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CORK Bibliography: The Elderly

40 citations. January 2009 to present

Prepared: September 2009

Abbasimoghadam MA; Dabiran S; Safdari R; Djafarian K. Quality of life and its relation to sociodemographic factors among elderly people living in Tehran. Geriatrics & Gerontology International 9(3): 270-275, 2009. (19 refs.)

Aim: The objective of this study was to assess the quality of life (QOL) and its relation to sociodemographic factors among elderly living in Tehran. Methods: A descriptive/correlational study was conducted. The sample consisted of 5600 people aged 60 years or older from 11 districts of Tehran. QOL was measured with the 36-item short form questionnaire. Results: QOL was positively associated with education levels, having previous state jobs and being employees, and negatively associated with smoking and having disease. Compared to men, women had lower scores for overall QOL and its dimensions. Conclusion: Sociodemographic inequalities, smoking and having diseases should be the main targets for improving the QOL in the elderly population.

Adams J. The mediating role of time perspective in socio-economic inequalities in smoking and physical activity in older English adults. Journal of Health Psychology 14(6): 794-799, 2009. (31 refs.)

Socio-economic variations in health behaviours contribute to socio-economic inequalities in health. Time perspective describes how individuals' consideration of future outcomes influences their present day behaviours and is associated with health behaviours and socio-economic position. Although theoretically plausible, the potential mediating role of time perspective in socio-economic inequalities in health behaviours has received little research attention. Analysis of data from wave 1 of the English Longitudinal Study of Ageing revealed that time perspective played a small partial mediating role in socioeconomic inequalities in smoking and physical activity. The data were self-report and cross-sectional, and the sample restricted to individuals aged 50+.

Bell RA; Arcury TA; Chen HY; Anderson AM; Savoca MR; Kohrman T et al. Use of tobacco products among rural older adults: Prevalence of ever use and cumulative lifetime use. Addictive Behaviors 34(8): 662-667, 2009. (26 refs.)

Tobacco use is a well-documented contributor to morbidity and mortality in the US and worldwide. Information on the comprehensive use of tobacco products is lacking, particularly smokeless tobacco in its various forms. Data from 635 older ( >= 60 years) African American, American Indian and White adults in rural North Carolina were analyzed to assess current and lifetime use of cigarettes, cigars, pipe. snuff and chewing tobacco. Participants were classified as being current, former or never users of each product. Lifetime use of each product was determined by asking about typical intensity of use per day and length of time the product has been used. About 70% of participants were current or former users of any tobacco product, and about one-third of participants currently used at least one product. Variations in use were observed by ethnicity and sex, particularly for cigarettes, snuff and chewing tobacco. Variations were also seen according to other demographic and health characteristics. These data add to a limited body of literature on lifetime use of smoked and smokeless tobacco products, and are useful in identifying the impact of these products on morbidity and mortality, particularly for vulnerable populations.

Beynon CM. Drug use and ageing: Older people do take drugs! (editorial). Age and Ageing 38(1): 8-10, 2009. (12 refs.)

While usually perceived as behaviour of the young, use of illicit drugs by people aged 50 and over is increasing in Europe and the USA. This increase largely reflects the ageing of general populations, and people who use drugs continuing to do so as they age. For those people dependent upon drugs [usually users of opiates (heroin) and stimulants (cocaine, crack cocaine and amphetamine)], the last 30 years has seen the advent of effective treatment and harm minimisation initiatives and, coupled with general advances in medicine, has increased the life expectancy of these drug users. Drug use by older people presents unique problems; biological systems and processes alter naturally across the life course and the effect of concurrent drug use on some of these systems is not well understood. The natural progression of certain diseases means that symptoms only manifest in older age and the lives of older drug users are likely to be characterised by considerable levels of morbidity. Further work is needed on the epidemiology of drug use by older people---a group of people who currently represent a hidden and vulnerable population.

Blay SL; Fillenbaum GG; Andreoli SB; Gastal FL. Correlates of lifetime alcohol misuse among older community residents in Brazil. International Psychogeriatrics 21(2): 384-391, 2009. (30 refs.)

Background: Little is known about the sociodemographic correlates and health effects associated with lifetime alcohol misuse in community dwelling elderly people in Brazil. Method: Data were obtained from a representative sample of 6961 residents aged 60+ in the state of Rio Grande do Sul, Brazil. The structured interview included a five-item lifetime alcohol use questionnaire addressing abuse and dependence, and questions regarding sociodemographic characteristics, lifestyle and social support, and health conditions. Results: In the interview, 10.6% respondents (25.3% men, 2.9% women) endorsed at least one lifetime alcohol misuse question. Controlled analyses comparing a gradient of alcohol misuse (none, one or more than one item endorsed), found that men, people aged 60-69 (compared to older persons) and tobacco users were more likely to endorse alcohol misuse items. Persons reporting lower income and who were of non-white race/ethnicity did not differ from their comparison groups with respect to endorsing one item, but they were more likely to endorse two or more items. Endorsing more than one item was associated with impaired activities of daily living, the presence of respiratory problems and psychiatric disorders, but was protective against vascular conditions. Conclusions: Major lifetime alcohol misuse (defined as endorsing more than one of five items reflecting alcohol abuse or dependence) is more common in certain sociodemographic groups (men, younger elderly) lower income, non-whites). With the exception of vascular conditions, it is associated with smoking, poorer functional status, respiratory problems, and psychiatric disorder. Endorsing only one item has a reduced association, significant only for male gender, smoking, and psychiatric disorder.

Blazer DG; Wu LT. Nonprescription use of pain relievers by middle-aged and elderly community-living adults: National Survey on Drug Use and Health. Journal of the American Geriatrics Society 57(7): 1252-1257, 2009. (20 refs.)

OBJECTIVES: To estimate the frequency, distribution, and correlates of nonprescription use of pain relievers by middle-aged and elderly persons in the United States. DESIGN: Cross-sectional data analysis of a national community survey. SETTING: The 2005 and 2006 National Surveys on Drug Use and Health. PARTICIPANTS: Ten thousand nine hundred fifty-three respondents aged 50 and older (6,717 aged 50-64 and 4,236 aged >= 65). MEASUREMENTS: Social and demographic variables, detailed assessment of nonprescription use (and abuse) of prescription pain relievers (e.g., acetaminophen with codeine, morphine), substance use, major depression, self-reported medical illnesses, and self-rated health. RESULTS: A small proportion of the sample (1.4%) reported nonprescription use of prescription pain relievers during the previous year. Combinations of acetaminophen and hydrocodone or propoxyphene were the most commonly used drugs. Use was associated with younger age (odds ratio (OR)=2.39, 95% confidence interval (CI)=1.31-4.36), American Indian and Alaska native (OR=8.78, 95% CI=2.50-30.85), and use of marijuana (OR=7.07, 95% CI=3.99-12.53). Fewer than 10% of nonprescription users were abusing these medications or dependent upon them. CONCLUSION: In a representative sample of middle-aged and older adults, nonprescription use of prescription pain relievers is relatively uncommon, but the much higher use by middle-aged adults suggests that, as this cohort ages, the problem may increase in elderly people.

Blazer DG; Wu LT. The epidemiology of substance use and disorders among middle aged and elderly community adults: National Survey on Drug Use and Health. American Journal of Geriatric Psychiatry 17(3): 237-245, 2009. (20 refs.)

Objective: To estimate the prevalence, distribution, and correlates of drug use among middle aged and elderly persons in the United States and to compare with alcohol use in this age group. Setting: The 2005 and 2006 National Surveys oil Drug Use and Health. Participants: A total of 10,953 subjects age 50 years and older (6,717 subjects age 50-64 years and 4,236 subjects age 65+ years). Measurements: Social and demographic variables detailed assessment of alcohol and drug use and disorders (marijuana, cocaine, inhalants, hallucinogens, methamphetamine, and heroin), major depression, and self-rated health. Results: Nearly 60% of subjects used alcohol during the past year, 2.6% marijuana, and 0.41% cocaine. Both alcohol and drug use were far more frequent in subjects age 50-64 years and among men. Drug use, in contrast to alcohol use, was not associated with education but was more common among those not married and those with major depression. The prevalence of drug abuse or dependence in the 50+ age group was very low (only 0-33% for any abuse or dependence, 0.12% for marijuana abuse or dependence, and 0.18% for cocaine abuse or dependence). Nevertheless, the use of marijuana approached 4% in the 50-64 age group in comparison with 0.7% in the 65+ age group. Conclusions: Drug use is not prevalent, although use is much more common in the middle aged, suggesting that prevalence may rise substantially in the 65+ age group as the younger cohort ages.

Bolling BW; Chen CYO; Blumberg JB. Tea and health: Preventive and therapeutic usefulness in the elderly? Current Opinion in Clinical Nutrition and Metabolic Care 12(1): 42-48, 2009. (82 refs.)

Purpose of review: To update the growing literature suggesting that tea and its constituent flavonoids are inversely related to the risk of chronic diseases common among the elderly. Recent findings: Results are provided from recent observational studies and clinical trials on the relationship of tea and tea catechins to body weight control and energy metabolism, impaired glucose tolerance and diabetes, cardiovascular disease, bone mineral density, cognitive function and neurodegenerative disease, and cancer. The evidence for the efficacy and potency of tea and tea extracts in benefiting these outcomes ranges from compelling for cardiovascular disease to equivocal at best for some forms of cancer. Summary: Although randomized clinical trials of tea have generally been of short duration and with small sample sizes, together with experimental and epidemiological studies, the totality of the data suggests a role for tea in health promotion as a beverage absent in calories and rich in phytochemicals. Further research is warranted on the putative benefits of tea and the potential for synergy among its constituent flavonoidS, L-theanine, and caffeine.

Cabrera MAS; Dip RM; Furlan MO; Rodrigues SL. Use of drugs that act on the cytocrhrome P450 system in the elderly. Clinics 64(4): 273-278, 2009. (28 refs.)

OBJECTIVES: The objective of this study was to analyze medications that act on the cytochrome P450 (CYP450) enzymatic system and are used daily by non-institutionalized elderly individuals. METHODS: A cross-sectional population-based study of elderly individuals (>= 60 years old) was conducted. All continuously used medications with hepatic metabolism via CYP450 that are classified as substrates, inducers or inhibitors were considered. For the analysis, elderly individuals were stratified according to age groups, and hepatic metabolism activity due to daily alcohol consumption and smoking were considered. RESULTS: Elderly individuals (396 in total: 222 women and 174 men) between 60 and 95 years of age (mean: 72.1) were assessed. Use of drugs that act on CYP450 was identified in 61.6% of the subjects. Drug use was observed among 16.2% of the subjects: three drugs among 9.8% and four or more among 6.3% of the subjects. The metabolic activities of the drugs used were classified as substrates (58.8%), inhibitors (14.9%), and inducers (4.3%). The main drugs used were beta-blockers and statins (as substrates), proton pump inhibitors and fluoxetine (as inhibitors), and prednisone and carbamazepine (as inducers). CONCLUSIONS: The results demonstrate that the elderly use high levels of medications that act on CYP450, thereby increasing the risk of drug interactions in a group that is already vulnerable to adverse drug effects.

Chan AM; von Muhlen D; Kritz-Silverstein D; Barrett-Connor E. Regular alcohol consumption is associated with increasing quality of life and mood in older men and women: The Rancho Bernardo Study. Maturitas 62(3): 294-300, 2009. (42 refs.)

Objective: This study examines the sex-specific association between alcohol intake and health-related quality of life in middle class community-dwelling older adults. Methods: Information on alcohol intake and measures of quality of life were obtained from 1594 participants (n = 633 men, n = 961 women) aged 50-97 years during a research clinic visit in 1992-1996, and from their responses to a phone interview and mailed questionnaires. Quality of life measures included the Medical Outcome Study Short Form 36 (SF-36), Quality of Well-Being (QWB) Scale, Life Satisfaction Index-Z (LSI-Z), and Satisfaction with Life Survey (SWLS). Depressed mood was assessed using the Beck Depression Inventory (BDI). Men and women were stratified into four groups of reported alcohol intake: non-drinker, occasional drinker (alcohol <3 times/week), light regular drinker (alcohol intake >= 3 times/week, but <170g/week), and moderate regular drinker (alcohol intake >= 3 times/week and >= 170g/week). Results: Average age of both sexes was 72 +/- 10 years. Only 11% of the men and 17% of the women were nondrinkers; 54% of men and 40% of women reported drinking alcohol >= 3 times per week; 18% of men and 7.5% of women were heavier regular drinkers. In multivariable regression analyses, increasing frequency of alcohol use was positively associated with better quality of life in men and in women. Associations were not explained by age, physical activity, smoking, depressed mood, or common chronic diseases including diabetes, hypertension and cardiovascular disease. Conclusions: Regular alcohol consumption is associated with increased quality of life in older men and women.

Chueh KH; Yang MS; Chen CS; Chiou SM. Poor sleep quality and alcohol use problems among elderly Taiwanese aboriginal women. International Psychogeriatrics 21(3): 593-599, 2009. (41 refs.)

Background: Little is known about sleep quality and alcohol use problems in the elderly minority population. This study aimed to identify a one-month prevalence of poor sleep quality and alcohol use problems among elderly Taiwanese aboriginal women and to examine the association between them. Methods: A cross-sectional survey with stratified random sampling was conducted in eight aboriginal communities in Taiwan. The 1261 elderly aboriginal women (response rate 84%) completed all assessments. Sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), while the CAGE questionnaire was used to evaluate alcohol use problems. Results: Of the study participants, 20.54% and 25.59% had poor sleep quality and alcohol use problems, respectively. Controlling for confounding factors, alcohol use problems were a risk factor for poor sleep quality (AOR = 1.44, p = 0.0433). Alcohol use problems were associated with three components of PSQI: sleep disturbances, subjective sleep quality, and daytime dysfunction. Conclusions: The elderly Taiwanese aboriginal women with problematic alcohol drinking experienced poorer sleep quality. Development of a program to reduce alcohol use problems might improve sleep quality among elderly Taiwanese aboriginal women.

Crome I; Sidhu H; Crome P. No longer only a young man's disease - Illicit drugs and older people. (editorial). Journal of Nutrition, Health & Aging 13(2): 141-143, 2009. (34 refs.)

Dietz TL. Drug and alcohol use among homeless older adults: Predictors of reported current and lifetime substance misuse problems in a national sample. Journal of Applied Gerontology 28(2): 235-255, 2009. (49 refs.)

Using data from the National Survey of Homeless Assistance Providers and Clients (NSHAPC), predictors of current alcohol and drug misuse problems among homeless, previously homeless, and marginally housed older adults are identified. Childhood sexual assault, victimization, and neglect, being male, being younger, being homeless or previously homeless, being a minority, and having income below US$499 per month increased the odds of reporting a drug problem. Being male, being younger, being homeless, having mental illness increased the odds of reporting an alcohol problem. Reporting any type of substance use problem increased the odds of reporting the other.

Fareed A; Casarella J; Amar R; Vayalapalli S; Drexler K. Benefits of retention in methadone maintenance and chronic medical conditions as risk factors for premature death among older heroin addicts. Journal of Psychiatric Practice 15(3): 227-234, 2009. (39 refs.)

Background. Methadone maintenance treatment reduces rates of premature mortality in heroin addicts. However, few published studies have addressed the effectiveness of treatment, mortality rates, or causes of death in older (geriatric) patients maintained on methadone. Identifying risk factors for premature mortality and potential targets for early intervention may reduce rates of premature mortality in older patients maintained on methadone. Methods. We conducted a retrospective chart review for patients enrolled in the methadone maintenance program at the Atlanta Veterans Affairs Medical Center. We reviewed the charts of 91 patients and collected the following information: demographics (age, gender, marital status, and race); composite score at admission on the Addiction Severity Index (ASI); most recent ASI score for alcohol use, drug use, and medical, psychiatric, family, legal, and employment problems; results of urine drug screens for opiates, cocaine, and benzodiazepines (first 4 screens after admission and last 4 screens); dose and duration of methadone treatment; HIV and hepatitis B and C status; tobacco smoking; presence of diabetes mellitus, hypertension, heart disease, chronic obstructive pulmonary disease, or cancer; history of intravenous drug use; and missed primary care appointments (last five appointments). Results. A statistically significant association was found between diabetes mellitus and between liver and gastrointestinal cancer and premature mortality in this sample of older patients maintained on methadone (OR = 30.79, p = 0.008 for diabetes mellitus; OR = 19.91, p = 0.017 for cancer). Patients who remained in treatment showed statistically significant improvement in ASI scores for problems related to drug use and for psychiatric, medical, and legal problems. They showed a nonsignificant trend toward reduction of problems associated with alcohol use. The group of patients who dropped out of methadone treatment did not show statistically significant improvement on any area of the ASI except family problems. The group who remained in treatment also showed a statistically significant reduction in drug use when results of the first four and last four urine drug screens for opiates, cocaine, and benzodiazepines were compared (p < 0.0001 for opiates and cocaine, p = 0.02 for benzodiazepines). On the other hand, the group who dropped out of methadone treatment did not show any statistically significant reduction in drug use based on urine screens (p = 0.05 for opiates, p = 0.38 for cocaine, and p = 0.53 for benzodiazepines). Conclusions. The results presented here suggest potential targets for intervention related to lifestyle risk factors and comorbid medical conditions, such as nicotine dependence and diabetes mellitus, that may have the potential to improve health outcomes for older patients with opioid dependence.

Fareed A; Casarella J; Amar R; Drexler K. Dose-dependent cognitive impairment in an elder methadone-maintained patient. Journal of Addiction Medicine 3(2): 109-110, 2009. (10 refs.)

Flood M; Buckwater KC. Recommendations for mental health care of older adults. Part 2. An overview of dementia, delirium, and substance abuse. Journal of Gerontological Nursing 35(2): 35-47, 2009. (59 refs.)

Expansion and diversification of the older adult demographic group is a key indication that nurses need to be aware of current recommended practice related to the most common mental health diagnoses in this age group. Such conditions include depression, anxiety, dementia, delirium, and substance abuse/dependence. This article, the second in a two-part series, focuses on key assessment components and suggested interventions for dementia, delirium, and substance abuse/dependence.

Fonad E; Emami A; Wahlin TBR; Winblad B; Sandmark H. Falls in somatic and dementia wards at Community Care Units. Scandinavian Journal of Caring Sciences 23(1): 2-10, 2009. (57 refs.)

Falls and fall injuries are common problems for patients at nursing homes in Sweden. Impaired cognitive function, a poor sense of orientation and a high intake of medicine, can lead to an increase in falls among older people. The objective of this study was to investigate the associations between falls and: fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively. The study design is ecological, and aggregated data regarding falls, fall risk assessments, fractures, the use of physical restraints and medication were collected between 2000 and 2003. The Pearson correlation analysis and regression analyses were used to investigate associations between fall risks, medication, fractures, wheelchair-bound situations, bed rails and falls. The total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also a significant correlation between falls and assessed risk of falling, the use of certain medication, and physical restraints such as wheelchairs and bed rails in dementia wards. Falls at somatic wards were associated with the use of sleeping pills with benzodiazepines. For dementia wards there were associations between falls and fractures, physical restraints and the use of certain medications. Fractures were associated with the use of neuroleptics, sleeping pills and sleeping pills with benzodiazepines. At somatic wards, falls correlated with the use of sleeping pills with benzodiazepines, and with the use of wheelchairs and bed rails.

Gallagher R. Methadone: An effective, safe drug of first choice for pain management in frail older adults. Pain Medicine 10(2): 319-326, 2009. (44 refs.)

Frail older adults have a high prevalence of chronic pain with major effects on function and quality of life. Many analgesics, including opioids, have adverse effects on older adults with multiple co-morbidities. Methadone has been increasingly used for analgesia in the last 10 years. However, a number of adverse events such as sleep-disordered breathing, methadone-induced torsades de pointes arrhythmias, as well as the "addiction stigma," have made people reluctant to use this medication. This article uses examples of five cases of pain in frail older adults living in a skilled nursing facility. Safe and effective use of methadone is illustrated with these cases. The pharmacology of methadone in frail elders is reviewed to demonstrate the specific benefits of the drug in older adults and how adverse events can be minimized. Methadone is an excellent choice for pain in frail older adults.

Haider SI; Johnell K; Weitoft GR; Thorslund M; Fastbom J. The Influence of educational level on polypharmacy and inappropriate drug use: A register-based study of more than 600,000 older people. Journal of the American Geriatrics Society 57(1): 62-69, 2009. (41 refs.)

To investigate whether low educational attainment is associated with polypharmacy and potential inappropriate drug use (IDU) in older people. Cross-sectional register-based study. Sweden. Older people aged 75 to 89 who, filled at least one drug prescription between August and October 2005 and, consequently, were listed in the Swedish Prescribed Drug Register (SPDR) (N=626,258). Data were obtained from the SPDR, the inpatient register, and the education register. The main outcome measures were polypharmacy (concurrent use of >= 5 drugs), excessive polypharmacy (concurrent use of >= 10 drugs), and potential IDU. Four quality indicators developed by the Swedish National Board of Health and Welfare were used for the assessment of potential IDU: concurrent use of three or more psychotropic drugs, prescription of long-acting benzodiazepines, prescription of anticholinergics, and at least one clinically relevant potential drug-drug interaction (DDI). Comorbidity was measured using the Charlson Comorbidity Index. Subjects with low education had a higher probability of polypharmacy (odds ratio (OR)=1.11, 95% confidence interval (CI)=1.10-1.12), excessive polypharmacy (OR=1.15, 95% CI=1.13-1.17), and potential IDU (OR=1.09, 95% CI=1.07-1.17), after adjustment for age, sex, comorbidity, and type of residential area (urban or rural). Decreasing educational attainment was associated with a higher probability of using three or more psychotropic drugs and potential DDIs, whereas the opposite association was observed for anticholinergic drugs. Long-acting benzodiazepines showed no association. Elderly women with low education were slightly more likely to have polypharmacy, excessive polypharmacy, and potential IDU than men with low education. Overall, the ORs were modest and statistically significant because of the large sample size. Low educational attainment was associated with a greater likelihood of poypharmacy, excessive polypharmacy, and potential IDU in elderly Swedish persons, even after controlling for age, sex, place of residence, and comorbidity. Women with low education had slightly higher likelihood of receiving polypharmacy and potential IDU than men with low education. The recently established SPDR may be useful for continuous monitoring and for designing interventions to improve drug quality in low-educated elderly people.

Hall SM; Humfleet GL; Munoz RF; Reus VI; Robbins JA; Prochaska JJ. Extended treatment of older cigarette smokers. Addiction 104(6): 1043-1052, 2009. (44 refs.)

Tobacco dependence treatments achieve abstinence rates of 25-30% at 1 year. Low rates may reflect failure to conceptualize tobacco dependence as a chronic disorder. The aims of the present study were to determine the efficacy of extended cognitive behavioral and pharmacological interventions in smokers >= 50 years of age, and to determine if gender differences in efficacy existed. Open randomized clinical trial. A free-standing, smoking treatment research clinic. A total of 402 smokers of >= 10 cigarettes per day, all 50 years of age or older. Participants completed a 12-week treatment that included group counseling, nicotine replacement therapy (NRT) and bupropion. Participants, independent of smoking status, were then assigned randomly to follow-up conditions: (i) standard treatment (ST; no further treatment); (ii) extended NRT (E-NRT; 40 weeks of nicotine gum availability); (iii) extended cognitive behavioral therapy (E-CBT; 11 cognitive behavioral sessions over a 40-week period); or (iv) E-CBT plus E-NRT (E-combined; 11 cognitive behavioral sessions plus 40 weeks nicotine gum availability). Primary outcome variable was 7-day point prevalence cigarette abstinence verified biochemically at weeks 24, 52, 64 and 104. The most clinically important findings were significant main effects for treatment condition, time and the treatment x time interaction. The E-CBT condition produced high cigarette abstinence rates that were maintained throughout the 2-year study period [(week 24 (58%), 52 (55%), 64 (55%) and 104 (55%)], and was significantly more effective than E-NRT and ST across that period. No other treatment condition was significantly different to ST. No effects for gender were found. Extended cognitive behavioral treatments can produce high and stable cigarette abstinence rates for both men and women. NRT does not add to the efficacy of extended CBT, and may hamper its efficacy. Research is needed to determine if these results can be replicated in a sample with a greater range of ages, and improved upon with the addition of medications other than NRT.

Hamilton AB; Grella CE. Gender differences among older heroin users. Journal of Women & Aging 21(2): 111-124, 2009

Objectives: This purpose of this study was to explore the following question: Are there gender differences among older individuals with a history of heroin addiction with regard to social and family relationships and health problems? Methods: Eight gender-specific focus groups were conducted with 38 (19 women, 19 men) older (50+ years) individuals with long-term histories of heroin dependence. Four groups were conducted in a methadone maintenance (MM) clinic and four groups were derived from the Los Angeles community. Results: Modest gender differences were observed, but mainly in the focus-group dynamics. Women typically described the impact of their addiction on their families, while men typically described their surprise at still being alive. Hepatitis C was the primary health concern in all groups; mental health issues were also discussed. Discussion: Remarkable gender differences were not apparent in the qualitative experiences of these participants. Instead, we found overriding similarities related to the interactive effects of drug use and aging. Longitudinal studies of this population as they age and interact with the health-care system and other social systems will help to untangle the complicated relationship between aging, drug addiction, gender, and health.

Han B; Gfroerer JC; Colliver JD; Penne MA. Substance use disorder among older adults in the United States in 2020. Addiction 104(1): 88-96, 2009. (50 refs.)

Aims: This study aimed to project the number of people aged 50 years or older with substance use disorder (alcohol/illicit drug dependence or abuse) in the United States in 2020. Design: Logistic regression models were applied to estimate parameters predicting past-year substance use disorder using the 2002-06 National Survey on Drug Use and Health data. We applied these parameters to the projected US 2020 population to estimate the number of adults aged 50 or older with substance use disorder in 2020. Setting: Non-institutionalized US residences. Participants: Representative sample of the US civilian, non-institutionalized population. Measurements: Substance use disorder is classified based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Findings: Due to the large population size and high substance use rate of the baby-boom cohort, the number of adults aged 50 or older with substance use disorder is projected to double from 2.8 million (annual average) in 2002-06 to 5.7 million in 2020. Increases are projected for all examined gender, race/ethnicity and age groups. Conclusions: Our estimates provide critical information for policymakers to allocate resources and develop prevention and treatment approaches to address future needs of the US older adult population with substance use disorder.

Hirayama F; Lee AH; Binns CW; Okumura C; Yamamoto S. Alcohol consumption by older adults in central and southern Japan. Asia-Pacific Journal of Public Health 21(2): 170-176, 2009

This study ascertained the level of alcohol intake and alcoholic beverages consumed by Japanese older adults. Persons aged 55 to 75 years residing in central and southern Japan were recruited and interviewed face-to-face on their habitual alcohol consumption. Among the 577 (359 men and 218 women) participants from 10 districts/prefectures, 60.5% (75.5% for men and 35.7% for women) regularly drank alcoholic beverages on at least a monthly basis. Beer was the most preferred beverage (45.2%), followed by shochu (19.8%) and sake (16.1%). The mean alcohol consumption was 22.2 g/day (95% confidence interval 19.3-25.2) overall, but drinkers had a much higher mean intake of 36.6 g/day (95% CI 32.4-40.8). Moreover, it is alarming that 25.5% of male drinkers were heavy drinkers consuming more than 60 g of alcohol on average per day. Alcohol control measures should be developed to curtail the excessive drinking by older adults.

John PDS; Montgomery PR; Tyas SL. Alcohol misuse, gender and depressive symptoms in community-dwelling seniors. International Journal of Geriatric Psychiatry 24(4): 369-375, 2009. (37 refs.)

Objectives: Alcohol misuse in seniors has been studied in clinical samples and in small communi ties, but relatively few Studies are population-based. Objectives are: (1) to describe the characteristics of seniors who score 1 or more on the CAGE (Cut down; Annoyed; Guilty; Eye-opener) questionnaire of alcohol problems; (2) to determine if depressive symptoms are associated with alcohol misuse after accounting for other factors. Methods: Cross-sectional study of community-dwelling older people (65+ years) sampled from a representative population registry in Manitoba, Canada. Participants were initially interviewed in 1991-1992 and reinterviewed in 1996-1997. Data from Time 2 were used; 1,028 persons were included in the analyses. Sociodemographic characteristics, the CAGE questionnaire. Activities of Daily Living (ADLs) and instrumental ADLs (IADLs), the Center for Epidemiologic Studies-Depression (CES-D) scale and the Mini-Mental State Examination (MMSE) were assessed by trained interviewers. Results: Males were more likely to score positive on the CAGE questionnaire. After adjusting for gender, age, and education, there was a strong association between depressive symptoms and alcohol misuse. Poor self-rated health and impairments in IADLs were also associated with alcohol misuse. Conclusions: Male gender, depressive symptoms, and poor functional status were associated with alcohol misuse in this population-based study. Attention to depressive symptoms and functional status may be important in the care of seniors with alcohol misuse. Alternatively, physicians should enquire about alcohol use in seniors with functional impairment or depressive symptoms.

Johnson PB; Sung HE. Substance abuse among aging baby boomers: Health and treatment implications. Journal of Addictions Nursing 20(3): 124-126, 2009. (26 refs.)

This paper highlights a looming crisis that will soon significantly impact the health of many older Americans: substance abuse among aging baby boomers. It first outlines what is known both about the size of this population and its previous and current abuse both of licit and illicit substances. It then enumerates some of the most likely areas where this crisis will impact the healthcare system and the treatment of elderly Americans. The paper also discusses both the co-occurring nature of baby boomer substance abuse as well as its likely impact on co-occurring mental disorders. The paper concludes with a call for researchers and policy makers to quickly move to better understand and address this impending threat to the health and well-being of millions of older Americans and their families.

Kane M; Green D. Substance abuse by elders and self-enhancement bias. Educational Gerontology 35(2): 95-120, 2009. (62 refs.)

Human service professionals regularly do not recognize the symptoms of substance abuse in older populations and are unlikely to provide intervention. In this study, human service students (N=242) were given one of three vignettes in which the main character was an 80-year-old man, an 80-year-old woman, or they were asked to imagine themselves at 80. The vignette character was described as living alone, smelling of alcohol, and whose garbage was filled with empty beer and wine containers. Respondents were asked whether they believed the character had a substance abuse problem, if intervention was appropriate, if the character was depressed or suffering from self-neglect, and if the neighbors should express their concerns to the character. The largest number of respondents perceived that the vignette character may have a drinking problem, may be lonely, and would benefit from professional help. Most did not believe neighbors should express concern or that the character was suffering from self-neglect. Those who completed the vignette in which they were asked to imagine themselves at age 80 were prone to self-enhancement bias. Using the Wilks' Lambda criteria, the General Linear Model was significant (F=1.474, p=.024), with 8 of the 25 items possessing significant p values.

Kenney BA; Holahan CJ; Holahan CK; Brennan PL; Schutte KK; Moos RH. Depressive symptoms, drinking problems, and smoking cessation in older smokers. Addictive Behaviors 34(6-7): 548-553, 2009. (75 refs.)

This study modeled the predictive association between depressive symptoms and smoking cessation in a sample of 442 late-middle-aged smokers; assessments occurred at four time-points across a 10-year period. In addition, the study examined the role of baseline drinking problems in moderating the relationship between depressive symptoms and smoking cessation. Findings supported hypotheses. More depressive symptoms prospectively predicted a lower likelihood of smoking cessation. In addition, the presence of baseline drinking problems strengthened the relationship between depressive symptoms and a lower likelihood of smoking cessation. Understanding the mechanisms underlying depression and cigarette smoking among older adults is applicable to secondary prevention and treatment and suggests additional public health benefits from treating depression in older persons.

Kleber C; Kleber AJ. Opiate intoxication in elderly emergency patients. Notofall & Rettungsmedizin 12(1): 40-44, 2009. (20 refs.)

Acute opiate intoxication in aged people is an atypical emergency case. The challenge is to keep pre-hospital opiate intoxication as a potential cause of emergency in mind. The prescription of opiate patches for out-patient pain therapy has increased. Therefore, in aged patients with several chronic diseases and permanent medication, there is the danger of pharmacological and pharmacokinetic interactions with extension of the opiate effect leading to acute opiate intoxication. The pre-hospital diagnosis and therapy of acute opiate intoxication in aged emergency patients poses a challenge. Important preclinical factors are to check the pupils, the breathing frequency and the complete medical history. In this article two cases of preclinical management of acute opiate intoxication are demonstrated. Naloxone is the antidote of choice in acute opiate intoxication. The side-effects, pharmacologic interactions and the danger of the rebound effect are described below. Antidote therapy, airway maintenance and assurance of adequate ventilation and oxygenation have priority and must not be neglected. In the age of out-patient pain therapy, the acute opiate intoxication is no longer a "drug emergency".

Lesk VE; Honey TEM; de Jager CA. The effect of recent consumption of caffeine-containing foodstuffs on neuropsychological tests in the elderly. Dementia and Geriatric Cognitive Disorders 27(4): 322-328, 2009. (37 refs.)

We investigated the effect of recent intake of caffeine-containing foodstuffs (CCFS) on a group of elderly participants (age range 67-95 years) on a series of neuropsychological tests. There was no significant effect of CCFS intake on performance in any of the tests in the battery used. However, a significant interaction effect was found between age and CCFS consumption on scores of some neuropsychological tests. In these tests, participants with recent consumption of CCFS show a linear decrease in performance with increasing age, a pattern not seen for those that have no CCFS in their system. Accuracy in the neuropsychological assessment is of great importance when determining whether someone has a cognitive impairment or early Alzheimer's disease. We therefore propose that recent consumption of CCFS should be taken into account when scoring the neuropsychological assessment.

Moos RH; Schutte KK; Brennan PL; Moos BS. Older adults' alcohol consumption and late-life drinking problems: A 20-year perspective. Addiction 104(8): 1293-1302, 2009. (50 refs.)

Aims: The aim of this study was to identify changes in patterns of alcohol consumption over a 20-year interval among older women and men, and to examine the associations between guideline-defined excessive drinking and late-life drinking problems. Design, participants and measures: A community sample of 719 adults between 55 and 65 years of age who consumed alcohol at or prior to baseline participated in a survey of alcohol consumption and drinking problems and was followed 10 years and 20 years later. Findings: The likelihood of excessive drinking declined over the 20-year interval as adults matured into their 70s and 80s. However, at ages 75-85, 27.1% of women and 48.6% of men consumed more than two drinks per day or seven drinks per week. At comparable guideline levels of alcohol consumption, older men were more likely to have drinking problems than were older women. Consumption of more than two drinks per day or seven drinks per week was identified as a potential conservative guideline for identifying excessive drinking associated with an elevated likelihood of drinking problems. Conclusions A substantial percentage of older adults who consume alcohol engage in guideline-defined excessive drinking and incur drinking problems. The finding that older men may be more likely than older women to experience problems when they drink beyond guideline levels suggests that alcohol guidelines for men should not be set higher than those for women.

Panza F; Capurso C; D'Introno A; Colacicco AM; Frisardi V; Lorusso M et al. Alcohol drinking, cognitive functions in older age, predementia, and dementia syndromes. (review). Journal of Alzheime's Disease 17(1): 7-31, 2009. (167 refs.)

Among lifestyle-related factors, low to moderate alcohol drinking has been proposed as a protective factor against the development of age-related changes in cognitive function, predementia syndromes, and cognitive decline of degenerative (Alzheimer's disease, AD) or vascular origin (vascular dementia, VaD) in several longitudinal studies, but contrasting findings also exist. Furthermore, many of these studies were limited by cross-sectional design, restriction by age or sex, or incomplete ascertainment. Different outcomes, beverages, drinking patterns, or follow-up periods, or possible interactions with other lifestyle-related (i.e., smoking) or genetic factors [i.e., apolipoprotein E (APOE) genotyping] may be sources of great variability. Light to moderate alcohol use may be associated with a reduced risk of unspecified incident dementia and AD, while for VaD, cognitive decline, and predementia syndromes, the current evidence is only suggestive of a protective effect. In conclusion, as intervention studies are not feasible in this area, the best evidence comes from an overview of epidemiological studies, suggesting that the protective effects are more likely with wine consumption and the absence of an APOE e4 allele. At present, there is no indication that light to moderate alcohol drinking would be harmful to cognition and dementia, and it is not possible to define a specific beneficial level of alcohol intake.

Pelletier AL; Thomas J; Shaw FR. Vision loss in older persons. American Family Physician 79(11): 963-970, 2009. (47 refs.)

Family physicians have an essential role in assessing, identifying, treating, and preventing or delaying vision loss in the aging population. Approximately one in 28 U.S. adults older than 40 years is visually impaired. Vision loss is associated with depression, social isolation, falls, and medication errors, and it can cause disturbing hallucinations. Adults older than 65 years should be screened for vision problems every one to two years, with attention to specific disorders, such as diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Vision-related adverse effects of commonly used medications, such as amiodarone or phosphodiesterase inhibitors, should be considered when evaluating vision problems. Prompt recognition and management of sudden vision loss can be vision saving, as can treatment of diabetic retinopathy, refractive error, cataracts, glaucoma, and age-related macular degeneration. Aggressive medical management of diabetes, hypertension, and hyperlipidemia; encouraging smoking cessation; reducing ultraviolet light exposure; and appropriate response to medication adverse effects can preserve and protect vision in many older persons. Antioxidant and mineral supplements do not prevent age-related macular degeneration, but may play a role in slowing progression in those with advanced disease.

Sachs-Ericsson N; Schmidt NB; Zvolensky MJ; Mitchell M; Collins N; Blazer DG. Smoking cessation behavior in older adults by race and gender: The role of health problems and psychological distress. Nicotine & Tobacco Research 11(4): 433-443, 2009. (51 refs.)

Initial research on older smokers suggests that a subgroup of smokers with higher levels of psychological distress and health problems may be more likely to quit smoking than older smokers with fewer such problems. The present study, based on prospective data from a biracial sample of older adults (N= 4,162), examined characteristics of older adult smokers by race and gender. The present study uses both cross-sectional and prospective data to examine the association between smoking behavior, smoking cessation, health functioning, and psychological distress in a biracial sample of community-dwelling older adults. We found baseline psychological distress to be associated with poor health functioning. Consistent with hypotheses, baseline (Time 1) psychological distress predicted smoking cessation 3 years later (Time 2). Moreover, the change in health problems between Time 1 and Time 2 fully mediated the association between Time 1 distress and smoking cessation. Smoking cessation behavior of older adults is best explained by higher levels of distress and health problems regardless of race or gender. These findings may have important treatment implications regarding smoking cessation programs among older adults. Older adult smokers with higher levels of psychological distress and health problems may be more motivated to quit smoking than those with fewer such problems. These difficulties should be targeted within the context of the smoking cessation protocol. Also, we identified a subgroup of older smokers who are reporting fairly good health and lower levels of distress and who are less likely to quit smoking. Motivational methods may need to be developed to engage this group in smoking cessation treatment.

Schneider S; Huy C; Schuessler M; Diehl K; Schwarz S. Optimising lifestyle interventions: identification of health behaviour patterns by cluster analysis in a German 50 survey. European Journal of Public Health 19(3): 271-277, 2009. (42 refs.)

Background: Many prevention and intervention measures are still targeting isolated behaviours such as tobacco use or physical inactivity. Cluster analysis enables the aggregation of single health behaviours in order to identify distinctive behaviour patterns. The purpose of this study was to group a sample of the over-50 population into clusters that exhibit specific health behaviour patterns regarding regular tobacco use, excessive alcohol consumption, unhealthy diet and physical inactivity. Methods: From the total population of the federal state of Baden-Wuerttemberg, Germany, 982 men and 1020 women aged 5070 were randomly selected. Subjects were asked by trained interviewers in computer-assisted telephone interviews (CATI) about health behaviour and sociodemographic characteristics. Cluster analysis was conducted to identify distinct health behaviour patterns. Multinomial logistic regression was used to characterize clusters by specific social attributes. Results: Five homogeneous health behaviour clusters were identified: No Risk Behaviours (25.3), Physically Inactives (21.1), Fruit and Vegetable Avoiders (18.2), Smokers with Risk Behaviours (12.7) and Drinkers with Risk Behaviours (22.7). Whereas the first cluster is the ideal in terms of risk and prevention, the latter two groups include regular users of tobacco and excessive consumers of alcohol, who also engage in other risk behaviours like inactivity and maintaining an unhealthy diet. These two risk groups also exhibit specific sociodemographic attributes (male, living alone, social class affiliation). Conclusion: Unhealthy behaviours evidently occur in typical combinations. An awareness of this clustering enables prevention and intervention measures to be planned so that multiple behaviours can be modified simultaneously.

Schutte KK; Brennan PL; Moos RH. Treated and untreated remission from problem drinking in late life: Post-remission functioning and health-related quality of life. Drug and Alcohol Dependence 99(1-3): 150-159, 2009. (42 refs.)

Objective: To evaluate the post-remission status of older remitted problem drinkers who achieved stable remission without treatment. Method: The post-remission drinking behavior, health-related functioning, life context, coping, and help-seeking of older. untreated (n = 330) and treated (n = 120) former problem drinkers who had been remitted for a minimum of 6 years were compared twice over the course of 6 years to each other and to lifetime nonproblem drinkers (n = 232). Analyses considered the impact of severity of drinking problem history. Results: Untreated remitters were more likely than treated remitters to continue to drink, exhibited fewer chronic health problems and less depressive symptomatology, and were less likely to smoke. Untreated remitters' life contexts were somewhat more benign than those of treated ones, and they were less likely to describe a coping motive for drinking and engage in post-remission help-seeking. Although untreated remitters more closely resembled lifetime nonproblem drinkers than did treated remitters, both untreated and treated remitter groups exhibited worse health-related functioning, more financial and interpersonal stressors, and more post-remission help-seeking than did lifetime nonproblem drinkers. Conclusions: Regardless of whether late-life remission was gained without or with treatment, prior drinking problems conveyed a legacy of health-related and life context deficits.

Shibusawa T; Padgett D. The experiences of "aging" among formerly homeless adults with chronic mental illness: A qualitative study. Journal of Aging Studies 23(3): 188-196, 2009. (48 refs.)

Little is known about the life course of older adults with serious mental illness who have also been homeless. Using 44 life history interviews with 25 study participants ages 40 to 62, this study used case study and thematic analysis to examine the lived experience of such individuals as they enter their mid- and later-life years. Participants whose lives were marred by early-onset substance abuse, symptoms of mental illness and a descent into homelessness, spoke of an awareness of aging and premature mortality. Major themes that emerged were: (1) reflecting on losses, (2) growing older and wiser, (3) struggling with normality, (4) having space and time to reevaluate, and (5) awareness of the future and "time left." Life histories which focus on the person-in-context and their subjective experiences provide a viable research method to further the understanding of one of the most underserved and hardest-to-reach populations.

Siiskonen SJ; Visser LE; Tiemeier H; Hofman A; Lamberts SWJ; Uitterlinden AG et al. BclI glucocorticoid receptor polymorphism and smoking in the general population. Addiction Biology 14(3): 349-355, 2009. (25 refs.)

We studied the hypothesis that the BclI polymorphism of the glucocorticoid receptor gene is associated with ail increased probability of being a (heavy) smoker and a decreased ability to quit smoking. The study cohort consisted of all subjects in the Rotterdam Study, a Dutch population-based cohort of people aged 55 years and older, for whom BclI genotyping and smoking status at baseline were available. In prospective analyses, the smoking status was reassessed during three additional examination rounds. Logistic regression analysis was used to study the association between BclI polymorphism and being a smoker or a heavy smoker at baseline. Furthermore, the relationship between BclI polymorphism and incident smoking cessation was tested with Cox proportional hazards analysis within those who smoked at baseline. In total, 6358 subjects were included in the study. The presence of a G-allele was not associated with current smoking at baseline [odds ratio (OR) = 0.96, 95%confidence interval (CI): 0.85-1.09] or with the incidence of smoking cessation during follow-up [hazard ratio (HR) = 0.98, 95%CI: 0.80-1.19]. Within current smokers having a G-allele was not significantly associated with the risk of being a heavy smoker when measured by pack-years smoked (OR = 1.07, 95%CI: 0.85-1.35) or daily consumption of tobacco (OR = 1.10, 95%CI: 0.88-1.37). We were not able to replicate the earlier findings indicating that the proportion of current smokers is lower among carriers of the CC-genotype of the BclI glucocorticoid receptor. Furthermore. the BclI glucocorticoid receptor polymorphism did not predict the incidence of smoking cessation in the general elderly population.

Uchida H; Suzuki T; Mamo DC; Mulsant BH; Kikuchi T; Takeuchi H et al. Benzodiazepine and antidepressant use in elderly patients with anxiety disorders: A survey of 796 outpatients in Japan. Journal of Anxiety Disorders 23(4): 477-481, 2009. (37 refs.)

Since the literature on benzodiazepine use in elderly patients with anxiety disorders is limited, a large cross-sectional review of psychotropic prescriptions in 796 patients with neurotic disorders (ICID-10) (age range = 11-91 years) was conducted across 30 sites in Japan. Use of benzodiazepine-derivative anxiolytics was approximately 70% in all decades without a group difference. The proportion of subjects who received prescriptions for benzodiazepine-derivative anxiolytics in the absence of antidepressants was higher in older age groups (e.g., 27.7% and 43.2% in the third and sixth decades, respectively). On the other hand, antidepressants were less frequently prescribed in older age groups (e.g., 59.8% and 41.5% in the third and sixth decades, respectively). The very high use of anxiolytics in the elderly, especially in the absence of concomitant antidepressant use, is a cause for concern since they are not a preferred long-term treatment strategy given their adverse effects in the elderly.

Watt CA; Lassiter JW; Boyle JR; Kulak JA; Ossip-Klein D. An examination of policies addressing resident smoking in nursing homes. Journal of the American Medical Directors Association 10(4): 258-263, 2009. (26 refs.)

Objectives: To report findings of a nationwide project that examined nursing homes' tobacco policies for residents. Design: A random selection procedure was used to sample nursing homes proportional to the geographic distribution of nursing homes in the United States. Rubrics were developed to objectively describe and compare policies. Setting: Policies were obtained from 4 types of facilities: (1) facilities that allow smoking indoors and outdoors (I/O-SFs), (2) facilities that allow residents to smoke outdoors only (O-SFs), (3) facilities that do not allow residents to smoke indoors or out of doors (NSFs), and (4) facilities in transition (TFs) from a smoking facility to an NSF. Measures: Rubrics used to score policies had common categories: administrative/authority issues, notification, resident smoking, safety, cessation assistance/encouragement, and smoking areas. Criteria within each category varied to reflect the smoking regulations of each type of facility (eg, policies of facilities that do not allow smoking indoors were not examined for inclusion of issues related to ventilation). Results: Facilities' policies from geographically diverse facilities are described. Across all facilities, mean percentages reflecting policies' overall comprehensiveness were low, and when examining specific components of the policies, few areas were consistently addressed across facilities. Conclusions: Considerable gaps were found in written policies regarding smoking. Although nursing homes may in fact have practices that are more extensive than their policies portray, creating policies that guide practice can assist these long-term care facilities to promote an environment that aligns with their goals and desired practices to protect the health of residents and staff.

Wright RM; Roumani YF; Boudreau R; Newman AB; Ruby CM; Studenski SA et al. Effect of central nervous system medication use on decline in cognition in community-dwelling older adults: Findings from the Health, Aging and Body Composition Study. Journal of the American Geriatrics Society 57(2): 243-250, 2009. (53 refs.)

To evaluate whether combined use of multiple central nervous system (CNS) medications over time is associated with cognitive change. Longitudinal cohort study. Pittsburgh, Pennsylvania, and Memphis, Tennessee. Two thousand seven hundred thirty-seven healthy adults (aged >= 65) enrolled in the Health, Aging and Body Composition study without baseline cognitive impairment (modified Mini-Mental State Examination (3MS) score >= 80). CNS medication (benzodiazepine- and opioid-receptor agonists, antipsychotics, antidepressants) use, duration, and dose were determined at baseline (Year 1) and Years 3 and 5. Cognitive function was measured using the 3MS at baseline and Years 3 and 5. The outcome variables were incident cognitive impairment (3MS score < 80) and cognitive decline (>= 5-point decline on 3MS). Multivariable interval-censored survival analyses were conducted. By Year 5, 7.7% of subjects had incident cognitive impairment; 25.2% demonstrated cognitive decline. CNS medication use increased from 13.9% at baseline to 15.3% and 17.1% at Years 3 and 5, respectively. It was not associated with incident cognitive impairment (adjusted hazard ratio (adj HR)=1.11, 95% confidence interval (CI)=0.73-1.69) but was associated with cognitive decline (adj HR 1.37, 95% CI=1.11-1.70). Longer duration (adj HR=1.39, CI=1.08-1.79) and higher doses (> 3 standardized daily doses) (adj HR=1.87, 95% CI=1.25-2.79) of CNS medications suggested greater risk of cognitive decline than with nonuse. Combined use of CNS medications, especially at higher doses, appears to be associated with cognitive decline in older adults. Future studies must explore the effect of combined CNS medication use on vulnerable older adults.