Melatonin in older people with age-related sleep maintenance problems: a comparison with age matched normal sleepers.

STUDY OBJECTIVES: To determine whether older people with age-related sleep maintenance problems have significantly lower melatonin levels than comparable normal sleepers. DESIGN: Case-control study. SETTING: A largely urban population, Auckland, New Zealand. PARTICIPANTS: People over the age of 65 years, who either slept normally, or had age-related sleep maintenance problems. Participants were recruited through media advertising, and local interest groups. Initial screening was by mail (Pittsburgh Sleep Quality Index), followed by interviews at a hospital day clinic. Exclusions included those with depression, cognitive impairment, medical and/or environmental problems which might impair sleep. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: A metabolite of plasma melatonin, 6-sulphatoxymelatonin (aMT6s) was measured in the urine of 57 normal sleepers, and 53 people with age-related problems over 24 hours in three aliquots: 12:00-19:00h, 19:00-07:00h, 07:00-12:00h. There were clear differences in self reported quality of sleep but no difference in mean aMT6s 24 hour or total night excretory levels, or night/day ratios. CONCLUSIONS: Older people with age-related sleep maintenance problems do not have lower melatonin levels than older people reporting normal sleep.

Shared responsibility for ongoing rehabilitation: a new approach to home-based therapy after stroke.

OBJECTIVE: To assess the efficacy of a programme of continuing self-directed exercises for people discharged home after a stroke, supervised once a week by therapists. DESIGN: A randomized controlled trial of 100 patients discharged from hospital after a stroke, requiring ongoing therapy. The control group received outpatient or day hospital therapy; the experimental group were visited once a week by an occupational and/or physiotherapist who prescribed a programme of exercises and activities for the following week. Subjects were studied for the first three months after discharge from hospital. SETTING: A district general hospital, or the homes of subjects randomized to the experimental group, in New Zealand. MAIN OUTCOME MEASURES: (1) Characteristics of the groups, (2) gait speed, limb function, activities of daily living, (3) time with therapists, (4) mood of both subjects and caregivers, (5) anticipation of outcome at entry, compared with perceived outcome at exit. RESULTS: No statistical differences between the control and experimental groups in characteristics, or in any outcomes measured, except that the contact time period, but not the number of visits, was longer in the experimental group (p = 0.003). CONCLUSIONS: A supervised home-based programme is as effective as outpatient or day hospital therapy.

Sulphatoxymelatonin excretion in older people: relationship to plasma melatonin and renal function.

In order to validate measurement of urinary sulphatoxymelatonin as an accurate method of estimating plasma melatonin secretion in older people, we compared 24 h plasma melatonin secretion and sulphatoxymelatonin excretion with renal function in 20 subjects 62-89 years of age. There was a good correlation between plasma and urinary sulphatoxymelatonin over the same 24 h period (R2 = 0.797) and no relationship between creatinine clearance and sulphatoxymelatonin excretion (R2 = 0.075). The results suggest that sulphatoxymelatonin excretion estimation is a good surrogate measurement of plasma melatonin secretion in older people, at least across the range of creatinine clearance for the subjects in the study, 0.41-1.81 ml/sec.

The good side after stroke: ipsilateral sensory-motor function needs careful assessment.

Twenty subjects were examined 4-6 weeks after stroke to establish whether a sensory-motor ipsilateral deficit occurs early after stroke. Each underwent a timed test of repetitive side-to-side movement of both the upper and lower limbs ipsilateral to the cerebral infarct, and an assessment of motor disability using the Motor Assessment Scale. Results were compared with a group studied almost a year after their stroke, and with 41 age-matched healthy volunteers. There was a significantly worse performance (p < 0.005) on the right ipsilateral side, but not the left ipsilateral side, compared with normal volunteers, a finding similar to that of a group previously studied about a year after the stroke. There was no relationship between the severity of the motor deficit and performance of the side, possibly owing to reduction in cerebral activation as a result of a right hemispheric lesion. These observations have importance in rehabilitation and education as well as practical skills, including driving a car and maintaining balance.

Assessment for rest home subsidy: are the elderly getting a fair deal?

AIM: To describe the role of a geriatric service in assessing the needs of elderly people at home or in rest homes referred for a subsidy for rest home care, and to compare this assessment with the composite dependency scale (CDS), a Department of Social Welfare assessment instrument. METHODS: A 47 item questionnaire was completed by the geriatric service at the time of assessment of elderly people in the community or in rest homes. RESULTS: Of 280 assessments, 100 were from private homes, 180 from rest homes. Sixty-three per cent in rest homes were referred only because private funds were exhausted, 33% for a change in dependency category. These two groups plus those at home were used as a basis for comparison in subsequent analysis. Of those at home: 30% already had a rest home bed arranged; 77% remembered being consulted about rest home care, but only 38% were sure they wanted to go into such care. The proportion of those too independent or too sick for rest home care was: private homes 14%, rest home resident requiring subsidy 6%, rest home requiring change in category status 11%. Twenty three percent of those at home could continue there with or without additional support. No significant difference was found in dependency between those in rest homes only seeking funding, and those at home, but both of these groups were significantly less dependent than those seeking an increase in subsidy. There was only a moderate correlation (rs = 0.778) between the geriatric service assessment of dependency and the composite dependency score. CONCLUSIONS: Many elderly people do not feel properly consulted about rest home placement, and some could be supported at home for longer. It is likely that many who can afford rest home fees are entering too early and then asking for a subsidy when their funds are exhausted. By then it is almost impossible to insist on alternatives in the community. A policy of geriatric service assessment for all seeking entry into rest home care should ensure independent consultation and consideration of alternative strategies. More research is required to examine cost implications of unrestricted movement into rest homes.

Melatonin levels in hospitalized elderly patients: a comparison with community based volunteers.

Twenty-one-hour melatonin plasma profiles were studied in 15 normal elderly volunteers from the community, and eight who had been in hospital for more than six weeks and who had not been exposed to strong natural lighting. The hospital group had significantly higher daytime plasma melatonin levels, an earlier nocturnal rise, and the timing of their secretory profiles was more variable. These results suggest that currently used artificial and supplementary natural lighting may not be sufficient to suppress melatonin secretion adequately during daylight hours nor act efficiently to entrain day/night secretion of melatonin in a physiological circadian manner. Raised melatonin levels by day and variable secretory profiles at night may account for certain mood and sleep disorders observed in institutionalized people.

Young disabled residents in old people's homes.

A survey of the status of residents in aged care facilities in the Auckland region conducted in 1988 indicated that almost 9% (645) of the 7516 people studied were under 65 years of age. Rates were markedly higher for people of Maori descent than for those of European descent in this age group. For nonMaori, the rate for men was higher than that for women, but for Maori the opposite was the case. The majority of these young residents (94%) were being cared for in commercial old people's homes. One half were cared for in just 29 of the 223 homes in the region. While most (59%) were admitted after the age of 50, 15% were admitted before they were 40 and must expect to liver their lives out in institutions primarily housing elderly residents. Almost half of those in old people's homes had been admitted from a psychiatric hospital. The authors are concerned that so many young people appear to be in old people's homes because of a lack of alternative accommodation which is more suited to their care.

Functional disability in residents of Auckland rest homes.

OBJECT: to measure the extent of disability in residents of Auckland rest homes and to document any differences between religious and welfare homes and commercial homes. METHODS: analysis of a 36 item questionnaire on 2087 residents in 32 religious and welfare homes and 3126 residents in 191 commercial homes (98.7% response rate). RESULTS: residents in commercial homes were significantly more disabled than those in religious and welfare homes: 24% compared with 12% were incontinent, 62% and 31% confused, and 78% and 49% respectively needed assistance with mobility and selfcare. Of special concern were 7% and 3% who were doubly incontinent, 7% and 2% confused to the point of disturbing other residents, and 4% and 2% who met the criteria for hospital care. CONCLUSIONS: a significant number of residents were disabled and required help in important aspects of simple self care. Informed advice, variety, and choice in type of care are mandatory before entering a rest home. Homes must employ trained staff who can identify and minimise problems so as to ensure optimal quality of life for residents.

A profile of the 7500 people in aged-care institutions in Auckland.

A study was carried out in 1988 to describe the residents and patients of aged-care institutions in Auckland against which future measures, including planned changes in licensing and funding, could be made. Information was collected for each patient in every hospital (public and private) and each resident in all old people's homes in the Auckland region between January and June 1988. Of the 7516 people surveyed (99.4% response rate), 70% were residents in old people's homes, 25% were patients in private hospitals and 6% were cared for in the public hospital sector. Of the people surveyed, 71% were women. The average age of women, 82 years, was 6.5 years older than that of men. Three-quarters of all women and 44% of men in care were widowed. Women had a higher rate of admission to institutions than did men with almost one in two women and one in four men in the age group 85 years and over being in long term care. Rates of institutionalisation for Maoris and Pacific Islanders were the same as for Europeans. The majority of elderly people received regular contact and concern from family members. This study has demonstrated that Auckland has a higher proportion of the elderly population (7.6% of the population 65 years and over) in long term care compared with other areas of New Zealand.

Dependency levels of people in aged care institutions in Auckland.

Between January and June 1988, a survey of 7516 people in aged care facilities in the Auckland region (99.4% response rate) was undertaken to ascertain the extent and provision of care for elderly people requiring ongoing care in order to make comparisons with other centres in New Zealand. Information was gathered about their ability to perform various activities of daily living by staff members who completed a structured precoded and pretested questionnaire for each resident or patient. Overall levels of dependency were also assessed as part of the questionnaire: 13% were assessed as requiring long stay hospital care, 48% had moderate or appreciable dependency, and the remainder had some dependency (23%) or none at all (16%). Almost one quarter (23%) of the 5213 residents in old people's homes were rated as apparently independent. Of people in religious and welfare residential homes, 38% were rated as independent whereas in commercial rest homes 12% of people were classified in this way. This high level of apparent independence in religious and welfare homes is the main aspect in which the Auckland long term care scene is distinct from other regions in the country.

Changes in carotid artery compliance with age.

Doppler-shifted ultrasound was used to measure arterial compliance non-invasively in the internal and external carotid pathways of 270 male and 388 female asymptomatic volunteers aged 5 to 90 years. There was a significant decrease in the compliance of both arteries from 5 to 50 years of age (p less than 0.001), when it then levelled out. Arteries of women were more compliant than those of men at ages 35 to 60 years.

Inhaler devices and the elderly.

This study compared the relative ease of use of the metered dose inhaler, the FO2 Inhalator and the Diskhaler by elderly subjects in a randomised cross over trial using placebo inhalants. Thirty-one nonasthmatic volunteers (average age 79.6 years) who lived independently in two residential homes for the elderly were recruited. One failed to complete the study. Subjects were taught to use the three inhaler devices in a randomly assigned sequence with a two week period elapsing between each training session. The Diskhaler device took longest to learn (16.5 minutes) and the Inhalator was significantly easier to learn to use than the other two (x2 = 40.3, p = 0.001). The Inhalator was preferred by 64%, metered dose inhaler by 25% and Diskhaler by 11% (p = 0.03). Problems in the use of each are described. The study found that the Inhalator was simple to use and was reliably self administered by older people. The metered dose inhaler was simple to use only for a minority who could accurately coordinate actuation and inhalation. The Diskhaler had no advantages in this age group.

Cognitive impairment and its relationship to gait rehabilitation in the elderly.

In a prospective study of 116 elderly people admitted to a geriatric rehabilitation ward, mini-mental state score on admission was used to classify nonaphasic subjects into three groups: cognitively normal (24-30), mildly impaired (17-23) and severely impaired (less than 17). Forty-three percent of the subjects were normal, 34% had mild and 23% had severe cognitive impairment. Using walking speed as the index of gait rehabilitation, subjects with normal cognition had significantly greater gait improvement than those with cognitive impairment. Age and urinary incontinence did not contribute to predicting gait improvement in regression modelling. Cognitive impairment also predicted discharge placement to long term hospital care and to a higher level of care than the subject received prior to admission. Thus cognitive impairment on admission to a geriatric rehabilitation ward predicts poor rehabilitation outcome with respect to gait and discharge residence.

A prospective trial of serial gait speed as a measure of rehabilitation in the elderly.

Walking speed was measured on admission and then weekly during treatment of 125 subjects admitted to a geriatric rehabilitation ward. Walking speed was strongly related to the ability to stand up from a chair without help. Placement decisions at discharge were made without knowledge of gait speed data so that they could be used as a standard against which to compare walking speed as a valid and practical measure of mobility. It was found that a discharge walking speed of 0.15 m/s best separated immobile subjects who required long-term hospital care from those sufficiently mobile to be discharged home alone or to a rest home (54% versus 0% below cut-off, respectively). Relative walking speed (speed/height) was no better at predicting placement or mortality than walking speed. Uncorrected walking speed therefore remains the preferred clinical measure of velocity. A serial record showing improvement in walking speed proved useful in predicting eventual independent mobility of poorly mobile subjects. Thus walking speed is an objective yet inexpensive method of monitoring gait rehabilitation.

Red blood cell velocity changes with age and sex in the common carotid and supra-orbital arteries.

Doppler-shifted ultrasound and spectral analysis were used to assess signals from the resting supra-orbital artery and the common carotid artery at the base of the neck of 658 (270 male, 388 female) asymptomatic subjects aged 5 to 90 years. The sonagrams obtained showed two peaks (A and B) during cardiac systole. The ratio of these peaks (A/B) decreased from 20 to 50 years and then levelled out. The male A/B ratios from both arteries were higher than those for the females between 20 and 50 years, and for the common carotid these differences were highly significant (P less than 0.001).

Erythrocyte flow velocity changes with age and sex in augmented supraorbital, superficial temporal and common carotid pulses.

Doppler-shifted ultrasound and spectral analysis were used to assess signals from augmented supraorbital and superficial temporal pulses, and the common carotid pulse 4 cm above the base of the neck of 658 (270 male, 388 female) asymptomatic subjects aged 5-90 years. The sonagrams obtained showed two peaks (A and B) during cardiac systole and the ratio of these peaks (A/B) decreased between the ages of 20 and 50 years, and then levelled out. Mean male values of common carotid sonagrams were significantly higher than female values during this age range (p less than 0.001).

Screening for carotid junction disease by spectral analysis of Doppler signals.

The established test for disease in the internal carotid artery using continuous wave Doppler is to listen for flow velocity changes over the supraorbital artery with ipsilateral temporal (or facial) artery compression. This is only reliable when there is a reduction in mean pressure (and flow) distal to disease in the internal carotid artery, ie reduction of lumen diameter by more than 85%. In this study, 101 vessel segments (48 with disease at the carotid junction, 53 normal) were compared with the results of angiography. Seven gave a positive temporal artery occlusion test, all of which showed severe disease. However, spectral analysis of the Doppler signals from supraorbital and common carotid arteries showed sonagram changes both with ageing and with disease. In particular, the ratio of primary peak (A) to secondary peak (B) in systole falls, the A/B ratio being lower in disease than in health. At A/B ratios less than 1.05 there was an 88% probability of disease at the carotid junction. 36/48 (75%) diseased junctions were detected, including almost all major lesions. The method did not so reliably detect small lesions (less than 2 mm plaques, less than 60% lumen diameter stenosis, and 'minimal atheroma'). In 5/53 normal junctions the A/B ratio was in the disease range. Scanning the carotid junction for turbulence yielded additional information in some cases.