Zoledronic acid and bone health in older adults with cognitive impairment.

Fracture prevention in cognitively impaired individuals is lacking. This work highlights the benefits of zoledronic acid on bone health in cognitively impaired older adults. Demonstrating benefits of therapy may increase treatment uptake and reduce fracture risk in this group. INTRODUCTION: Osteoporosis has detrimental consequences for frail older adults. The effects on those with both osteoporosis and cognitive impairment are compounded due to increased risk of falls and changes in mobility, both of which can lead to fracture. However, there are limited data on treatment benefits for osteoporotic individuals with cognitive impairment. METHODS: This post hoc, secondary analysis of data from a randomized, double-blind, placebo-controlled clinical trial of single-dose zoledronic acid included 179 women age ≥ 65 years residing in assisted living facilities or nursing homes, 43 of whom had mild to severe cognitive impairment. We assessed bone mineral density (BMD) of the total hip, femoral neck, and lumbar spine by dual-energy x-ray absorptiometry and serum bone turnover markers (C-terminal telopeptide of type I collagen and procollagen type I N propeptide) at 6 and 12 months. RESULTS: In participants with cognitive impairment, those who received zoledronic acid had 4.3% greater BMD at the total hip (p=.005) and 5.3% greater BMD at the femoral neck (p<.001) after 12 months compared to those in the placebo group. Bone turnover markers demonstrated significant decreases at 6 months in those with cognitive impairment who received active treatment compared to the placebo group. Improvements in bone health measures with zoledronic acid were similar to those seen in participants without cognitive impairment. CONCLUSION: Zoledronic acid improves bone health in frail older women with cognitive impairment similar to those without impairment. Further studies are warranted to assess the benefit for fracture reduction in this undertreated population.

Vitamin D deficiency is associated with functional decline and falls in frail elderly women despite supplementation.

We examined the impact of daily supplementation on vitamin D deficiency, function, and falls in female long-term care residents. Initial vitamin D deficiency was associated with greater functional decline and increased fall risk despite guideline-recommended supplementation, highlighting the importance of preventing vitamin D deficiency in frail elderly. INTRODUCTION: Institute of Medicine (IOM) guidelines recommend 800 IU vitamin D daily for older adults and maintaining serum 25-hydroxyvitamin D [25(OH) D] above 20 ng/ml for optimal skeletal health. The adequacy of IOM guidelines for sustaining function and reducing falls in frail elderly is unknown. METHODS: Female long-term care residents aged ≥65 enrolled in an osteoporosis clinical trial were included in this analysis (n = 137). Participants were classified based on baseline 25(OH) D levels as deficient (<20 ng/ml, n = 26), insufficient (20-30 ng/ml, n = 40), or sufficient (>30 ng/ml, n = 71). Deficient women were provided initial vitamin D repletion (50,000 IU D3 weekly for 8 weeks). All were supplemented with 800 IU vitamin D3 daily for 24 months. Annual functional assessments included Activities of Daily Living (ADLs), Instrumental ADL (IADL), physical performance test (PPT), gait speed, cognition (SPMSQ), and mental health (PHQ-9). We used linear mixed models for analysis of functional measures and logistic regression for falls. RESULTS: Daily supplementation maintained 25(OH) D levels above 20 ng/ml in 95% of participants. All groups demonstrated functional decline. Women initially deficient had a greater decline in physical function at 12 (IADL -2.0 ± 0.4, PPT -3.1 ± 0.7, both p < 0.01) and 24 months (IADL -2.5 ± 0.6, ADL -2.5 ± 0.6, both p < 0.01), a larger increase in cognitive deficits at 12 months (1.7 ± 0.4: p = 0.01) and more fallers (88.5%, p = 0.04) compared to those sufficient at baseline, despite supplementation to sufficient levels. CONCLUSIONS: IOM guidelines may not be adequate for frail elderly. Further study of optimal 25(OH) D levels for maintaining function and preventing falls is needed.

Novel proteases with unusual specificities.

This review describes specific proteases that have been implicated in several interesting biological systems. Proteases have been selected for discussion in those instances where natural substrates appear to have been identified. The studies reviewed point to the critical role that proteases play in protein processing and degradation.

Leukocyte adhesion to vascular endothelium induces E-selectin linkage to the actin cytoskeleton.

We have examined functions of the cytoplasmic domain of E-selectin, an inducible endothelial transmembrane protein, especially its ability to associate with the cytoskeleton during leukocyte adhesion. Confocal microscopy of interleukin-1 beta (IL-1 beta)-activated human umbilical vein endothelial cells (HUVEC) visualized clustering of E-selectin molecules in the vicinity of leukocyte-endothelial cell attachment sites. A detergent based extraction and Western blotting procedure demonstrated an association of E-selectin with the insoluble (cytoskeletal) fraction of endothelial monolayers that correlated with adhesion of leukocytes via an E-selectin-dependent mechanism. A mutant form of E-selectin lacking the cytoplasmic domain (tailless E-selectin) was expressed in COS-7 cell and supported leukocyte attachment (in a nonstatic adhesion assay) in a fashion similar to the native E-selectin molecule, but failed to become associated with the cytoskeletal fraction. To identify the cytoskeletal components that associate with the cytoplasmic domain of E-selectin, paramagnetic beads coated with the adhesion-blocking anti-E-selectin monoclonal antibody H18/7 were incubated with IL-1 beta-activated HUVEC, and then subjected to detergent extraction and magnetic separation. Certain actin-associated proteins, including alpha-actinin, vinculin, filamin, paxillin, as well as focal adhesion kinase (FAK), were copurified by this procedure, however talin was not. When a mechanical stress was applied to H18/7-coated ferromagnetic beads bound to the surface of IL-1 beta-activated HUVEC, using a magnetical twisting cytometer, the observed resistance to the applied stress was inhibited by cytochalasin D, thus demonstrating transmembrane cytoskeletal mechanical linkage. COS-7 cells transfected with the tailless E-selectin failed to show resistance to the twisting stress. Taken together, these data indicate that leukocyte adhesion to cytokine-activated HUVEC induces transmembrane cytoskeletal linkage of E-selectin through its cytoplasmic domain, a process which may have important implications for cell-cell signaling as well as mechanical anchoring during leukocyte-endothelial adhesive interactions.

Nuclear factor-kappa B interacts functionally with the platelet-derived growth factor B-chain shear-stress response element in vascular endothelial cells exposed to fluid shear stress.

Hemodynamic forces, such as fluid shear stress, that act on the endothelial lining of the cardiovascular system can modulate the expression of an expanding number of genes crucial for homeostasis and the pathogenesis of vascular disease. A 6-bp core element (5'-GAGACC-3'), defined previously as a shear-stress response element is present in the promoters of many genes, including the PDGF B-chain, whose expression is modulated by shear stress. The identity of the nuclear protein(s) binding to this element has not yet been elucidated. Using electrophoretic mobility shift assays and in vitro DNase I footprinting, we demonstrate that nuclear factor-kappa B p50-p65 heterodimers, which accumulate in the nuclei of cultured vascular endothelial cells exposed to fluid shear stress, bind to the PDGF-B shear-stress response element in a specific manner. Mutation of this binding motif abrogated its interaction with p50-p65 and abolished the ability of the promoter to mediate increased gene expression in endothelial cells exposed to shear stress. Transient cotransfection studies indicate that p50-p65 is able to activate PDGF-B shear-stress response element-dependent reporter gene expression in these cells. These findings thus implicate nuclear factor-kappa B in the transactivation of an endothelial gene responding to a defined fluid mechanical force.

Shear stress selectively upregulates intercellular adhesion molecule-1 expression in cultured human vascular endothelial cells.

Hemodynamic forces induce various functional changes in vascular endothelium, many of which reflect alterations in gene expression. We have recently identified a cis-acting transcriptional regulatory element, the shear stress response element (SSRE), present in the promoters of several genes, that may represent a common pathway by which biomechanical forces influence gene expression. In this study, we have examined the effect of shear stress on endothelial expression of three adhesion molecules: intercellular adhesion molecule-1 (ICAM-1), which contains the SSRE in its promoter, and E-selectin (ELAM-1) and vascular cell adhesion molecule-1 (VCAM-1), both of which lack the SSRE. Cultured human umbilical vein endothelial cells, subjected to a physiologically relevant range of laminar shear stresses (2.5-46 dyn/cm2) in a cone and plate apparatus for up to 48 h, showed time-dependent but force-independent increases in surface immunoreactive ICAM-1. Upregulated ICAM-1 expression was correlated with increased adhesion of the JY lymphocytic cell line. Northern blot analysis revealed increased ICAM-1 transcript as early as 2 h after the onset of shear stress. In contrast, E-selectin and vascular cell adhesion molecule-1 transcript and cell-surface protein were not upregulated at any time point examined. This selective regulation of adhesion molecule expression in vascular endothelium suggests that biomechanical forces, in addition to humoral stimuli, may contribute to differential endothelial gene expression and thus represent pathophysiologically relevant stimuli in inflammation and atherosclerosis.

Retrotransposon transposition intermediates are encapsidated into virus-like particles.

Virus-like particles (VLPs) possessing reverse transcriptase activity are persistently present in Drosophila melanogaster cultured cells and are formed in yeast induced for transposition. Different retrotransposon transposition intermediates consistent with those expected from the model of reverse transcription pathway of retrotransposon transposition have been detected during the analysis of nucleic acids isolated from VLPs. These data indicate that the act of reverse transcription takes place in VLPs which may be considered as functional intermediates of transposition.

Skeletal integrity in premenopausal and postmenopausal women receiving long-term L-thyroxine therapy.

PURPOSE: The impact of long-term L-thyroxine replacement therapy on skeletal integrity is a growing concern because of the large number of women receiving thyroid hormone therapy. The purpose of this study was to examine the hypothesis that long-term L-thyroxine therapy in which the free thyroxine index (FT4I) is maintained within a physiologic range has minimal impact on vertebral or femoral bone mineral density in both premenopausal and postmenopausal women. PATIENTS AND METHODS: We measured hip integral and spinal trabecular and integral bone densities in 28 premenopausal and 28 postmenopausal women who had been receiving L-thyroxine therapy for a median of 12 and 15 years, respectively, and in whom therapy was titrated to keep the FT4I within the normal range. The relationship between bone density parameters and thyroid hormone status was examined using univariate and multivariate statistical methods. RESULTS: Seventy-nine percent of the premenopausal women and 86% of the postmenopausal women had FT4I values in the normal range at the time of bone density determination. Moreover, throughout the study's duration, the majority of annually measured values were in the normal range for more than 80% of subjects. Premenopausal women had slightly lower bone density than would be expected for age: -6.7% (z = -0.39 +/- 0.74 [mean +/- SD], p less than 0.01), -3.1% (z = -0.22 +/- 0.78, p = 0.15), and -5.1% (z = -0.36 +/- 0.74, p less than 0.02) for spinal trabecular, spinal integral, and hip integral bone density, respectively. Postmenopausal women likewise had slightly lower bone density values that were significant only at the hip: -0.2% (z = -0.01 +/- 1.01, p = 0.95), -1.0% (z = -0.05 +/- 1.11, p = 0.80), and -6.2% (z = -0.39 +/- 0.80, p less than 0.02) for spinal trabecular, spinal integral, and hip integral bone density, respectively. When patients with previously treated Graves' disease (n = 4 in each group) were eliminated, the differences in bone density at the hip were no longer seen. Correlation analysis revealed only weak and generally nonsignificant relationships between parameters of thyroid hormone status and bone density at any site in either subgroup. Results of multiple regression analysis among the pooled data of all subjects showed that age provided a consistently significant contribution (R2 = 0.18 to 0.66) to the variability in bone density at the spine and the hip, but parameters of thyroid hormone status did not. CONCLUSION: These data provide the first supportive evidence that long-term L-thyroxine therapy that maintains the FT4I in the physiologic range is associated with a statistically significant, but clinically minimal, decrement in spinal and hip bone density in both premenopausal and postmenopausal women. The decrement at the hip was entirely due to the inclusion of patients with treated Graves' diseases. Thus, the changes in bone density in women receiving long-term L-thyroxine therapy are minimal at most and should not be a contraindication to therapy.

Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly.

PURPOSE: To determine the importance of fall characteristics, body habitus, function, and hip bone mineral density as independent risk factors for hip fracture in frail nursing home residents. SUBJECTS AND METHODS: In this prospective, case-control study of a single, long-term care facility, we enrolled 132 ambulatory residents (95 women and 37 men) aged 65 and older, including 32 cases (fallers with hip fracture) and 100 controls (fallers with no hip fracture). Principal risk factors included fall characteristics, body habitus, measures of functional assessment, and hip bone mineral density by dual-energy X-ray absorptiometry. RESULTS: In multivariate analysis, including only those with knowledge of the fall direction (n=100), those who fell and suffered a hip fracture were more likely to have fallen sideways (odds ratio 5.7, 95% confidence interval [CI] 1.7 to 18, P= 0.004) and have a low hip bone mineral density (odds ratio 1.9, 95% CI 0.97 to 3.7, P=0.06) than those who fell and did not fracture. When all participants were included (n=132) and subjects who did not know fall direction were coded as not having fallen to the side, a fall to the side (odds ratio 3.9, 95% CI 1.3 to 11, P=0.01), low hip bone density (odds ratio 1.8, 95% CI 1.03 to 3, P=0.04), and impaired mobility (odds ratios 6.4, 95% CI 1.9 to 21, P=0.002) were independently associated with hip fracture. Sixty-seven percent of subjects (87% with and 62% without hip fracture) had a total hip bone mineral density greater than 2.5 SD below adult peak bone mass and were therefore classified as having osteoporosis using World Health Organization criteria. CONCLUSIONS: Among frail elderly nursing home fallers, the preponderance of whom are osteoporotic, a fall to the side, a low hip bone density, and impairment in mobility are all important and independent risk factors for hip fracture. These data suggest that, among the frailest elderly, measures to reduce the severity of a sideways fall and improve mobility touch on new domains of risk, independent of bone mineral density, that need to be targeted for hip fracture prevention in this high-risk group.

Special communicationthe critical role of mechanical forces in blood vessel development, physiology and pathology

The following extended abstracts were presented at the Research Initiatives in Vascular Disease Conference, Movers and Shakers in the Vascular Tree-Hemodynamic and Biomechanical Factors in Blood Vessel Pathology, sponsored by The Lifeline Foundation and the Cardiovascular & Interventional Radiology Research and Educational Foundation; jointly sponsored by the International Society for Cardiovascular Surgery, North American Chapter, The Society for Vascular Surgery, and The Society of Cardiovascular and Interventional Radiology; in cooperation with the National Institutes of Health-National Heart, Lung &Blood Institute on Mar 11-12, 1999, in Bethesda, Md.

Implications of the most bothersome prostatism symptom for clinical care and outcomes research.

OBJECTIVES: Because treatment of benign prostatic hyperplasia (BPH) is based largely on patients' symptoms, understanding and measuring the impact of these symptoms from the patient's perspective is critically important for clinical care. Such knowledge also is crucial for comparing patient-weighted outcomes because the increasing array of medical and surgical BPH treatments differ in their impact on specific symptoms. Our purpose was to determine the most bothersome symptom in older men seeking evaluation for symptomatic BPH and to examine whether age, comorbidity, or urodynamic evidence of prostatic obstruction were important covariates. DESIGN: Prospective evaluation of a consecutive series. SETTING: Veterans Affairs urology clinic. PARTICIPANTS: 115 men (age 69 +/- 6 years) presenting for initial evaluation of prostatism. MEASUREMENTS: Scores on standard symptom index and patients' reports of the most bothersome symptom. Bladder outlet obstruction was assessed by multichannel videourodynamic evaluation. RESULTS: An "irritative" symptom (frequency, urgency, or nocturia) was cited as most bothersome significantly more often than an "obstructive" symptom (weak stream, hesitancy, etc.) (53 vs. 35%, P < .05); older men were significantly more likely to name an irritative symptom as most bothersome (chi 2 for trend = 6.63, P < .025). Even among men with prostate obstruction, most cited an irritative symptom as the most bothersome, regardless of the severity of obstruction. These associations were not confounded by comorbid conditions or medications that independently may cause symptoms. CONCLUSIONS: Because irritative symptoms are most bothersome, have a diverse differential diagnosis, and do not respond as well to BPH treatment, neither providers nor researchers should rely solely on global assessments of symptom severity and bother in assessing men with voiding symptoms. Additional focus on individual symptom impact and etiology is needed, especially in older men.

Delirium is independently associated with poor functional recovery after hip fracture.

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.

Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure.

OBJECTIVE: To develop a condition-specific measure for assessing the impact of urge urinary incontinence (UI) on the quality of life (QoL) of older persons. DESIGN: A 32-item Urge Impact Scale (URIS) was drafted using content area data from focus groups composed of urge incontinent older persons. Pilot testing in 21 urge incontinent persons (mean age 67.7 years) resulted in the elimination of eight items by internal consistency, skew, and patient response criteria. The resulting scale (URIS-24) was tested for reliability (internal consistency and test-retest correlation) and construct validity (correlation with UI severity from voiding records) in a separate group of 27 urge incontinent persons (89% women, mean age 72 years). Factor analysis of URIS-24 data from the combined 48 persons was used to explore the conceptual structure underlying urge UI-related QoL. SETTING: University-affiliated community-based practice and tertiary hospital. PARTICIPANTS: Community-dwelling women and men, older than age 60 and with urge incontinence at least twice weekly, recruited from newspaper, newsletter, and radio advertisements. RESULTS: Cronbach's alpha for URIS-32 was 0.84, and for URIS-24 it was 0.94. When administered (mean +/- standard deviation) 9.2 +/- 5.1 days apart, URIS-24 had good test-retest reliability for total scores (interclass coefficient = .88, concordance coefficient = .88), and individual item scores at time 2 were within 1 point (on a 5-category Likert scale) of time 1 answers for 89% of responses. URIS-24 scores had modest but nearly significant correlation with the number of UI episodes (r = -0.39, P = .05). Factor analysis revealed a three component structure corresponding to psychological burden, perception of personal control, and self concept. CONCLUSIONS: The URIS-24 is an internally-consistent, highly reproducible tool for the assessment of the QoL impact of urge UI on older persons. It can be used to evaluate QoL impact by specific items as well as by overall score. Compared with other UI-specific QoL measures, the URIS-24 had similar or superior internal consistency, test-retest reliability, and validity, but it is the first measure designed and tested specifically for older persons with urge UI. These results also highlight the multifactorial structure of urge UI-related QoL and the importance of its psychological dimensions.

The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style.

OBJECTIVES: The impact of urinary incontinence (UI) on health-related quality of life (QoL) is significant yet variable, but little is known about patient-defined content areas regarding the influence of UI on QoL and whether patient-specific factors correlate with specific content areas of UI-related QoL. In order to identify the most valid content areas for a new UI-related QoL questionnaire, our primary goal was to determine the content areas of greatest concern regarding UI-related QoL among older persons with urge incontinence. The second goal was to examine the possible role of patients' explanatory style as a mediator of UI impact on health-related QoL. Data on the questionnaire will be presented elsewhere. DESIGN: Focus groups comprising urge-incontinent persons were used to obtain verbatim descriptions of the impact of UI on QoL. SETTING: A university-affiliated tertiary hospital. PARTICIPANTS: Community-dwelling women (n = 25) and men (n = 5) more than 60 years of age, with urge incontinence, recruited from newspaper, newsletter, and radio advertisements. MEASUREMENTS: Qualitative content analysis of focus group transcripts was used to determine QoL items. These were compared with previously described UI-related QoL items obtained from the literature. Subjects' statements regarding causes of UI were evaluated for predominant explanatory style. RESULTS: Thirty-two UI-related QoL items were identified, more than half of which were not described previously. Compared with expert-defined UI-related QoL items from the literature, patient-defined items focused more on coping with embarrassment and interference from UI than on prevention of actual activity performance. Explanatory statements were made frequently by patients talking about their UI. Although positive style explanatory statements were most common, they did not correlate with any QoL items. By contrast, there was a significant correlation between negative explanatory style and six specific UI-related QoL items. CONCLUSIONS: Focus groups of older persons with urge incontinence suggest that experts and patients view the impact of urge UI on QoL differently. Whereas experts focus more on functional impact, patients more often cite the impact of UI on their emotional well-being and on the interruption of activities. In addition, the association between negative explanatory style and specific UI-related QoL items suggests that explanatory style may be an important mediator of patients' perceptions of UI-related QoL.

Improving the utility of urine flow rate to exclude outlet obstruction in men with voiding symptoms.

OBJECTIVES: Many older men with voiding symptoms do not have bladder outlet obstruction (BOO) but have conditions amenable to medical treatment. If primary care providers could reliably exclude men who have BOO, then they could initiate appropriate evaluation and treatment in a substantial proportion of the remainder. Urine flow rate, although widely used, is insufficiently sensitive to exclude BOO reliably. We investigated whether the decline in flow rate with age could be utilized to improve the utility of flow rate for excluding BOO in symptomatic men, especially when combined with knowledge of the patient's postvoiding residual volume (PVR). DESIGN: Prospective study using two patient cohorts. SETTINGS: A Veterans Affairs urology clinic serving community-dwelling and institutionalized healthy older men. PARTICIPANTS: 111 men with voiding symptoms (mean age 72.4 +/- 9.2 years). MEASUREMENTS: Maximum urine flow rate, measured with standard flowmeter, and PVR, measured by catheterization. BOO was determined by multichannel videourodynamic testing. RESULTS: The sensitivity of flowrate for BOO increased significantly with age (P = .0001) and did not appear to be confounded by comorbid conditions. An algorithm incorporating age, flow rate, and PVR had a sensitivity of 90%, specificity of 43%, and accuracy of 74% in screening for BOO. The algorithm's sensitivity was better than that of flow rate alone (55%); its sensitivity was also similar to a "refer all" strategy (100%) but had improved specificity (41% vs 0%). CONCLUSIONS: Flow rate alone is insufficiently sensitive as a screening test to exclude BOO, but a simple diagnostic algorithm using age, flowrate, and PVR was more sensitive and accurate. This algorithm allows primary care evaluation and initial management of men with voiding symptoms while potentially reducing unnecessary referrals and costs.

Urinary incontinence knowledge among community-dwelling people 65 years of age and older.

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE). DESIGN: An intact-group pretest-posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI. PARTICIPANTS: A random sample of community-dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140). MEASUREMENT: A 14-item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participants answers to the quiz were part of a 20-minute telephone interview. RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of "don't know" responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses. CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.

The prevalence of potentially remediable urinary incontinence in frail older people: a study using the Minimum Data Set.

OBJECTIVES: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population. DESIGN: Cross-sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS. SETTING: 270 Medicaid-certified nursing homes in 10 states. PARTICIPANTS: A total of 2014 nursing home residents 60 years or older (mean = 84.3 +/- 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size. MEASUREMENTS: Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints). RESULTS: Forty-nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2,5.6), dementia (OR = 2.3;CI = 1.8,3.0), restraints-trunk (OR = 1.7; CI = 1.5,2.0), chair (OR = 1.4; CI = 1.2,1.6), bedrails (OR = 1.3; CI = 1.1,1.5), and use of antianxiety/hypnotic medications (OR = .7;CI = .5,1.0) (all P < .04). CONCLUSIONS: Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.

Short-term variability of self report of incontinence in older persons.

OBJECTIVE: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self-reported continence status. The goal of this study was to assess the reliability of this measure in older adults. DESIGN: Telephone interviews administered approximately 2 weeks apart. SETTING: Community-based congregate living facility. PARTICIPANTS: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women > 70 years old (79% > 80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent. MEASUREMENT: Responses to a structured questionnaire. MAIN RESULTS: The prevalence of urinary incontinence was 40% at baseline and 44% on re-interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67-.69. CONCLUSION: Prevalence estimates of incontinence are stable over a 2-week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community-dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.

Reducing delirium after hip fracture: a randomized trial.

OBJECTIVES: Delirium (or acute confusional state) affects 35% to 65% of patients after hip-fracture repair, and has been independently associated with poor functional recovery. We performed a randomized trial in an orthopedic surgery service at an academic hospital to determine whether proactive geriatrics consultation can reduce delirium after hip fracture. DESIGN: Prospective, randomized, blinded. SETTING: Inpatient academic tertiary medical center. PARTICIPANTS: 126 consenting patients 65 and older (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment through interviews with patients and designated proxies and review of medical records was performed at enrollment to ascertain prefracture status. Subjects were then randomized to proactive geriatrics consultation, which began preoperatively or within 24 hours of surgery, or "usual care." A geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol. To ascertain study outcomes, all subjects underwent daily, blinded interviews for the duration of their hospitalization, including the Mini-Mental State Examination (MMSE), the Delirium Symptom Interview (DSI), and the Memorial Delirium Assessment Scale (MDAS). Delirium was diagnosed using the Confusion Assessment Method (CAM) algorithm. RESULTS: The 62 patients randomized to geriatrics consultation were not significantly different (P>.1) from the 64 usual-care patients in terms of age, gender, prefracture dementia, comorbidity, type of hip fracture, or type of surgical repair. Sixty-one percent of geriatrics consultation patients were seen preoperatively and all were seen within 24 hours postoperatively. A mean of 10 recommendations were made throughout the duration of the hospitalization, with 77% adherence by the orthopedics team. Delirium occurred in 20 /62 (32%) intervention patients, versus 32 / 64 (50%) usual-care patients (P =.04), representing a relative risk of 0.64 (95% confidence interval (CI) = 0.37-0.98) for the consultation group. One case of delirium was prevented for every 5.6 patients in the geriatrics consultation group. There was an even greater reduction in cases of severe delirium, occurring in 7/ 60 (12%) of intervention patients and 18 / 62 (29%) of usual-care patients, with a relative risk of 0.40 (95% CI = 0.18-0.89). Despite this reduction in delirium, length of stay did not significantly differ between intervention and usual-care groups (median +/- interquartile range = 5 +/- 2 days in both groups), likely because protocols and pathways predetermined length of stay. In subgroup analyses, geriatrics consultation was most effective in reducing delirium in patients without prefracture dementia or activities of daily living (ADL) functional impairment. CONCLUSIONS: Proactive geriatrics consultation was successfully implemented with good adherence after hip-fracture repair. Geriatrics consultation reduced delirium by over one-third, and reduced severe delirium by over one-half. Our trial provides strong preliminary evidence that proactive geriatrics consultation may play an important role in the acute hospital management of hip-fracture patients.

Difficulty with holding urine among older persons in a geographically defined community: prevalence and correlates.

OBJECTIVE: The goal of this study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. DESIGN: Population-based cross-sectional study. SUBJECTS: A population census identified all residents aged 65 years and older residing in East Boston, Massachusetts, in 1982. MEASURES: Data collected via in-home interviews were used to estimate the prevalence of difficulty holding urine and to provide information regarding potential correlates of urinary difficulty. RESULTS: Of the 3809 study participants (85% response rate), 28% reported having "difficulty holding urine until they can get to a toilet" at least some of the time, and 8% reported difficulty "most" or "all of the time." Difficulty was associated with age and sex; 44% of women and 34% of men reported some difficulty (P < .001), and 9% of women and 6% of men (P < .001) reported difficulty most or all of the time. For respondents aged 65 to 74 years, 40% reported some difficulty, compared with 47% of those aged 85 and older (Ptrend < .001); difficulty most or all of the time was reported by 6% of those aged 65 to 74 and 12% of those aged 85 and older (Ptrend < .001). Difficulty holding urine was associated with important health and functional measures including depression, stroke, chronic cough, night awakening, fecal incontinence, problems with activities of daily living, decreased frequency and ease in getting out of the house, and poor self-perception of health. CONCLUSIONS: Difficulty holding urine is a prevalent condition among older people living in the community and is associated highly with a number of health conditions and functional problems.