Thomas W. Jackson

Autoimmunity in Alzheimer's disease: Increased levels of circulating IgGs binding Aβ and RAGE peptides

Plasma samples derived from 33 Alzheimers disease (AD) and 42 control participants were subjected to several steps to purify specific anti-(amyloid)Abeta IgGs. Affinity-purified IgGs binding the peptide Abeta1-42, a neurotoxic sequence derived from the trans-membrane amyloid precursor protein, exhibited nearly four-fold higher titers in AD patients compared with their control non-AD cohort. Affinity-purified IgGs binding a fragment of the receptor for advanced glycation end products (RAGE) likewise were increased nearly three-fold in AD individuals. Abeta and RAGE IgG titers were negatively correlated with cognitive status, i.e. the more cognitively impaired individuals tended to exhibit higher IgG titers. Abeta IgG titers were negatively correlated with age in the control group, but not with the AD group. Levels of circulating AB- and RAGE-like proteins were not different between AD and control participants, nor was there a relationship between individual IgG titers and the respective Abeta- and RAGE-like proteins. Freshly prepared leukocyte preparations were subjected to flow cytometric analysis. AD individuals exhibited significantly increased populations of cells expressing binding sites for monoclonal antibodies directed against Abeta (5.5-fold), betaAPP (3.5-fold), and RAGE (2.6-fold) relative to the control group. These findings confirm the presence of circulating IgGs specifically directed at proteins implicated in immunological processes linked to AD. The close relationship between titers for Abeta and RAGE IgGs suggests the possibility that the antibodies are being produced in response to a common mechanism or protein complex (with the respective epitopes) linked to the disease.

The Effect of Age on Driving Skills

To assess the effect of age on driving skills independent of the limitations related to disease or dementia.

CHARACTERISTICS OF AN ELDERLY DRIVING POPULATION REFERRED TO A GERIATRIC ASSESSMENT CENTER

A retrospective, case‐control study was performed to determine the characteristics of elderly drivers referred to an outpatient geriatric assessment center. It was hypothesized that the driving population was operating at a higher cognitive and functional level than nondrivers. One hundred eighty‐two subjects meeting the entry criteria were studied. Twenty‐three percent of the subjects were driving at the time of their assessment. Compared to nondrivers, drivers were younger (P = .0001), were more likely to be male (P = .003), scored higher on a mental status examination (P = .0001), and were more independent in Physical and Instrumental Activities of Daily Living (P < .0001). Despite these findings, the mean Folstein Mini‐Mental score for drivers (23.7) was below normal; 40% of drivers were diagnosed as having Alzheimers dementia at the time of their evaluation, and over 26% of the drivers needed help with either dressing or bathing. The frequency of impaired elderly drivers in this referral setting was high. The authors conclude that conditions that affect the driving task are common in geriatric assessment centers. Prospective studies of elderly drivers are needed to answer the difficult question of who among the elderly should drive.

A multidisciplinary approach in the evaluation of demented drivers referred to geriatric assessment centers

Geriatric assessment clinics are often faced with evaluating the elderly, cognitively impaired driver. Since a generalized approach has so many limitations, there is a need to assess drivers with cognitive impairment systematically and to individualize recommendations. One can look to the literature for guidelines, but few exist. To improve this situation, the authors report methods for evaluating elderly drivers with cognitive impairment. These methods are derived from clinical experience and inferences from driving research. They represent a consensus among health professionals at the Geriatric Assessment Center at Michigan State University, the Geriatric Evaluation and Treatment Clinic at Duke University Medical Center, and the Geriatric Assessment Center at St. Johns Mercy Medical Center.

Why students choose a primary care or nonprimary care career

PURPOSE To analyze the factors influencing students to choose residency training in primary care (internal medicine, family medicine, and pediatrics) or nonprimary care specialties and study the combined effect of reported responses on their choice. MATERIALS AND METHODS A 12-item questionnaire using a 7-point Likert scale was mailed to the 1,164 graduating seniors from 9 medical schools in 1991. Responses ranged from 1, very negative influence, to 7, very positive influence. Four indicated no influence. The overall response rate was 69%. Univariate analysis of factors associated with specialty choice was done with the Mantel-Haenzsel chi-square test. Odds ratios were calculated for each significant variable without controlling for other variables. Factors found to have univariate significance were then tested for combined significance with logistic regression analysis. The regression was performed on a randomly chosen training sample, and validated on a test sample. RESULTS Forty-five percent of respondents chose an internship and planned residency training in a primary care specialty. Factors that remained positively associated with choosing a primary care specialty when controlling for other factors were desire to provide comprehensive care, to keep options open, and to undertake ambulatory care. Desire for monetary reward was negatively associated with choice of a primary care specialty. CONCLUSIONS Positive educational experiences in the ambulatory setting should be enhanced, and disparity in remuneration among disciplines reduced.

The treatment of urinary incontinence with electrical stimulation in nursing home patients : a pilot study

To test the effectiveness of electrical stimulation in the treatment of urinary incontinence in female nursing home patients.

MEDICAL EDUCATION IN GERIATRICS: THE LASTING IMPACT OF THE AGING GAME

In an effort to sensitize medical students to the problems of the frail elderly, a simulation experience known as the Aging Game is a required portion of the Introduction to Clinical Medicine course for medical students at Duke University. The immediate positive effect of the Aging Game has been documented (Journal of the American Medical Association, 262, 1507‐1509), but its long‐term impact has not been established. To obtain follow‐up, a brief 10‐item questionnaire was mailed to all medical students. Both objective and subjective data were collected to ascertain the impact of the Aging Game over time (class years two through four), and objective responses were analyzed by the Mantel‐Haenszel chi‐square test of general association. The lasting effect of the intervention was confirmed over the 2‐year follow‐up period. The experiential nature of the intervention and the resultant increase in empathy for the frail elder explain the success of the Aging Game.

Effects of Short-Term Administration of Glucocorticoids on Bone Metabolism in Healthy Elderly Men

Objective: To determine the effects of short‐term glucocorticoid administration in healthy elderly men on bone GLA protein (BGP) levels, as well as levels of calcium, phosphorus, immunoreactive parathyroid hormone (PTH), and alkaline phosphatase.

Clinical Evaluation of the Elderly Hypertensive

When confronted with an elevation in blood pressure (BP) in an elderly patient, additional measurements are necessary because of increased variability in older persons possibly caused by impaired baroreceptor sensitivity (Fig. 1) (1). In addition to lability of BP, there should be consideration given to the presence of an auscultatory gap (2), orthostatic hypotension (3), and pseudohypertension (4).

A patient with concurrent primary hyperaldosteronism and adrenal insufficiency.

A 73-year-old man with history of longstanding primary hyperaldosteronism developed adrenal insufficiency after he ruptured an abdominal aortic aneurysm and had a prolonged hypotensive episode. The patient presented as a diagnostic dilemma with recurrent hypotensive episodes and hypokalemia. A cosyntropin (Cortrosyn) stimulation test demonstrated a blunted cortisol response while at the same time having a suppressed plasma renin activity level and an elevated plasma aldosterone value. Diagnosis of Addison disease and concurrent primary hyperaldosteronism resulted in the patient’s being treated with an unusual combination of prednisone and spironolactone followed by marked improvement in his symptoms.