulties.

Two-Year Trends in Physical Performance following Supervised Exercise among Community-Dwelling Older Veterans

The extent to which exercise can delay the normal decline in physical performance associated with aging is unknown. We examined the impact of 2 years of supervised exercise on cardiovascular fitness, flexibility, and strength in a group of elderly (age 65–74) veterans. Seventy‐five patients exercised 3 days/week for 90‐minute sessions emphasizing aerobic, flexibility, and strength development. Thirty‐six (47%) completed 2 years of a voluntary supervised exercise program (n = 16–25 with complete data). Over a 2‐year follow‐up period, cardiovascular outcome variables improved significantly: metabolic equivalents increased 20% (7.4 ± 2.2 to 9.0 ± 2.4, P < 0.001) and submaximal heart rate decreased 7% (131.4 ± 14.8 to 121.0 ± 18.5 beats/minute, P = 0.06). Resting heart rate decreased 8% (68.5 ± 8.0 to 63.6 ± 8.4 beats/minute, P = 0.02) but this difference did not reach statistical significance. Flexibility, measured by hamstring length, improved 11% (57.5 ± 15.1 to 64.0 ± 11.1 degrees, P = 0.02). Strength variables did not improve. The study indicates that improvements in cardiovascular function and flexibility achieved by the elderly in the early stages of an exercise program can be maintained for at least 2 years.

Evaluation of a Supervised Exercise Program in a Geriatric Population

Most studies that assess the effects of exercise in the elderly involve subjects who are in good health. The objective of this prospective longitudinal study was to examine the impact of exercise on cardiovascular fitness, flexibility, and strength in an elderly population that included chronically ill individuals. Patients were recruited initially from a population of veterans over 64 years of age who use a VA outpatient clinic as their regular source of care. The exercise intervention consisted of 90 minutes of exercise 3 days per week at 70% of the patients maximal capacity. Activities included stationary cycling, stretching, weight training, and walking. Of 69 patients who began the program, 49 (71%) reached 4‐month follow‐up. Most patients completing follow‐up (76%) had at least one chronic disease, such as arthritis, hypertension, or heart disease. Patients who dropped out were more likely to have multiple chronic illnesses than those who remained in the program. Average weekly attendance was 65% and was stable over time. Improvements in cardiovascular fitness at 4‐month follow‐up were significant: Metabolic equivalents increased from 7.1 ± 2.3 to 8.3 ± 1.6 (P < .001), treadmill time increased from 8.5 ± 3.8 to 11.2 ± 4.1 minutes (P < .001), submaximal heart rate decreased from 123.7 ± 18.8 to 118.8 ± 19.4 beats per minute (P < .001) and resting heart rate decreased from 68.1 ± 10.6 to 63.3 ± 11.6 beats per minute (P = .005). Hip flexibility also increased significantly from 58.5 ± 13.8 to 67.7 ± 9.9 degrees (P < .001), and abdominal strength increased significantly from 88.8 ± 32.4 to 104 ± 28.4 foot‐pounds (P < .001). No major complications resulted from exercise. This study demonstrates that elderly individuals, including those with chronic diseases, will participate in an exercise program and experience improvements in cardiovascular fitness, strength, and flexibility. Whether these improvements will enable elderly individuals to live independently for a longer period of time and avoid or postpone the need for long‐term care requires additional study and follow‐up.

Exercise Adherence and 10-Year Mortality in Chronically Ill Older Adults

OBJECTIVES: To compare mortality of adherents and nonadherents of an exercise program.

Medical assessment for health advocacy and practical strategies for exercise initiation

The universal caution to consult your family doctor before beginning an exercise program creates an image of exercise as potentially harmful. Moreover, insistence on extensive screening prior to exercise is both unrealistic and often inappropriate for the older adult. Recasting the role of the physician as a physical activity advocate rather than as a gatekeeper is recommended for incorporation into guidelines for exercise screening. A geriatric assessment focusing on identification of specific parameters predictive of disablement risk can be incorporated into the exercise prescription as a guide for initiating exercise. The purpose of this article is to: (1). review the role of the primary care physician in screening and advocating exercise; (2). examine objectively the risk of exercise among older adults and place these risks in context with current screening guidelines with a particular emphasis on the exercise test; and (3). examine how key concepts derived from epidemiologic studies of disability can be distilled into practical guidelines for exercise therapy. We provide an overview of relevant literature related to screening and initiating exercise. Key challenges are highlighted and discussed. Suggestions for changes in policy are recommended. Given the apparent discordance between screening guidelines for the older adult and risk of adverse events, and between existing recommendations for physical activity and epidemiologic studies of disability, an evidence-based approach is recommended to review and revise screening and prescribing practices.

The impact of supervised exercise on the psychological well-being and health status of older veterans

This study examined the impact of supervised exercise on the health status (measured by the Sickness Impact Profile [SIP]) and well-being (measured by the Psychological General Well- Being Index [PGWB]) of a sample of 43 elderly veterans. The intervention consisted of 90 minutes of exercise, 3 days per week at 70% of maximal capacity. Twenty-three (53%) partici pants completed a 1-year follow-up. The mean PGWB score increased significantly from 83.0 ± 15.8 to 89.4 ± 8.9 (p = .01). Cardiovascular fitness (measured by treadmill performance) increased significantly (p = .004). Baseline SIP scores were low (little dysfunction) and changed little. The study suggests that small but significant improvements in well-being accompany physiological benefits that the elderly experience with exercise.

Five-Year Performance Trends for Older Exercisers: A Hierarchical Model of Endurance, Strength, and Flexibility

OBJECTIVE: To examine 5‐year trends in measures of physical performance, and the impact of disease upon performance, in three domains: cardiovascular fitness, musculoskeletal strength, and flexibility among older adults participating in a medically supervised exercise program.

Adherence to Explicit Strategies for Common Medical Conditions

Explicit strategies (protocols) were prepared by the staff of a primary care clinic for use as professional standards by physicians, nurse practitioners and physicians assistants to improve care and facilitate quality assessment in cases of urinary tract infection and upper respiratory illness. Over a 2-year period, audit of 3,442 records for adherence to protocol guidelines revealed a variation with time of 38 to 100 per cent in checklist utilization and 55 to 100 per cent in compliance with specified procedures. Shifting patterns of clinic load and alterations in feedback mechanisms to providers had little relation to guideline adherence. The range in scores was attributed to patient symptom variability with subsequent difficulty applying explicit strategies, and to failure of providers to record details contributing to clinical decisions. With this range of “success” following self-imposed predefined strategies, it is not surprising that retrospective record reviews using short sample periods and criteria established by outside expert panels document wide variation in quality.

Standards for Practice: Effectiveness and Acceptance

Carefully designed and highly specific standards for medical practice can improve the pattern of practice when applied by interested and committed physicians or by other similarly motivated health care providers. However, this is not popular with the physician, and the improved pattern of practice is dependent on continued feedback. The standards must be designed with a specific population and setting in mind; therefore it is unlikely that an effective operational plan can be devised and implemented that will achieve improved practice patterns in the immediate future. Meanwhile, more general standards might be used to identify a smaller number of cases, which can then be reviewed by other physicians, using professionally accepted but subjective practice criteria.