Influence of Depression and Hostility on Exercise Tolerance and Improvement in Patients with Coronary Heart Disease.

PURPOSE: Although hostility and depression have been linked to higher cardiac risk and poor prognosis of patients with coronary heart disease (CHD), there is a lack of research that studies how they may influence the short-term outcomes among patients participating in cardiac rehabilitation (CR). This study aimed to investigate the influence of hostility and depression on patients' exercise tolerance and improvement trajectory in a CR program over 6 weeks. METHOD: Participants were 142 patients with CHD, with a mean age of 62 years. Latent growth curve modeling was conducted to determine whether hostility and depression predicted patients' baseline exercise tolerance and rates of improvement on treadmill, while controlling for age and severity of illness. In addition, analysis was conducted to examine whether depression mediated the influence of hostility on exercise outcomes. RESULTS: Patients with CHD with higher hostility scores had a lower baseline exercise tolerance and slower rates of improvement over 6 weeks. Depressive symptom severity mediated the influence of hostility on exercise baseline and improvement. Patients with higher hostility were more likely to have more severe depressive symptoms, which in turn were associated with lower baseline exercise tolerance and slower improvement. CONCLUSION: While both hostility and depression predicted the exercise outcomes in CR, depression explained the influence of hostility. The findings underscore the importance of addressing psychosocial issues in treatment of CHD patients and provide support for psychosocial interventions in CR to facilitate patients' recovery.

Risk factors associated with lower defecation frequency in hospitalized older adults: a case control study.

BACKGROUND: Constipation is highly prevalent in older adults and may be associated with greater frequency of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We investigated the prevalence of lower defecation frequency (DF) and risk factors (including AECOPD) associated with lower DF among hospitalized elderly patients. METHODS: We conducted a retrospective case-control study in a community hospital of Southeast Ohio. Adults aged 65 years or older admitted during 2004 and 2006 were reviewed (N = 1288). Patients were excluded (N = 212) if their length of stay was less than 3 days, discharge diagnosis of Clostridium difficile-associated diarrhea, death or ventilator- dependent respiratory failure during hospitalization. Lower DF was defined as either an average DF of 0.33 or less per day or no defecation in the first three days of hospitalization; cases (N = 406) and controls (N = 670) were included for the final analysis. RESULTS: Approximately 38% had lower DF in this patient population. Fecal soiling/smearing of at least two episodes was documented in 7% of the patients. With the adjustment of confounders, AECOPD (adjusted odds ratio [AOR] =1.47, 95% confidence interval [CI] =1.01-2.13) and muscle relaxant use (AOR =2.94; 95% CI =1.29-6.69) were significantly associated with lower DF. Supplementation of potassium and antibiotic use prior to hospitalization was associated with lower risk of lower DF. CONCLUSIONS: Approximately 38% of hospitalized older adults had lower DF. AECOPD and use of muscle relaxant were significantly associated with lower DF; while supplementation of potassium and antibiotic use were protective for lower DF risk after adjusting for other variables.

Supportive-expressive and coping group teletherapies for HIV-infected older adults: a randomized clinical trial.

This clinical trial tested whether telephone-administered supportive-expressive group therapy or coping effectiveness training reduce depressive symptoms in HIV-infected older adults. Participants from 24 states (N = 361) completed the Geriatric Depression Scale at pre-intervention, post-intervention, and 4- and 8-month follow-up and were randomized to one of three study arms: (1) 12 weekly sessions of telephone-administered, supportive-expressive group therapy (tele-SEGT; n = 122); (2) 12 weekly sessions of telephone-administered, coping effectiveness training (tele-CET; n = 118); or (3) a standard of care (SOC) control group (n = 121). Tele-SEGT participants reported fewer depressive symptoms than SOC controls at post-intervention (MSEGT = 11.9, MSOC = 14.3) and 4- (MSEGT = 12.5, MSOC = 14.4) and 8-month follow-up (MSEGT = 12.7, MSOC = 14.5) and fewer depressive symptoms than tele-CET participants at post-intervention (MSEGT = 12.4, MCET = 13.6) and 8-month follow-up (MSEGT = 12.7, MCET = 14.1). Tele-CET participants reported no statistically significant differences from SOC controls in GDS values at any assessment period. Tele-SEGT constitutes an efficacious treatment to reduce depressive symptoms in HIV-infected older adults.

Uses of proton pump inhibitors and hypomagnesemia.

PURPOSE: Hypomagnesemia associated with proton pump inhibitor (PPI) therapy has been documented in case reports. We performed a cross-sectional study to examine the association between PPI use and serum magnesium (Mg) levels or hypomagnesemia. METHODS: Data were extracted from hospitalized adults with basic metabolic panels and/or serum magnesium levels available during the hospital stays. The first Mg value was used for data analysis. Hypomagnesemia is defined as levels less than 1.7 mg/dL (or 0.70 mmol/L). Multiple linear and logistic regression analyses were used to assess the association between PPI use and Mg levels or hypomagnesemia, respectively. RESULTS: Among study patients, PPI users (n = 207) had a mean Mg level of 1.91[SD = 0.34] mg/dL, and non-users (n = 280) 2.00 (0.30) mg/dL, p = 0.004. PPI use was associated with lower serum Mg levels (adjusted coefficient ß = -0.10, 95% CI = [-0.16, -0.04]) after adjusting for confounders. PPI use was associated with risk of hypomagnesemia after adjusting for confounders (adjusted OR = 2.50, 95% CI = [1.43, 4.36]). Both standard (1) and high (2 or higher) defined daily dose units of PPI therapy were associated with hypomagnesemia. CONCLUSIONS: PPI use was associated with lower serum Mg levels and hypomagnesemia in a population of hospitalized adult patients. Our study supports the general notion that long-term PPI use could be associated with sub-clinical Mg insufficiency or deficiency status.

A preliminary study of symptomatic fatigue in rural older adults.

BACKGROUND AND AIMS: The purpose of this study was to evaluate the prevalence of symptomatic fatigue and its relation to physical function and self-perceived health in a sample of older, rural community-dwelling adults with commonly-used clinical fatigue scales. METHODS: This is an exploratory, descriptive study of 30 subjects from 4 rural counties. All subjects were 70+ years of age and had no recent history of hospitalization. Subjects were assessed in their homes and completed a standard test of physical function, twelve functional assessment instruments, and two commonly-used clinical fatigue scales: the Fatigue Severity Scale and the Functional Assessment of Chronic Illness Therapy-Fatigue Scale. RESULTS: Depending on the fatigue instrument and criteria used, 23-47% of subjects exhibited symptomatic fatigue. Regardless of the scale, fatigue was associated with several negative consequences: decreased physical function performance, lower morale, and reduced physical composite scores on the Short Form-36 quality of life questionnaire. Of note, these differences remained significant even after accounting for depression scale scores. In addition, fatigue was associated with a greater incidence of risk for malnutrition. CONCLUSIONS: Together, these findings suggest that symptomatic fatigue may be quite prevalent in older individuals in rural settings, and warrants further consideration when presented in the clinical setting, as it may be associated with several negative health outcomes.

Analyzing fecal loading and retention patterns by abdominal X-rays of hospitalized older adults: A retrospective study.

Background: Aging may affect ascending colon (AC) differently from descending colon (DC) and increase the risk of fecal loading (FL) in AC. Methods: Patients aged ≥65 years admitted to a community hospital were analyzed by abdominal x-ray for fecal loads and stool retention patterns. FL was scored between 0 and 5 (severe) on each segment of colon with a possible total score 20. Mean segment scores ≥3.5 were designated as high scores for both AC and DC. Logistic regression was performed between groups to identify factors associated with FL patterns. Results: Groups identified were high FL in both AC and DC (N = 21, 17.2%), FL predominantly in AC (N = 38, 31.1%), low FL in both AC and DC (N=60, 49.2%), and FL low in AC and high in DC (N = 3, 2.5%). Among 71 patients with total FL scores ≥13 (indicating significant stool retention), 37 (52.1%) had the FL predominantly in AC. Patients prescribed antibiotic(s) prior to hospitalization had lower odds of FL predominantly in AC (adjusted odds ratio = 0.18, 95% confidence interval = 0.04-0.84) compared to the group of low FL in both AC and DC with the adjustment of confounders. Conclusion: This study found that 52.1% of those with significant stool retention on x-ray had the FL predominantly in AC. Antibiotic use was associated with lower odds of having FL predominately in AC. This study provided insights of FL distribution in colon and AC could be an area for significant stool burden in older adults with stool retention.

Ryodoraku as a tool monitoring the effects of walking exercise.

OBJECTIVE: To investigate the possibility of using Ryodoraku as a tool to indicate sympathetic neuronal activity. METHODS: Twenty-two female college students were assigned to an treadmill exercise program (three times a week for six weeks), and another 25 were assigned as controls. Skin conductance levels of the subjects were measured at 24 Ryodoraku points on the wrists and the ankles, along with heart rate variability (HRV) analysis, during and after the treadmill exercise period. RESULTS: The six-week exercise training resulted in a significant elevation of the average electrical conductance, which returned to the pre-training level after three months of cessation of the exercise training. CONCLUSION: HRV data have shown no similar changes, suggesting that Ryodoraku is a useful tool in detecting subtle, non-cardiovascular physical responses.

Association between serum zinc levels and basic physical functioning: secondary data analysis of NHANES 2011-14.

BACKGROUND: Serum zinc (Zn) levels have been shown to be associated with functional status; however, it is not clear whether this association differs by other sociodemographic characteristics. We examined the association between serum Zn levels and physical functioning difficulty in a representative sample of older adults in the US. DESIGN AND METHODS: A cross-sectional study was conducted on participants 50 years and older from the 2011-12 and 2013-14 National Health and Nutrition Examination Surveys (n = 1136). Serum Zn levels were analyzed as tertiles. The main outcome of interest was physical functioning difficulty, defined as self-reported difficulty of basic physical functioning that included walking, transferring, dressing, and feeding. RESULTS: Mean Zn levels (SE) were 0.67(0.1), 0.81(0.1), and 0.98(0.1) µg/mL in the low, middle, and high Zn groups, respectively. Approximately 24.9% participants reported physical functioning difficulty. In the multivariable model, we found a significant multiplicative interaction between sex and serum Zn (P for interaction =0.028) and between education and serum Zn (P for interaction = 0.001) on basic physical functioning difficulty. The stratified analysis revealed that among men, compared to those with low serum Zn, the odds of having physical functioning difficulty were lower in men who had high serum Zn [aOR 0.43 (95% CI: 0.25-0.76)]. For women, compared to those with low serum Zn the odds of having physical functioning difficulty were higher in women who had middle serum Zn [aOR 2.67 (1.58-4.50)]. Among individuals with less than high school education, the odds of having physical functioning difficulty were lower in those who had middle serum Zn compared to those who had low serum Zn [aOR 0.48 (0.26-0.89)]. However, the odds of having physical functioning difficulty were higher in those who had middle serum Zn compared to those who had low serum Zn for individuals with high school [aOR 5.72 (1.92-17.00)] and beyond high school education [aOR 1.77 (1.05-2.97)], respectively. CONCLUSION: Sex and educational attainment interact with serum Zn levels to influence basic physical functioning difficulty in older adults.

Pharmacotherapy and the risk for community-acquired pneumonia.

BACKGROUND: Some forms of pharmacotherapy are shown to increase the risk of community-acquired pneumonia (CAP). The purpose of this study is to investigate whether pharmacotherapy with proton pump inhibitors (PPI), inhaled corticosteroids, and atypical antipsychotics was associated with the increased risk for CAP in hospitalized older adults with the adjustment of known risk factors (such as smoking status and serum albumin levels). METHODS: A retrospective case-control study of adults aged 65 years or older at a rural community hospital during 2004 and 2006 was conducted. Cases (N = 194) were those with radiographic evidence of pneumonia on admission. The controls were patients without the discharge diagnosis of pneumonia or acute exacerbation of chronic obstructive pulmonary disease (COPD) (N = 952). Patients with gastric tube feeding, ventilator support, requiring hemodialysis, metastatic diseases or active lung cancers were excluded. RESULTS: Multiple logistic regression analysis revealed that the current use of inhaled corticosteroids (adjusted odds ratio [AOR] = 2.89, 95% confidence interval [CI] = 1.56-5.35) and atypical antipsychotics (AOR = 2.26, 95% CI = 1.23-4.15) was an independent risk factor for CAP after adjusting for confounders, including age, serum albumin levels, sex, smoking status, a history of congestive heart failure, coronary artery disease, and COPD, the current use of PPI, beta2 agonist and anticholinergic bronchodilators, antibiotic(s), iron supplement, narcotics, and non-steroidal anti-inflammatory drugs. The crude OR and the AOR of PPI use for CAP was 1.41 [95% CI = 1.03 - 1.93] and 1.18 [95% CI = 0.80 - 1.74] after adjusting for the above confounders, respectively. Lower serum albumin levels independently increased the risk of CAP 1.89- fold by decreasing a gram per deciliter (AOR = 2.89, 95% CI = 2.01 - 4.16). CONCLUSION: Our study reaffirmed that the use of inhaled corticosteroids and atypical antipsychotics was both associated with an increased risk for CAP in hospitalized older adults of a rural community. No association was found between current PPI use and the risk for CAP in this patient population of our study.

Serum Zinc Concentrations of Adults in an Outpatient Clinic and Risk Factors Associated With Zinc Deficiency.

CONTEXT: Subclinical features of zinc deficiency can be challenging to recognize. The prevalence of zinc deficiency based on blood zinc concentration in an adult outpatient clinic setting has not been well-studied. OBJECTIVE: To estimate the prevalence of low serum zinc concentrations among community-dwelling adults, and to characterize clinical features and risk factors associated with zinc deficiency. METHODS: This retrospective pilot prevalence study took place from 2014 to 2017 at an outpatient clinic in southeast Ohio. Patients aged 50 years or older with a stable health status were categorized into a case group with zinc deficiency (serum zinc concentration, <0.66 µg/mL) and a control group (serum zinc concentration, ≥0.66 µg/mL). Measurements included serum zinc concentration, nutritional biomarkers (ie, magnesium, calcium, albumin, and total 25-hydroxy vitamin D levels), patient history of fractures and events such as hospitalization, antibiotic use, and self-reported falls that occurred within 1 year prior to the date serum zinc concentration was measured (index date). Patients were excluded if they had a serum zinc measurement within 2 months after a hospitalization, severe renal insufficiency (3 patients with serum creatinine concentration above 2.5 mg/dL), or serum zinc concentration above 1.20 µg/mL. RESULTS: This study included 157 patients, consisting of a case group of 41 (26%) patients with zinc deficiency and a control group of 116 (74%) without zinc deficiency. Mean (SD) zinc concentrations of the case and control groups were 0.58 (0.05) µg/mL and 0.803 (0.13) µg/mL, respectively (P<.01). Patients in the case group were more likely to have had a history of hospitalization, antibiotic use, a fall within 1 year before the index date, and a history of fractures and hip fracture (P<.01 in each case). Patients taking gastric acid suppressants had increased odds of lower zinc concentrations (odds ratio, 2.24; 95% CI, 1.08-4.63). Both logistic and multivariate linear regression models revealed that past fractures, hip fractures, and hypoalbuminemia (albumin <3.5 g/dL) were associated with zinc deficiency or lower zinc concentrations. CONCLUSION: This study revealed that 26% of patients in an outpatient adult clinic had zinc deficiency based on serum concentrations. Patients with fracture history and low serum albumin were at higher risk for zinc deficiency.

Uses of proton pump inhibitors and serum potassium levels.

PURPOSE: Proton pump inhibitor (PPI) may suppress adrenal cortical steroid synthesis and release, thereby leading to electrolyte disturbances. Both hyponatremia and hyperkalemia in the setting of PPI therapy have been documented in case reports. The objective of this study was to examine the association between serum potassium (K(+)) level and PPI use. METHODS: A retrospective data analysis of hospitalized adults aged > or = 65 years during 2006, including PPI users (N = 257) and PPI non-users (N = 388), was conducted. Multiple linear and logistic regression analyses were used to assess the association between PPI use and serum K(+) level. RESULTS: PPI users [mean age (SD):79.7 (8.0) years; 70% female] had significantly higher serum K(+) levels than PPI non-users [80.2 (8.8) years; 64% female] on admission [4.13 (0.62) vs. 3.97 (0.57) mmol/L; p < 0.001]. The linear regression model revealed that > or = 2 defined daily dose (DDD) units of PPI use were a significantly positive contributor to serum K(+) levels (p = 0.021) after adjusting for age, serum creatinine levels, sex, history of diabetes, and uses of the following drugs: angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta blocker, diuretics, spironolactone, K(+) supplement, non-steroidal anti-inflammatory drugs, atypical antipsychotics, and narcotics. However, multiple logistic regression model revealed that high dose PPI therapy was not associated with an increased risk for hyperkalemia occurrence (p = 0.762). CONCLUSION: Higher serum K(+) levels were observed among PPI users when compared to PPI non-users. High daily dose PPI therapy may be an independent positive predictor of serum potassium levels.

Pyoderma Gangrenosum-Like Lesion in an Older Adult.

Pyoderma gangrenosum (PG) is a rare but serious neutrophilic dermatosis characterized by ulcerative lesions with violaceous borders. The disease mainly occurs in young or middle-aged adults. The authors present the case of a 79-year-old female nursing home patient who had an idiopathic PG-like ulcer on her lower extremity. Initial treatment with 3 courses of antibiotics and topical wound care for assumed cellulitis failed to improve the lesion, but the ulcer healed rapidly after a 1-week course of prednisone therapy (15 mg/d). This case provides insights into the challenges that arise in the diagnosis and management of PG in an older patient with extensive comorbidities. It also highlights the importance of considering PG as a diagnosis for older patients with a distinctive inflammatory ulcer that does not respond to antibiotics and topical wound care, since timely treatment with low-dose steroids can lead to quick healing by aborting the underlying autoinflammatory process.

Risk factors associated with stool retention assessed by abdominal radiography for constipation.

OBJECTIVES: To assess the reliability of applying a radiographic scoring system in estimating the severity of stool retention (SR) in hospitalized older adults with constipation, and to identify risk factors associated with clinical constipation and SR scores. DESIGN: Retrospective, case series study. SETTING: Southeast Ohio community hospital. PARTICIPANTS: Adults 65 years or older with constipation or fecal impaction and abdominal radiographs available (N=122). Bowel obstruction was excluded. MEASUREMENT: Radiographs were independently scored by four readers twice, "5" being the most severe, for each quadrant of an abdominal film; possible total score was 0 to 20. Clinical constipation was defined as an average SR score of 13 or higher. Intra-class correlation was used to measure inter-rater agreement. RESULTS: The overall inter-rater agreement on abdominal radiograph readings was 0.91, 95% confidence interval (CI)=0.88-0.93. Clinical constipation was associated with the use of statins and antimuscarinics by univariate logistic regression analysis. After adjusting for age, sex, residency, smoking history, oral laxatives, and self-reported constipation, the use of statins remained significantly associated with clinical constipation (OR=3.86, 95% CI=1.08-13.77, P=.036). Univariate linear regression analysis revealed that higher SR scores were associated with community residency, self-reported constipation, and the use of statins and antimuscarinics. After adjusting for the above confounders by multiple linear regression analyses, the use of antimuscarinics was independently associated with higher SR score (ß=1.769, 95% CI=0.008-3.531, P=.049). CONCLUSION: Abdominal radiography was reliable in assessing the severity of SR in older adults with constipation. The use of statins and antimuscarinics was associated with clinical constipation and greater SR.

Interexpert agreement on diagnosis of bacteriuria and urinary tract infection in hospitalized older adults.

CONTEXT: Although bacteriuria with acute coexisting illness is common in hospitalized older adults, distinguishing it from urinary tract infection (UTI) can be challenging. OBJECTIVES: To examine the rate of agreement between two geriatricians in distinguishing UTI from asymptomatic bacteriuria (ASB). To analyze the incidence of associated acute comorbidities and determine if an association exists between clinical manifestations and bacteriuria status on acute hospital admission. METHODS: Two physicians conducted a retrospective analysis of 296 inpatient records, including 142 records from age- and condition-matched nonbacteriuria control subjects. Using consensus criteria to diagnose UTI vs ASB, these independent experts evaluated inpatient records, including admission and discharge diagnoses as well as urinalysis results. A kappa statistic was used to determine reviewer agreement. Risk assessment was measured by odds ratio with a 95% confidence interval. RESULTS: Expert agreement for the diagnosis of UTI and ASB was 98% and 44%, respectively. Agreement was reached at a level greater than chance (z=6.74, P<.001, kappa=0.49). In the 30 cases where interexpert agreement was not reached, half of the subjects had acute pulmonary disease. Symptom crossover for this comorbid condition is the likely cause for lack of diagnostic agreement. Among other conditions observed, delirium was most common in UTI subjects. CONCLUSION: Limited interexpert agreement seemed to result from difficulty in diagnosing patients who had no local symptoms but acute comorbid conditions with potential symptom crossover. Among the conditions observed in our sample population, delirium was most closely associated with UTI.

Hemolysis and hyperhomocysteinemia caused by cobalamin deficiency: three case reports and review of the literature.

Concurrent hemolysis in patients with vitamin B12 deficiency is a well-recognized phenomenon and has been attributed to intramedullary destruction of erythrocytes (ineffective erythropoiesis). Recent studies revealed that homocysteine increased the risk of hemolysis in vitamin B12 deficiency in vitro and there is a high frequency (30%) of vitamin B12 deficiency in asymptomatic patients with homozygous methylene tetrahydrofolate reductase (MTHFR) C677T mutation, a known cause of hyperhomocysteinemia. Here we report three patients with MTHFR mutations and vitamin B12 deficiency presenting with hemolytic anemia and severely elevated homocysteine levels. Patients demonstrated complete resolution of hemolysis with simultaneous normalization of serum homocysteine levels after vitamin B12 treatments. We reviewed pertinent literature, and hypothesized that hemolytic anemia may be more prevalent in patients who have a coexisting MTHFR gene mutation and vitamin B12 deficiency possibly related to severely elevated homocysteine levels. The hemolysis in these cases occurred predominantly in peripheral blood likely due to the combined effects of structurally defective erythrocytes and homocysteine-induced endothelial damage with microangiopathy.

Megacolon and stercoral proctitis after frequent fecal impactions: report of an unusual case and review of the literature.

Persistent megacolon that results from frequent episodes of fecal impaction without adequate treatment is a rare and seldom reported condition in the elderly. This report discusses a 72-year-old white woman presenting with a large abdominal mass, who had at least 4 episodes of radiographically demonstrated fecal impaction over the previous year without adequate treatment. The patient required hospitalization for a bleeding rectal ulcer during the second episode of fecal impaction. Computed tomography (CT) scans on this admission revealed a dilated colon up to 16 x 14 cm in maximal dimensions extending over 30 cm, filled with massive fecal material. Several follow-up abdominal radiographs revealed a persistent megacolon after 10 months despite the absence of significant fecal material in the rectosigmoid colon. While multiple contributing factors were likely involved in her frequent fecal impactions, the clinical course of this case suggests that frequent fecal impactions without adequate treatment can lead to megacolon in high-risk patients. Clinicians should aggressively treat fecal impaction and monitor the adequacy of treatment with abdominal radiography in order to avoid significant complications. Complications and management of fecal impaction and the pathophysiology of megacolon in the literature are reviewed and discussed.