Objectives: To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of ...psychotropic medications to these patients. Methods: 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient. Results: Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used. Conclusion: Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.
A cross-sectional study was performed to evaluate the concordance of the present criteria of delirium among elderly (>70 years) geriatric hospital patients (n = 230) and nursing home residents (n = ...195). Different subjects were diagnosed as having delirium when operationalized criteria according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-III-R, DSM-IV) and the World Health Organization’s International Classification of Diseases (ICD-10) were used. Whereas 132 subjects (31.1%) met the criteria for delirium by at least 1 classification, only 25 (5.9%) met all 4. The most inclusive was the DSM-IV (24.9% of the subjects) followed by DSM-III-R (19.5%), DSM-III (18.8%) and ICD-10 (10.1%), respectively. The DSM-IV and ICD-10 had the largest number of patients not overlapping with any other diagnostic group. The newest DSM-IV classification found more cases of delirium especially among acutely ill, hospitalized patients.
To evaluate the frequency, risk factors, and prognostic significances of postural hypotension (PH) and dizziness on postural testing (DPT).
A prospective cohort study.
General community, The Helsinki ...(Finland) Aging Study.
Persons of three age cohorts (75, 80, and 85 years, n = 569) were chosen randomly and followed for 4 years.
Postal questionnaires, structured interview, extensive clinical and laboratory examinations, blood pressure (BP) changes in a postural test using different definitions for PH, history of dizziness, dizziness on testing postural blood pressure reactions (DPT), and date of death during a 4-year follow-up.
The frequency of a fall in systolic blood pressure greater than 20 mm Hg or a fall in diastolic pressure greater than 10 mm Hg (PH-I) was 30.3%. Both criteria occurred simultaneously (PH-II) in 7.5%, and if dizziness on postural testing (DPT) was an additional symptom (PH-III), the prevalence was 2.6%. The overall prevalence of DPT was 19.7%. PH-I, PH-II, and DPT were also frequent among the healthy aged (26.6%, 6.6%, and 17.3%, respectively). The postural change in BP correlated inversely with the initial supine BP levels (systolic r = -.149, P < .001 and diastolic r = -.218, P < .001), but in persons with isolated systolic hypertension PH was rather less frequent (21.9% and 2.3%). DPT was more common in the subjects with heart failure (26.3%, P < .05), impaired exercise tolerance (NYHA III-IV) (33.7%, P < .05), and PH-II (37.2%, P < .05) compared with the healthy controls (17.3%). The 1-year mortality was higher in subjects with than without DPT (7.1% vs 4.8%, P < .05), but the difference was not significant after controlling for age and gender. PH-I, PH-II, and PH-III were not significantly related to 4-year mortality.
In this study of older people in Helsinki, Finland, asymptomatic hypotensive postural BP reactions and DPT were found frequently among healthy older people, and they tended to be increased in people with some diseases. Neither PH nor DPT were of prognostic significance for mortality in this population.
To investigate the regulation of serum levels of cholesterol precursor sterols and plant sterols, these noncholesterol sterols, fatty acids, and various parameters of cholesterol metabolism were ...analyzed in 63 volunteers from a randomly selected Finnish male population sample of 100 subjects, aged 50 years, who had normal dietary habits. Serum levels of cholesterol precursors, desmosterol and lathosterol (in terms of micrograms/mg cholesterol), were negatively related to both the fractional and absolute absorption of dietary cholesterol and serum high density lipoprotein (HDL) cholesterol, and positively related to overall cholesterol synthesis and serum very low density lipoprotein (VLDL) cholesterol. Serum levels of the plant sterols, campesterol and sitosterol, exhibited positive correlations with the polyunsaturated/saturated fatty acid ratio of dietary fat, the linoleic acid contents of plasma and dietary lipids, the amount of dietary plant sterols (as indicated by fecal output), fractional and absolute absorption of dietary cholesterol, and HDL cholesterol, but were inversely related to the overall cholesterol synthesis and VLDL cholesterol. Stepwise multiple regression analysis revealed that the serum level of campesterol was associated with fractional cholesterol absorption, dietary plant sterols, and biliary cholesterol secretion, and that of sitosterol with dietary plant sterols, cholesterol synthesis, fractional cholesterol absorption, and biliary cholesterol secretion. Thus, the serum non-cholesterol sterols are significant indicators of cholesterol absorption and synthesis even under basal conditions and, since gas liquid chromatographic determination of these sterols is quite simple, their measurement may be valuable for monitoring cholesterol metabolism in large-scale epidemiologic studies.
OBJECTIVES: To investigate use of prescribed analgesic drugs in relation to experience of joint or back pain in a home‐dwelling older population, to study changes in the use of analgesic drugs over ...10 years, and to investigate concomitant use of protective gastrointestinal drugs with prescribed analgesic drugs in 1999.
DESIGN: Cross‐sectional mailed surveys 10 years apart.
SETTING: Helsinki, Finland.
PARTICIPANTS: Random samples of older birth cohorts born in 1904, 1909, and 1914 in 1989 (n = 644) , and of three separate cohorts born in 1914, 1919, and 1924 in 1999 (n = 3,000).
MEASUREMENTS: Use of various types of analgesic and protective gastrointestinal drugs, prescribed and over the counter. Experience of joint and back pain that interferes with daily functioning.
RESULTS: The response rate of home‐dwelling older people was 83% in 1989 and 81% in 1999. Although the use of analgesic drugs as self‐treatment increased from 28.5% to 41.4% during the 10 years, in 1999, only 35.5% to 38.2% of those suffering joint or back pain that impaired daily functioning had been prescribed an analgesic drug for regular use. Of those using prescribed medication, 57.5% were on nonsteroidal antiinflammatory drugs (NSAIDs), 20.9% acetaminophen, and 18.5% weak opiates. Only one‐fifth of those individuals taking NSAIDs were on a concomitant gastroprotective drug.
CONCLUSIONS: Pain is markedly undertreated in community‐dwelling older people, which may have serious implications for their well‐being and functioning. Although we noted a tendency for safety in the use of prescribed analgesic drugs, a significant effort must sill be made to implement evidence‐based practice. Self‐treatment of pain has increased in 1 decade, which may reduce the overall safety of analgesic drug use among older people.
OBJECTIVE: To study the relationships between apoE phenotypes, dementia, and mortality.
SETTING: A population‐based study in Helsinki, Finland (the Helsinki Ageing Study).
DESIGN: A prospective birth ...cohort study with 5‐year follow‐up.
PARTICIPANTS: A total of 550 subjects of three birth cohorts of 75 (n = 182), 80 (n = 185), and 85 (n = 183) years of age.
MEASUREMENTS: ApoE phenotype was determined from baseline blood samples. The cognitive function of the subjects was tested at baseline and at a 5‐year follow‐up using the Mini‐Mental State Examination (MMSE) and the Clinical Dementia Rating (CDR). Diagnosis and type of dementia were determined by a neurologist. The cohorts were followed for 5 years, and causes of death were determined. Cox proportional hazards model was used for survival analyses. Analyses were performed comparing the apoE e4 allele and others.
RESULTS: At baseline, the apoE e4 allele was found in 148 of 550 subjects (27%), in 24% of nondemented persons, in 51% of patients with probable or uncertain Alzheimer's disease (AD), and in 34% patients with vascular dementia. The CDR score was worse among subjects with an e4 allele compared with others at baseline (P < .001) and after a 5‐year follow‐up (P = .007). The crude mortality rates of subjects with and without an e4 allele were 48% (n = 71) and 37% (n = 148), respectively. After controlling for age and gender, the hazard ratio of an e4 allele was 1.61 (95% CI, 1.21–2.14) for all‐cause mortality, deaths caused by dementia 2.20 (95% CI, 1.03–4.72), and presence of AD 3.24 (95% CI, 1.67–6.25).
CONCLUSIONS: In a population aged 75 to 85 years, the presence of an apoE e4 allele is associated with impaired cognitive function, clinical dementia, AD, and excess 5‐year mortality resulting from dementia and all causes.
A 2-year follow-up study was performed to compare the prognosis of delirium defined according to 4 different diagnostic classifications (DSM-III, DSM-III-R, DSM-IV and ICD-10 clinical criteria) among ...425 elderly geriatric hospital patients and nursing home residents. The proportion of delirium varied from 24.9% (DSM-IV) to 10.1% (ICD-10). The prognoses were similar particularly according to all DSM classifications: 31.3–36.3% of the delirious patients died within 1 year and 57.8–62.5% within 2 years. The number of subjects diagnosed as delirious according to the ICD-10 was small, and their prognosis did not differ significantly from the others either. The DSM-IV has simplified the criteria of delirium. It identifies new, acutely ill and relatively nondependent subjects as delirious who share the poor prognosis of patients diagnosed with the previous criteria.
To investigate older patients’ reasoning for their cardiopulmonary resuscitation (CPR) preferences and the related decision-making process (DMP).
In a descriptive study 220 elderly home-dwelling ...cardiovascular patients were interviewed and asked to justify their CPR preferences according to the given statements. Questions related to DMP were asked and their physical function, cognition, mood, and quality of life were assessed.
Resuscitation preferences were associated with several patient characteristics, such as age, mood and quality of life. Patients preferring CPR (114/220, 52%) estimated their prognosis of CPR to be better than those preferring to forgo CPR. They justified their view: “Life is precious and worth living for me” (92%), “Maintaining life is a value of its own” (92%), “I feel needed by my family and my closest” (81%). Participants preferring to forgo CPR (106/220, 48%) justified: “I have already gained old age and led a full life” (88%), “People cannot decide these things” (72%). Only 9% of patients had discussed, and 38% would like to discuss preferences for life-sustaining treatments (LSTs) with their physician. However, 80% of respondents felt that the patients should take some part in the DMP; either alone (9%), together with a physician (23%), or together with a physician and a close relative (48%).
Older people justify their resuscitation preferences highlighting their experiences of meaningful life or fulfillment of their life, interpersonal relationships with their loved ones and presumed outcome of CPR. Less than a half of the patients wished to discuss CPR and LSTs preferences in their current situation with their physician, but nevertheless wanted to participate in the DMP of end-of-life treatment. Physicians should assess patients’ own preferences in-depth.
