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PubMed2006

Interplay of stress and physical inactivity on muscle loss: Nutritional countermeasures.

Inactivity-mediated protein catabolism occurs in many circumstances ranging from catastrophic events such as severe illness or injury, to unique environments such as spaceflight/microgravity, to more insidious causes such as physical frailty and the progression of aging. Nevertheless, regardless of the etiology, the consequences of inactivity are readily observable and debilitating. Mechanistically, the loss of lean body mass during inactivity is the result of a chronic imbalance between muscle protein synthesis and breakdown. When inactivity is accompanied by the stress of trauma or disease, the rate of muscle protein catabolism can increase several fold. Bed rest studies in healthy volunteers provide a unique opportunity to examine the mechanisms contributing to muscle loss and evaluate strategies for intervention that may slow muscle catabolism and promote anabolism. The prerequisite for muscle protein synthesis and the most readily adaptable stimulus is dietary-derived amino acids. This review focuses on the role of amino acid supplementation in the maintenance of skeletal muscle mass during age-related and clinically mandated inactivity.

Adult↗

PubMed2006

Completion of therapy by Medicare patients with stage III colon cancer.

BACKGROUND: Certain factors, such as race or age, are known to be associated with variation in initiation of adjuvant chemotherapy for stage III colon cancer, but little is known about what factors are associated with completion of adjuvant therapy. To determine whether predictors of initiation also predict completion, we analyzed Surveillance, Epidemiology, and End Results (SEER) program data linked to Medicare claims. We investigated mortality as a means to testing the validity of the completion measure that we created. METHODS: We studied 3193 stage III colon cancer patients whose diagnosis was recorded in 1992-1996 SEER program data linked to 1991-1998 Medicare claims and who initiated adjuvant chemotherapy after colon cancer resection. We defined a measure of adjuvant chemotherapy completion as one chemotherapy administration claim in a month. We tested the validity of the created measure and its relation to 3-year cancer mortality adjusted for demographic, clinical, and environmental variables. We explored the association of patient characteristics and treating physician characteristics with chemotherapy completion by use of multivariable logistic regression modeling. RESULTS: Of the 3193 patients, 2497 (78.2%) completed the course. Risk of cancer-related mortality was statistically significantly lower among those completing chemotherapy (relative risk = 0.79, 95% confidence interval = 0.69 to 0.89) than those with no adjuvant therapy. Patients who were female, widowed, increasingly elderly, rehospitalized, and living in certain regions were less likely to complete adjuvant chemotherapy than other patients. Race and other clinical, environmental, and physician characteristics were not associated with completion of therapy. CONCLUSIONS: Factors associated with incomplete adjuvant chemotherapy may represent physical frailty, treatment complications, and lack of social and psychological support. Interventions to mitigate these influences are a logical next step toward increasing chemotherapy completion rates.

Aged↗

PubMed2003

Audit in occupational medicine: an audit of fitness to drive among voluntary drivers in an NHS trust.

BACKGROUND: A health surveillance programme, to assess fitness to drive, was initiated for voluntary drivers in an NHS Trust because of reports of increasing frailty and slow reactions among some drivers. After discussion between the occupational health department, voluntary services manager and personnel department it was considered appropriate to apply Driver and Vehicle Licensing Authority (DVLA) Group 2 fitness to drive standards to those voluntary drivers who drove the Trusts minibuses. RESULTS: An audit of the initial health surveillance of 47 drivers is presented. The mean age of the voluntary drivers was 66.4 years. A large number of medical problems with the potential to affect driving were discovered (average of 1.9 medical problems per driver). The outcome was that five voluntary drivers were found unfit to drive the hospital minibus and one voluntary driver was found unfit for car driving. CONCLUSIONS: A fitness assessment form for drivers is presented. This form is primarily for the use of occupational health nurses, to help them to decide when referral to an occupational health physician is indicated.

Aged↗

PubMed1999

Dynamics of cognitive aging: distinguishing functional age and disease from chronologic age in a population.

This paper introduces a methodological approach to the dynamics of cognitively normal (i.e., successful) aging compared with aging accompanied by different types of cognitive impairment and dementia. Using secondary analysis of a national representative database (Canadian Study of Health and Aging, 1991-1992), the authors show that the occurrence of an adverse event (symptom, sign, or disease), or the accumulation of a number of events, may be modeled as a logistic function of chronologic age in a population. In the cognitively normal, a linear relation between the logarithm of the odds of events and chronologic age was present for the majority of symptoms and signs. This regression represents the accumulation of each sign in a cognitively successful, aging population. The authors then estimated which ages for this cognitively unimpaired group correspond to the odds of the occurrence of symptoms found for a cognitively impaired population at any given chronologic age. This may be regarded as functional age, based upon the accumulation of a particular functional deficit in the impaired population, analogous to the concept of frailty. The dynamics of aging are a complex process of accumulation of deficits (morbidity), whereby decline from some previously healthy level of synergistically associated symptoms and signs results in distinct patterns of disease and staging. The modeling of these dynamics takes us a step further toward the definition and refinement of disease and normal aging.

Aged↗

PubMed1987

The prevalent cohort study and the acquired immunodeficiency syndrome.

The acquired immunodeficiency syndrome (AIDS) is caused by a retrovirus, the human immunodeficiency virus (HIV). A rapid and convenient method to identify additional cofactors or risk modifiers and markers of disease progression is to study a cohort prevalent with HIV antibody. However, because the time of viral infection is usually unknown in the cohort, there are several potential sources of bias. Three sources of bias in a prevalent cohort study are identified assuming a proportional hazards model: onset confounding, differential length-biased sampling, and frailty selection. A number of problems in the interpretation of results on markers from a prevalent cohort also are considered. It is concluded that risk estimates derived from a prevalent cohort are not directly comparable to risk estimates derived from an incident cohort.

Acquired Immunodeficiency Syndrome↗

PubMed2002

Alterations in TNF- and IL-related gene expression in space-flown WI38 human fibroblasts.

Spaceflight, just like aging, causes profound changes in musculoskeletal parameters, which result in decreased bone density and muscular weakness. As these conditions decrease our ability to conduct long-term manned space missions, and increase bone frailty in the elderly, the identification of genes responsible for the apparition of these physiological changes will be of great benefit. Thus, we developed and implemented a new microarray approach to investigate the changes in normal WI38 human fibroblast gene expression that arise as a consequence of space flight. Using our microarray, we identified changes in the level of expression of 10 genes, belonging to either the tumor necrosis factor- (TNF) or interleukin- (IL) related gene families in fibroblasts when WI38 cells exposed to microgravity during the STS-93 Space Shuttle mission were compared with ground controls. The genes included two ligands from the TNF superfamily, TWEAK and TNFSF15; two TNF receptor-associated proteins, NSMAF and PTPN13; three TNF-inducible genes, ABC50, PTX3, and SCYA13; TNF-alpha converting enzyme, IL-1 receptor antagonist, and IL-15 receptor alpha chain. Most of these are involved in either the regulation of bone density, and as such the development of spaceflight osteopenia, or in the development of proinflammatory status.

Cell Line↗

PubMed1994

The role of the NIH's Office of Research on Women's Health.

The Office of Research on Women's Health (ORWH) at the National Institutes of Health (NIH) was created in 1990 to carry out three major mandates: (1) to strengthen, develop, and increase research into diseases, disorders, and conditions that are unique to, more prevalent among, or more serious in women, or for which there are different risk factors for women than for men; (2) to ensure that women are appropriately represented in biomedical and biobehavioral research studies, especially clinical trials, that are supported by the NIH; and (3) to direct initiatives to increase the number of women in biomedical careers. One of the ORWH's first accomplishments was a 1992 report that serves as a basis for the ORWH's research agenda; its recommendations focus on scientific issues affecting women's health from birth to old age. To implement these recommendations, the ORWH does not fund studies directly but instead provides funds through NIH institutes and centers to augment new research initiatives, to expand ongoing studies to address high-priority areas concerning women's health (14 of which were identified for special consideration in FY 93), and to increase the participation of women in clinical studies. In addition, the ORWH is playing a key advisory role in the NIH's Women's Health Initiative, a long-term study of over 100,000 women to examine the major causes of death, disability, and frailty--heart disease and stroke, breast and colorectal cancers, and osteoporosis--in older women of all races and from all socioeconomic strata.(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral Research↗

PubMed1999

Scholarship, humanism, and the young physician.

It is time to understand the value of a broad liberal education for those college students who aim to be physicians, both because the medical curriculum is becoming more humanistic (which a liberal education would support) and because three enormous challenges confront physicians and educators alike: the relentless tide of biomedical discoveries, the great financial burden that medical care imposes, and the public's desperate plea for physicians who are more caring and communicative. A liberal education--meaning a course of study that is largely unrestricted and that attempts to sample the entire breadth of human knowledge--can help the premedical student cultivate, ripen, and enrich fundamental proficiencies such as accurate recording of observations, communicating ideas well, dealing with human emotions and becoming sensitive to human frailties, learning to listen and respond appropriately, learning to make sound judgments, and cultivating empathy and compassion. These are all skills that a liberal education can help the young student learn early rather than late, skills that prepare the student for dealing later with complex social, ethical, and clinical issues as a physician. A liberal education also can help prepare the student to take advantage of other general educational opportunities that are available in the small, closed community of a residency, such as learning to both assume and delegate responsibility, to participate in rational debate while respecting the opinions of others, and to exercise mature judgment, civility, empathy, and compassion. While a liberal education will not necessarily make the student a more technically proficient doctor, for some it will be essential to awaken and sharpen those essential skills that a physician needs to rise to the top of a profession that never fails to recognize excellence and humanity.

Curriculum↗

PubMed2001

A new course in age-based medicine at the University Medical Center of Nijmegen.

In 1995 the Medical Faculty of the University Medical Center of Nijmegen revised its curriculum to be more problem-oriented and student-centered. Each of the first four years now consists of ten four-week courses constructed around specific learning objectives. For the new curriculum the authors developed a fourth-year course on age-related health problems in which selected issues of pediatrics, general practice, and geriatrics are integrated. The primary objective of this course is to enable students to understand the differences and similarities in approaches to health problems in different age groups. Moreover, by the end of the course students should be able to analyze the physical, psychological, and social aspects of age-specific medical problems and understand their consequences for prevention and treatment. The course covers age-specific health concerns (e.g., neonatal jaundice, growth problems, sudden infant death syndrome, anorexia nervosa, dementia, multiple pathology, frailty) as well as important age-related differences in pathophysiology, etiology, diagnosis, and treatment (e.g., acute abdomen, constipation, maltreatment, urinary incontinence, pharmacokinetics). Based on assessments and evaluations after the first three implementations, the authors conclude that the enthusiastically received course is an effective introduction to age-specific health problems.

Age Factors↗

PubMedDate not supplied

Physical performance tests after stroke: reliability and validity.

OBJECTIVE: To evaluate the reliability and validity of the modified physical performance tests for stroke survivors who live in a community. DESIGN: The subjects included 40 stroke survivors and 40 apparently healthy independent elderly persons. The physical performance tests for the stroke survivors comprised two physical capacity evaluation tasks that represented physical abilities necessary to perform the main activities of daily living, e.g., standing-up ability (time needed to stand up from bed rest) and walking ability (time needed to walk 10 m). RESULTS: Regarding the reliability of tests, significant correlations were confirmed between test and retest of physical performance tests with both short and long intervals in individuals after stroke. Regarding the validity of tests, the authors studied the significant correlations between the maximum isometric strength of the quardriceps muscle and the time needed to walk 10 m, centimeters reached while sitting and reaching, and the time needed to stand up from bed rest. CONCLUSIONS: The authors confirmed that there were significant correlations between the instrumental activity of daily living and the time needed to stand up from bed rest, along with the time needed to walk 10 m for the stroke survivors. These physical performance tests are useful guides for evaluating a level of activity of daily living and physical frailty of stroke survivors living in a community.

Activities of Daily Living↗

PubMed1997

The transformative effects of illness.

In "The Soft Core" Arturo Vivante examines the bonds between a middle-aged son and his aging father. Years of habit that had solidified into accustomed but uncomfortable ways of behaving and interacting with each other are altered when the father's stroke evokes a tumultuous range of emotions in the son, leading him, in the end, to feel compassion, not just for his father but also for himself. Vivante shows the reader that illness has the ability to transform an individual who is willing to reexamine and reevaluate the meaning he or she gives to life. This process, however, is not an easy one, as it is often undertaken as in the story, when the individual fears the death of self or of a loved one. The suffering, though, can transform. The self-awareness gained leads to a more gentler way of being, and compassion results. This compassion is borne of understanding, recognition, and appreciation that the frailties of human nature exist in each of us. Recognizing and applying this to all manner of relationships in our lives is the wisdom that compassion gives to our existence.

Adaptation, Psychological↗

PubMedDate not supplied

Creating a wellness program/safety net for the medically complex and frail patient.

There is a small subgroup of Medicare and Medicaid patients (2%-4%) who have complex illnesses, frailties, and often disabilities. The medical problems of these patients are characterized by multiple diagnoses, complex medication routines, frequent hospitalizations, many physicians and physician visits, impairment of activities of daily life (including cognitive disabilities), and reliance on a caregiver for support and keeping them in the community. The cost of their care increases year after year averaging $40,000 per year. Strongly associated with these multiple problems is isolation and often depression, which compounds their medical problems resulting in nonadherence to their prescribed medical regimes which might otherwise keep them out of the hospital. This article describes a new approach to providing both a wellness program and medical safety net for this unstable population.

Case Management↗

PubMed2002

The confluence of mental, physical, social, and academic difficulties in middle childhood. I: exploring the "head waters" of early life morbidities.

OBJECTIVE: To present the conceptual and methodological backgrounds for development of the MacArthur Assessment Battery for Middle Childhood and one of its constituent instruments, the MacArthur Health and Behavior Questionnaire (HBQ). METHOD: As a component of HBQ development, research addressing "developmental psychopathology" as a nosological category of human disorder was reviewed. Such research bears, as its conceptual legacy, the strengths and frailties of the nosology from which the category was derived. RESULTS: Defining developmental psychopathology has done much to foster psychiatric and medical awareness of the particular dilemmas and problems intrinsic to childhood psychopathology. On the other hand, its delineation has obscured the tendency for psychiatric morbidities to emerge gradually along trajectories of development, to involve interactions among organismic and contextual factors, and to represent "confluences" of childhood difficulties suggesting common, less distinctive origins among psychiatric and biomedical disorders. The recognizable psychopathology of adolescence is most often preceded by protean manifestations of early difficulties resulting from the conjoint operation of child-specific vulnerabilities and context-derived risk factors. Co-occurrences of mental, physical, social, and academic difficulties in children's lives are more frequently the rule than the exception, and isolated, singular psychopathology is less common in childhood than the prevailing diagnostic nosology may imply. CONCLUSIONS: The MacArthur Assessment Battery represents an effort to assemble, in a single set of instruments, measures of child, context, and health risk factors for the prevalent morbidities of middle childhood. The HBQ, a component of the Battery, is a parent- and teacher-report instrument that assesses mental health, physical health, social, and school adaptation in 4- to 8-year-old children.

Child↗

PubMedDate not supplied

A developmental perspective on psychological principles of burn care.

The treatment of pediatric burn patients requires careful attention to psychological principles underlying good pain management. These principles, and a variety of specific psychological treatments, have been described thoroughly. In this article the cognitive capabilities, emotional understanding, and behavioral competencies that characterize children at various stages of development are outlined. Important age-related developmental issues are noted, and the child's experience of a burn injury at different ages is outlined. Guidelines for interventions tailored to the developmental capacities and frailties of children in different age groups are offered. Various psychological coping techniques are understood in light of their likely value for pain management with a developmental framework in mind.

Adolescent↗

PubMed1994

Drug disposition and hepatotoxicity in the elderly.

Overall, the aged liver seems to function remarkably well in the elderly. Decreased drug disposition is selective and modest and there is no compelling evidence of greater susceptibility to drug-induced or other types of injury. Drug-drug interactions and concurrent derangements accompanying advanced age may, however, contribute to adverse drug effects. Still, the aged, consume about three times as many therapeutic agents as other people. Most of these are metabolized in the liver before excretion. With increasing age, hepatic blood flow falls and so does hepatic volume. Moreover, binding of some agents normally carried on albumin may decrease. In contrast, increasing age has relatively modest effects on hepatic drug metabolism and these are highly selective. In the healthy aged, hepatic drug elimination is only modestly, if at all, impaired and this is likely to especially affect agents dependent on liver blood flow. Other factors that affect drug elimination in the aged are drug-drug interaction and the frailty and functional impairment of many elderly, as a result of poor diet, infection, multiple hospitalizations, or other events. Decreased host defense systems in the aged liver may lead to decreased adaptation to stress and slower regeneration after injury.

Aged↗

PubMed2001

Community case management for frail, elderly clients: the nurse case manager's role.

Capitated payment systems have forced healthcare providers to explore new methods of care delivery for frail, older clients who consume a disproportionate amount of time and resources. The authors describe the experiences of frail elders in a community case management program within a managed care setting. The experiences of living with frailty in a changing healthcare system, and perceptions of the case manager's ability to help navigate that system, are described. This article presents the benefits of community case management toward client goals of safety, support, and control.

Aged↗

PubMed1992

Strategies for improving and expanding the application of health status measures in clinical settings. A researcher-developer viewpoint.

Health status instruments may be useful in clinical settings to screen for functional problems, monitor disease progression or therapeutic response, improve doctor-patient communications, assess quality of care, or provide case-mix adjustment for comparing other outcomes between patient groups. However, conceptual, practical, and attitudinal barriers have prevented their wider implementation. Aside from providing more data on how these measures influence the process and outcomes of clinical care, several strategies may help to improve and expand their application. Wider application would be promoted by training health care providers about the methods of health status assessment, their validity, and the available instruments; comparing newer functional measures and older scales with which clinicians are familiar (to make scores more meaningful); providing better data for the selection of instruments; and improving the responsiveness of these questionnaires to clinical changes. If health status measures are used in direct patient care, it is important to determine whether the goal is to screen for functional problems or to monitor patient changes over time. These different purposes may influence the selection of instruments, the types of patients targeted (e.g., based on age or diagnosis), and the frequency of patient assessment. Health status measures must be easily incorporated into the office routine, requiring that they be brief, easy to interpret, and not require complex training or scoring algorithms. In this setting, it may be helpful to provide clinicians not only with functional status scores, but with interpretations and recommendations about management or community resources to consider. The costs of health status measurement and data analysis will probably be borne by third-party payers, who must be persuaded of their utility. When health status measures are used for quality assurance, average scores for groups of patients should be adjusted for disease severity, comorbid conditions, demographic characteristics, socioeconomic status, and baseline health status. Furthermore, the sickest or most vulnerable members of a clinical population may be least able to provide valid health status information because of dementia, frailty, blindness, illiteracy, or inability to speak English. These patients may be of particular interest, and are likely to alter average health status scores for a population, so methods to assure complete ascertainment must be considered.

Attitude of Health Personnel↗

PubMed1999

Exercise training guidelines for the elderly.

UNLABELLED: The capacity of older men and women to adapt to increased levels of physical activity is preserved, even in the most elderly. Aerobic exercise results in improvements in functional capacity and reduced risk of developing Type II diabetes in the elderly. High-intensity resistance training (above 60% of the one repetition maximum) has been demonstrated to cause large increases in strength in the elderly. In addition, resistance training result in significant increases in muscle size in elderly men and women. Resistance training has also been shown to significantly increase energy requirements and insulin action of the elderly. PURPOSE: We have recently demonstrated that resistance training has a positive effect on multiple risk factors for osteoporotic fracture in previously sedentary postmenopausal women. METHODS: Because the sedentary lifestyle of a long-term care facility may exacerbate losses of muscle function, we have applied this same training program to frail, institutionalized elderly men and women. RESULTS: In a population of 100 nursing home residents, a randomly assigned high-intensity strength-training program resulted in significant gains in strength and functional status. In addition, spontaneous activity, measured by activity monitors, increased significantly in those participating in the exercise program whereas there was no change in the sedentary control group. Before the strength training intervention, the relationship of whole body potassium and leg strength was seen to be relatively weak (r2 = 0.29, P < 0.001), indicating that in the very old, muscle mass is an important but not the only determining factor of functional status. CONCLUSIONS: Thus, exercise may minimize or reverse the syndrome of physical frailty, which is so prevalent among the most elderly. Because of their low functional status and high incidence of chronic disease, there is no segment of the population that can benefit more from exercise than the elderly.

Aged↗