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CORK Bibliography: Elderly

65 citations. October 2007 to present

Prepared: September 2008

Agostini JV; Concato J; Inouye SK. Improving sedative-hypnotic prescribing in older hospitalized patients: Provider-perceived benefits and barriers of a computer-based reminder. Journal of General Internal Medicine 23(Supplement 1): 32-36, 2008. (16 refs.)

BACKGROUND: Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium. OBJECTIVE: To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS AND SETTING: Thirty-six house staff physicians at a university hospital. MEASUREMENTS: Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Reponses were analyzed using grounded theory methodology. RESULTS: The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (+/-9 SD), with 10 indicating high satisfaction. CONCLUSIONS: Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing.

Alexander JA; Nahra TA; Lemak CH; Pollack H; Campbell CI. Tailored treatment in the outpatient substance abuse treatment sector: 1995-2005. Journal of Substance Abuse Treatment 34(3): 282-292, 2008. (41 refs.)

Interest in improving the quality of addiction treatment has led to the development of clinical paradigms that emphasize the principle of tailored care-matching treatments to the specific needs of each client or client subgroup. This work analyzes how trends in the provision of tailored treatment practices (TTPs) have changed between 1995 and 2005 across outpatient substance abuse treatment (OSAT) programs in the United States. Categories of interest include measures to capture needs assessment and treatment planning activities, treatment offerings for special populations, and case management activities. Results show that TTPs have diffused in an uneven fashion in the population of OSAT programs between 1995 and 2005. Specifically, needs assessment/treatment planning and case management remain a relatively common practice among OSAT programs, while treatment for special populations (especially same-race therapy) is less widely practiced and, indeed, experienced some decline over the study period. This trend is troublesome given that minority clients constitute a large proportion of those utilizing OSAT programs.

Alvarenga JM; de Loyola AI; Firmo JOA; Lima-Costa MF; Uchoa E. Prevalence and sociodemographic characteristics associated with benzodiazepines use among community dwelling older adults: Bambui Health and Aging Study (BHAS). Revista Brasileira de Psiquiatria 30(1): 7-11, 2008. (30 refs.)

Objectives: To assess the prevalence and sociodemographic characteristics associated with benzodiazepine use among community-dwelling older adults. Method. 1606 subjects, aged >= 60 years, corresponding to 92% of the residents of Bambui city, participated in this study. The information about medication use was obtained by means of a standard interview and the review of medication packaging. Substances were classified using the Anatomical Therapeutic Chemical Index. Results: The prevalence of benzodiazepine current use was 21.7% (26.7% among females and 14.0% among males). From these, 68.7% had been taking the medication for over one year 31.3% for over five years and 53.2% were using long half-life benzodiazepines. The medication most frequently used was bromazepam (35.6%), followed by diazepam (22.5%), clonazepam (12.6%) and lorazepam (7.8%). After adjustment for confounders, female gender (RP = 1.93; C195% = 1.51-2.46) was the only sociodemographic characteristic found to be independently associated with substance consumption. Conclusions: The prevalence of benzodiazepine use in the study population was high, but within the variation observed in developed countries. Chronic use of benzodiazepines and long half-life medications predominated.

Bacharach S; Bamberger PA; Sonnenstuhl WJ; Vashdi D. Aging and drinking problems among mature adults: The moderating effects of positive alcohol expectancies and workforce disengagement. Journal of Studies on Alcohol and Drugs 69(1): 151-159, 2008. (36 refs.)

Objective: This article examines the relationship between aging and drinking problems among mature workers and the moderating effects of positive alcohol expectancies (PAEs) and workforce disengagement. Method: This longitudinal study collected data on mature adults (i.e., retirement eligible) in three employment sectors (i.e., construction, manufacturing, and transportation) over five periods: T1 was 6 months before their retirement eligibility date and T5 was 4 years afterward. At T1, 1,122 subjects participated in the survey; at T5, 917 participated in the survey. Problem drinking was assessed in all five waves by the Drinking Problems Index. PAEs were measured at T4 and T5 by the Alcohol Outcomes Expectancies Scale. Workforce disengagement was assessed by subjects' employment status at T5 (i.e., still working despite eligibility versus fully retired/not working). Control variables were employment sector, age at T1, and gender. Results: PAEs moderated the relationship between aging and drinking problems: High PAEs were associated with an increase in drinking problems, whereas low PAEs were associated with a decrease in drinking problems. With regard to disengagement, continuing to work amplified the moderating effects of PAEs on the relationship between aging and drinking problems, whereas the moderating effects of PAEs were attenuated for the fully retired. Conclusions: This study provides further evidence of the significance of PAEs and drinking problems among mature adults, particularly as they are conditioned by disengagement from work. Implications for employee/member assistance program are discussed.

Beechem M. Elderly alcoholism: Implications for human service education. Journal of Teaching in the Addictions 3(2): 57-62, 2004

Incumbent upon those faculty who teach substance abuse courses is the need to integrate elderly alcoholism-related course content to encourage and adequately prepare university students to serve this "hidden" population. Course content would ideally include theories specific to loss-grief, aging, and alcoholism. In addition, field placement settings need to be established in treatment programs whereby students can apply theories learned in classroom instruction to develop practice skills to optimally serve this neglected population. Because only scant literature exists that specifically addresses elderly-alcoholism issues, it is hoped that the outgrowth of attention to this neglected population would be a proliferation of articles. The following is an abbreviated discussion of the recommended alcoholism theories specific to an elderly substance-abuse course curriculum to prepare students to better serve this "hidden" population.

Bell CM; Fischer HD; Gill SS; Zagorski B; Sykora K; Wodchis WP et al. Initiation of benzodiazepines in the elderly after hospitalization. Journal of General Internal Medicine 22(7): 1024-1029, 2007. (42 refs.)

Objective: To estimate the rate of new chronic benzodiazepine use after hospitalization in older adults not previously prescribed with benzodiazepines. Design: Retrospective cohort study using linked, population-based administrative data. Setting: Ontario, Canada between April 1, 1992 and March 31, 2005. Participants: Community-dwelling seniors who had not been prescribed benzodiazepine drugs in the year before hospitalization were selected from all 1.4 million Ontario residents aged 66 years and older. Main outcome measures: New chronic benzodiazepine users, defined as initiation of benzodiazepines within 7 days after hospital discharge and an additional claim within 8 days to 6 months. We used multivariate logistic regression to examine for the effect of hospitalization on the primary outcome after adjusting for confounders. Results: There were 405,128 patient hospitalizations included in the cohort. Benzodiazepines were prescribed to 12,484 (3.1%) patients within 7 days of being discharged from hospital. A total of 6,136 (1.5%) patients were identified as new chronic benzodiazepine users. The rate of new chronic benzodiazepine users decreased over the study period from 1.8% in the first year to 1.2% in the final year (P < .001). Multivariate logistic regression found that women, patients admitted to the intensive care unit or nonsurgical wards, those with longer hospital stays, higher overall comorbidity, a prior diagnosis of alcoholism, and those prescribed more medications had significantly elevated adjusted odds ratios for new chronic benzodiazepine users. Older individuals had a lower risk for the primary outcome. Conclusions: New benzodiazepine prescription after hospitalization occurs frequently in older adults and may result in chronic use. A systemic effort to address this risky practice should be considered.

Benitez CIP; Smith K; Vasile RG; Rende R; Edelen MO; Keller MB. Use of benzodiazepines and selective serotonin reuptake inhibitors in middle-aged and older adults with anxiety disorders: A longitudinal and prospective study. American Journal of Geriatric Psychiatry 16(1): 5-13, 2008. (39 refs.)

Objective: The purpose of this study was to examine the use of benzodiazepines (BZs) and selective serotonin reuptake inbibitors/selective norepinepbrine reuptake inhibitors (SSRIs/SNRIs) over nine years of follow-up in middle-aged and older adults with diagnoses of panic disorder with or without agoraphobia, social phobia, or generalized anxiety disorder. Setting and Participants: Participants in this study were enrolled in the Harvard/Brown Anxiety Research Project (HARP). HARP is a naturalistic, longitudinal, multisite study of adults with anxiety disorders who are recruited from psychiatric settings. The analytic sample consisted of 51 participants with anxiety disorders who were 55 to 70 years old at baseline and a younger cobort of 211 participants added for comparative analysis. Design: The authors examined patterns of medication use (BZs and SSRIs/SNRIs) in participants with anxiety disorders as the aged, by assessing the proportion of participants taking they medications using generalized estimating equation modeling. Measurements: The present data were derived from the structured diagnostic interview administered at enrollment using a combination of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Third Edition-R Non-Affective Disorder, Patient Version, Research Diagnostic Criteria Schedule for Affective Disorders-Lifetime, and subsequent follow-up interviews over a nine-year period using the Longitudinal Interval Follow-up Evaluation-Pharmacia & Upjohn to assess the weekly course of disorders to indicate syndrome severity and document medication use by specific type and dose on a weekly basis. Results: Findings showed that rates of BZ use were high among both the older (53% at baseline) and the younger (57.4%) age groups and did not significantly decrease over time, after controlling for time in episode of their anxiety disorders. There was a statistically significant increase in SSRI/SNRI use over time in both groups. At the beginning of the study, 18% of the older group and 21% of the younger group were using SSRIs/SNRls; however, at the end of the study, the rates increased to 35% and 43%, respectively, Conclusions: Although there was an increase in SSRI/SNRI use in older participants with anxiety disorders over the course of study, at nine years of follow-up, only 35% of participants were utilizing SSRI/SNRI medication, while more than one-half of the same participants were continuing to use BZs. To the authors' knowledge, there are no randomized clinical trials that have addressed comparative efficacy and safety of BZs and SSRIs/SNRIs in this population. However, there is documented evidence of adverse effects of chronic BZ use and the risk of developing dependency in older populations.

Bjork C; Thygesen LC; Vinther-Larsen M; Gronbaek MN. Time trends in heavy drinking among middle-aged and older adults in Denmark. Alcoholism: Clinical and Experimental Research 32(1): 120-127, 2008. (34 refs.)

Background: Studies have indicated an increasing proportion of heavy drinking among middle-aged and older Danes. Trends in consumption are often extremely sensitive to influence from various components of the time trends but only few have explored the age, period and cohort-related influences on late life alcohol consumption. By using age, period, and cohort modeling this study explores the time trends in heavy drinking. Methods: Data derive from five National Health and Morbidity Surveys conducted by the Danish National Institute of Public Health in 1987, 1994, 2000, 2003, and 2005. A total of 15,144 randomly selected Danes between the age of 50 and 74 were interviewed about their alcohol intake on the last weekday and their alcohol intake in the last week. By applying the age-period-cohort model the probability of heavy alcohol drinking is estimated to separate the influence of age, period (calendar time) and cohort (year of birth). Results: The unadjusted probability of heavy drinking declines by age and increases by calendar year and year of birth for both men and women. However, the negative effect of age is attenuated for women when adjusted for birth cohort, indicating that the proportion of heavy drinking women increases in younger birth cohorts. This trend is not observed for men as their drinking pattern mainly increase slightly by calendar year. Conclusions: Our Danish observations for older aged individuals correspond to the social and cultural changes in the 1960s and 1970s that possibly have affected the drinking behavior of the cohorts. Time trend analyses, such as this may serve as an excellent opportunity to extrapolate and forecast alcohol mortality and morbidity.

Brekke M; Rognstad S; Straand J; Furu K; Gjelstad S; Bjorner T et al. Pharmacologically inappropriate prescriptions for elderly patients in general practice: How common? Scandinavian Journal of Primary Health Care 26(2): 80-85, 2008. (33 refs.)

Objective. To assess Norwegian general practitioners' (GPs') level of potentially harmful drug prescribing for elderly patients. Design. Prescription data for 12 months were retrospectively retrieved from the Norwegian Prescription Database (NorPD). Data were assessed in relation to 13 prescription quality indicators. Setting. General practice. Subjects. A total of 454 GPs attending continuous medical education (CME) groups in Southern Norway, 85 836 patients >= 70 years who received any prescription from the GPs during the study period. Main outcome measures. Number of prescriptions assessed in relation to pharmacological inappropriateness based on a list of 13 explicit prescription quality indicators. Results. Some 18.4% of the patients (66% females with mean age 79.8 years, 34% males with mean age 78.7 years) received one or more inappropriate prescriptions from their GP. An NSAID in a potentially harmful combination with another drug (7%) and a long-acting benzodiazepine (4.6%) were the most frequent inappropriate prescriptions made. Doctor characteristics associated with more inappropriate prescribing practice were old age and working single-handed with many elderly patients. Conclusion. The study reveals areas where GPs' prescribing practice for elderly patients can be improved and which can be targeted in educational interventions.

Brooks JO; Hoblyn JC. Neurocognitive costs and benefits of psychotropic medications in older adults. (review). Journal of Geriatric Psychiatry and Neurology 20(4): 199-214, 2007. (222 refs.)

Psychotropic medications are widely used in older adults and may cause neurocognitive deficits. Older adults are at increased risk of developing adverse effects because of age-related pharmacodynamic and pharmacokinetic changes. This article provides a comprehensive review of the undesirable, and at times beneficial, effects of psychotropic medications. The review covers a wide range of medications that impair executive function, memory, and attention, as well as a much smaller group of medications that lead to improved neurocognitive function. Some of the most commonly used psychotropic medications in older adults, namely, antidepressants, sedatives, and hypnotics, are among the drugs that most consistently lead to cognitive impairments. Medications with anticholinergic properties almost invariably lead to neurocognitive dysfunction, despite symptom improvement. The neurocognitive costs and benefits of psychiatric medications should be considered in the context of disease treatment in older adults.

Bulat T; Castle SC; Rutledge M; Quigley P. Clinical practice algorithms: Medication management to reduce fall risk in the elderly. Part 3, benzodiazepines, cardiovascular agents, and antidepressants. Journal of the American Academy of Nurse Practitioners 20(2): 55-62, 2008. (55 refs.)

There are associations between falls and the use of sedatives, psychotropics, cardiovascular agents, antidepressants, and polypharmacy. Our third article in the series will review the development of specific subalgorithms for benzodiazepines (BZDs), cardiovascular agents, and antidepressants (algorithms 3-5). We presented the process of development in our first article and the summary algorithm (algorithms 1 and 2) in our second article in this series. There are a number of ways in which drugs might increase the risk of an elderly person falling, most common being sedation, impaired balance and reaction time, orthostatic hypotension, and drug-induced parkinsonism. Medications are a potentially modifiable factor which can reduce fall risk The Guideline for the prevention of falls in older persons (American Geriatrics Society, British Geriatrics Society and American Academy of Orthopaedic Surgeons Panel of Falls Prevention, 2001) states that patients who have fallen should have their medications reviewed and altered or stopped as appropriate in light of their risk of future falls.

Cataldo JK. Clinical implications of smoking and aging - Breaking through the barriers. Journal of Gerontological Nursing 33(8): 32-41, 2007. (74 refs.)

In the United States, there are almost 4 million smokers older than 65. Yet, older smokers often receive suboptimal care. Inaccurate information and myths about older smokers may have become ingrained in the attitudes and beliefs of both older smokers and health care providers. In this article, prominent myths about older smokers will be explored and refuted. The realities include the following: Smoking tobacco has no benefit; it does not improve cognition or mood; smoking cessation, even among older, frail adults, produces significant benefits in terms of health and quality of life; and using filtered cigarettes or reducing the number of cigarettes smoked per day does not reduce harm. Gerontological nurses are at the forefront of treating tobacco use among older smokers. They should assess the smoking status of all older adults at every contact, treat smokers with pharmacotherapy and counseling, follow up with patients, and stay informed.

Chang CM; Wu ECH; Chang IS; Lin KM. Benzodiazepine and risk of hip fractures in older people: A nested case-control study in Taiwan. American Journal of Geriatric Psychiatry 16(8): 686-692, 2008. (39 refs.)

Objective: To examine the characteristics of benzodiazepines usage and their associations with hip fractures. Method: All subjects were aged 65 and older and enrolled in the National Health Insurance program in Taiwan, 2001-2004. Cases (N = 217) were elderly patients who were identified with hip fractures for the first time in their outpatient claims. They were individually matched to 1,214 comparison patients based on age, gender, and index year. Benzodiazepine usage (doses, duration, half-life) and the other covariates including comorbidities, health care utilization, and psychotropic medications used in the 180 days before index events were constructed. Results: Using nonusers as reference group, use of benzodiazepines was significantly associated with hip fractures (adjusted odds ratio [AOR] = 1.7, 95% confidence interval [CI] = 1.2-2.5). Such risks appear to be particularly high during the first month (AOR = 5.6, 95% CI = 2.7-11.8) of exposure, doses higher than 3.0 mg/day in diazepam equivalents (AOR = 1.8, 95% CI = 1.1-3.1), and using short-acting benzodiazepines (AOR = 1.8, 95% CI = 1.3-2.7). Conclusions: Benzodiazepine exposure in the elderly increases the risk of hip fractures. This is true even with modest dosage, short-acting agents and short-term exposures. Clinicians should prescribe benzodiazepines judiciously with the elderly to minimize drug-related hip fractures.

Christie IC; Price J; Edwards L; Muldoon M; Meltzer CC; Jennings JR. Alcohol consumption and cerebral blood flow among older adults. Alcohol 42(4): 269-275, 2008. (49 refs.)

A substantial epidemiological literature now supports the existence of a J or U-shaped association between alcohol consumption and a broad range cardiovascular health outcomes including stroke. Although it is well documented that alcoholics exhibit both global and regional cerebral hypoperfusion in the sober state, little is known regarding the effects of a broader range of alcohol consumption on cerebral blood flow (CBF). The present study employed positron emission tomography with (H2O)-O-15 to assess quantitative global and regional CBF in 86 participants (51 men and 35 women; mean age 60.1) as a function of self-reported weekly alcohol consumption (none, < 1, 1 to < 7, 7 to < 15, and > 15 drinks per week). Analyses controlling for age, gender, and vascular health (carotid intima-media thickness) revealed that, relative to the weighted population mean, global CBF was greater in the lightest alcohol consumption group (< 1 per week) and lower in the heaviest (> 15 per week). Effects did not vary across regions of interest. This report is the first to describe an inverted J-shaped relationship between alcohol consumption and CBF in the absence of stroke.

Coma M; Munoz J; Postigo P; Ayuso M; Sierra C; Sayrol T. Primary care doctors' and nurses' opinion of elder abuse and neglect. Gaceta Sanitaria 21(3): 235-241, 2007. (37 refs.)

Objective: To identify primary care health professionals' opinion of elder abuse and its management. Qualitative study through focus groups. Participants: Twenty-seven health professionals in primary care. Analyses of the thematic content of data, codification, segmentation and creation of categories of the text corpus. Results: The most frequent types of abuse were psychological and financial. Neglect was associated with current lifestyles. Physical and sexual abuse was considered infrequent, but possibly under-detected. Important risk factors were dysfunctional families, stressed and under-trained caregivers, and elder hostility. The profile of the abuser was associated with mental disorders, drug addiction and prior family violence in physical and financial abuse, but no clear profile was identified in the categories of neglect and abandonment. Social and health resources were insufficient and limited intervention, thus making detection fruitless. Education, monitoring and counseling of health professionals in elder abuse was considered necessary because, given external and well coordinated support, primary care could intervene effectively in situations of elder abuse. Conclusions: Although the phenomenon of elder abuse is well known, consensus guidelines for its detection and intervention need to be defined. The lack of resources and the difficulties of delimiting responsibilities in the management of elder abuse should be taken into account when planning strategies. The health professionals considered themselves as a resource and did not avoid involvement.

Cooper TV; Resor MR; Stoever CJ; Dubbert PM. Physical activity and physical activity adherence in the elderly based on smoking status. Addictive Behaviors 32(10): 2268-2273, 2007. (10 refs.)

This study assessed the impact of current smoking status and lifetime smoking status on physical fitness and physical activity regimen adherence as part of a larger study on walking for exercise in elderly primary care patients at a Veterans Affairs Medical Center. At baseline, 218 participants self-reported smoking status which was verified by carbon monoxide expiration. Former and current smokers responded to questions about length of time quit, average daily cigarette intake, and years a smoker. Smoking measures were re-collected at 6- and 12-month follow-ups if the participants indicated a change in smoking status. Veterans completed multiple measures of physical activity (e.g., 6-min walk, 7-day Physical Activity Recall), and adherence to a physical activity goal was assessed. The Physical Component Summary (PCS) subscale of the Medical Outcomes Study Short Form-36 (MOS SF-36) was used to assess health-related quality of life. Hierarchical regression models indicated smoking status was a predictor of the baseline 6-min walk such that smokers walked significantly shorter distances than nonsmokers. In addition, smoking status was found to be a significant predictor of adherence; however, the overall model that included smoking status as a predictor did not demonstrate a significant effect on adherence. Neither smoking status nor pack years were predictors of baseline self-reported physical activity or changes in physical activity post intervention. Results are consistent with recommendations to use physical exercise as an aid to tobacco cessation, even in aging men with extensive smoking histories.

Craig BM; Kraus CK; Chewning BA; Davis JE. Quality of care for older adults with chronic obstructive pulmonary disease and asthma based on comparisons to practice guidelines and smoking status. BMC Health Services Research 8(article 144), 2008. (26 refs.)

Background: The purpose of this study was to describe the prevalence of respiratory diseases in older adults and compare the demographic, health and smoking characteristics of those with and without these diseases. Furthermore, we evaluate the association between smoking status and patterns in health care and how concordant this care is with guidelines. Methods: Using a nationally representative sample of 29,902 older adults who participated in the Medicare Current Beneficiary Survey (1992-2002), we compared guideline recommendations on the treatment and prevention of chronic obstructive pulmonary disease and asthma with survey utilization data, including the use of bronchodilators, spirometry and influenza vaccine. Results: 26% to 30% of older adults were diagnosed with or self-reported chronic respiratory diseases; however 69% received no pharmacological treatment and 30% of patients reporting use of pharmacological treatments did not receive short-acting bronchodilator inhalers. Current smokers appeared to receive significantly less care for respiratory diseases than non-smokers or former smokers. Conclusion: Disparities between recommended and actual care for older adults with chronic lung disease require further research. The needs of older adults with co-morbidities and nicotine addiction deserve special attention in care as well as guideline development and implementation.

Doolan DM; Stotts NA; Benowitz NL; Covinsky KE; Froelicher ES. The Women's Initiative for Nonsmoking (WINS) XI: Age-related differences in smoking cessation responses among women with cardiovascular disease. American Journal of Geriatric Cardiology 17(1): 37-47, 2008. (24 refs.)

Smoking cessation has immediate health benefits; however, the efficacy of smoking cessation interventions among older adults and women has received limited research attention. The original Women's Initiative for Nonsmoking (WINS) study was a randomized controlled trial that tested the efficacy of a smoking cessation intervention for Bay Area women hospitalized with cardiovascular disease. The current study, which used the WINS dataset, compares participants 62 and older with those younger than 62 years. The sample (n =277) contained 136 older smokers and 141 younger smokers. At the 6-month, follow-up, 52.1% of older smokers had quit smoking compared with 40.6% of younger smokers. At the 12-month follow-up, 52.0% of older smokers had quit smoking compared with 38.1% of younger smokers. The difference at 12 months was statistically significant, and a Kaplan-Meier survival analysis further supported these findings. Clinicians should be sure to also include older smokers in smoking assessments and smoking cessation interventions.

Fein G; McGillivray S. Cognitive performance in long-term abstinent elderly alcoholics. Alcoholism: Clinical and Experimental Research 31(11): 1788-1799, 2007. (84 refs.)

Background: To date, there is a wealth of literature describing the deleterious effects of active alcoholism on cognitive function. There is also a growing body of literature on the extent of cognitive recovery that can occur with abstinence. However, there is still a dearth of published findings on cognitive functioning in very long-term abstinence alcoholics, especially in the elderly population. Methods: The current study examines 91 elderly abstinent alcoholics (EAA) (49 men and 42 women) with an average age of 67.3 years, abstinent for an average of 14.8 years (range 0.5 to 45 years), and age and gender comparable light/nondrinking controls. The EAA group was divided into 3 subgroups: individuals that attained abstinence before age 50 years, between the ages 50 and 60 years, and after age 60 years. Attention, verbal fluency, abstraction/cognitive flexibility, psychomotor, immediate memory, delayed memory, reaction time, spatial processing, and auditory working memory were assessed. The AMNART and cranium size were used as estimates of brain reserve capacity, and the association of all variables with alcohol use measures was examined. Results: Overall, the EAA groups performed comparably to controls on the assessments of cognitive function. Only the abstinent in group before 50 years of age performed worse than controls, and this was only in the domain of auditory working memory. EAAs had larger craniums than their controls. This effect was strongest for those who drank the longest and had the shortest abstinence. Such individuals also performed better cognitively. Conclusions: Our data showed that elderly alcoholics that drank late into life, but with at least 6 months abstinence can exhibit normal cognitive functioning. Selective survivorship and selection bias probably play a part in these findings. Cognitively healthier alcoholics, with more brain reserve capacity, may be more likely to live into their 60s, 70s, or 80s of age with relatively intact cognition, and to volunteer for studies such as this. Our results do not imply that all elderly alcoholics with long-term abstinence will attain normal cognition.

Floel A; Witte AV; Lohmann H; Wersching H; Ringelstein EB; Berger K et al. Lifestyle and memory in the elderly. Neuroepidemiology 31(1): 39-47, 2008. (85 refs.)

Background: Healthy lifestyle has been associated with a decreased risk of developing cardiovascular disease, but its relationship with memory functions is still inconclusive. This study aims to analyze the association between a composite lifestyle index and memory performance. Methods: In this cross-sectional survey, 198 healthy individuals ( aged 65-84 years) underwent tests of verbal episodic memory. A composite lifestyle index was calculated that included the following lifestyle dimensions: physical exercise, dietary habits, BMI, smoking and alcohol consumption. The healthiest behavior was defined as: a BMI ! 22; a diet high in fruits, vegetables, wholemeal/low-fat foods and unsaturated fatty acids; energy expenditure through physical activity 1 13,000 kcal/week; a history of never smoking; an alcohol consumption of 4-10 drinks per week. Results: Linear regression analysis revealed that a high lifestyle index score was associated with a better memory score ( after adjusting for age, sex, education and blood pressure). The composite index had a stronger relationship with memory scores than single factors. Conclusions: This cross-sectional study revealed that a healthy lifestyle, assessed by a simple composite index, is related to better memory performance in healthy elderly individuals. Our findings point to the importance of a comprehensive modulation of lifestyle factors when finding ways to preserve memory functions in the elderly.

Ford J; Spallek M; Dobson A. Self-rated health and a healthy lifestyle are the most important predictors of survival in elderly women. Age and Ageing 37(2): 194-200, 2008. (28 refs.)

Objective: to test the hypothesis that morbidity and health related behavioural factors are stronger than social factors as predictors of death among older women. Methods: we used data from 12,422 participants in the Australian Longitudinal Study on Womens Health who were aged 7075 in 1996. Proportional hazards models of survival up to 31 October 2005 were fitted separately for the whole cohort and those women who were initially in good health. Results: among the whole cohort, 18.7% died during the follow_up period. The strongest predictor of death was poor or fair self-rated health (with 52.3% and 28.0%, respectively, of women in these categories dying). Among the women in good health at baseline 11.5% died, with current cigarette smoking (hazard ratio HR = 2.19, 95% confidence interval (1.71, 2.81), physical inactivity (HR = 1.45 (1.17, 1.81)), and age (HR = 1.10 (1.04, 1.16) per year) as statistically significant predictors of death. Discussion: among older women, current health and health related behaviours are stronger predictors than social factors of relatively early mortality. Adopting a healthier lifestyle, by doing more exercise and not smoking, is beneficial even in old age.

Fujisawa K; Takata Y; Matsumoto T; Esaki M; Ansai T; Iida M. Impact of smoking on mortality in 80-year-old Japanese from the general population. Gerontology 54(4): 210-216, 2008. (32 refs.)

Background: It is well known that cigarette smoking is the main health hazard in middle-aged people. However, data regarding smoking and health in old-aged people are limited, especially in the Japanese population. Objective: The present study aimed to investigate the influence of smoking on mortality in the elderly Japanese population. Methods: A cohort of 690 individuals of 80 years of age were categorized into 3 groups: non-smokers, ex-smokers and current smokers. The adjusted mortality after 4 years was compared among the 3 groups. The possible influence of smoking status on the cause of death was also investigated. Results: The overall mortality was significantly higher in males [ relative risk (RR): 2.3, 95% confidence interval (CI): 1.0-5.2] and females ( RR: 4.2, 95% CI: 1.9-9.5) in the current-smoker group than in the non-smoker group. The risk of any-cause mortality in the ex-smoker group was not statistically different from that in the non-smoker group. In males, current smokers died of cancer more frequently than non-smokers ( RR: 10.7, 95% CI: 1.3-90.8). Cardiovascular disease was a significant cause of death in female current smokers ( RR: 5.2, 95% CI: 1.6-16.9). This difference in mortality was not observed between groups of non-smokers and ex-smokers of both genders. In male smokers, there was a positive relationship between the daily amount of consumed cigarettes and overall mortality. Conclusion: Smokers should be encouraged to stop smoking, since habitual smoking increases the risk of mortality even in old age.

Glintborg B; Olsen L; Poulsen H; Linnet K; Dalhoff K. Reliability of self-reported use of amphetamine, barbiturates, benzodiazepines, cannabinoids, cocaine, methadone, and opiates among acutely hospitalized elderly medical patients. Clinical Toxicology 46(3): 239-242, 2008. (21 refs.)

Background. Undisclosed use of illicit drugs and prescription controlled substances is frequent in some settings. The aim of the present study was to estimate the reliability of self-reported use of amphetamine, barbiturates, benzodiazepines, cannabinoids, cocaine, methadone, and opiates among acutely hospitalized medical patients. Methods. Patients admitted to an acute medical department were interviewed about their drug use. Patients provided blood and urine samples for drug analysis. Results of a toxicology screen were compared to self-reported drug use. Toxicology screens positive for drugs not reported during the interview were only considered truly positive after verification by a substance specific analysis. Results. Five hundred patients were included. The median age was 72 years and 298 (60%) were female. In total, 103 patients (21%) reported use of opiates and 65 patients (13%) used benzodiazepines. Only 8 patients reported use of illicit drugs (cannabinoids, 2%). Toxicology analyses were performed in a randomly selected sub-sample of 100 patients. Among 27 patients (27%), the analyses indicated use of one or more drugs, mainly benzodiazepines (15 patients), morphine (12 patients) or cannabinoids (5 patients). Another 6 patients had screenings unexpectedly positive for opiates, but the verification analysis indicated use of codeine-containing drugs. The overall sensitivity of self-reports in detecting drug use was 66%. The negative predictive value of a patient not reporting use of a drug was over 90% for all 7 drug-types screened. Conclusion. Among 100 randomly selected mainly elderly medical patients, undeclared use of illicit drugs was rare. However, some patients underreported use of benzodiazepines and cannabinoids.

Hall SM; Humfleet GL; Gorecki JA; Munoz RF; Reus VI; Prochaska JJ. Older versus younger treatment-seeking smokers: Differences in smoking behavior, drug and alcohol use, and psychosocial and physical functioning. Nicotine & Tobacco Research 10(3): 463-470, 2008. (40 refs.)

Quitting smoking benefits older individuals, yet few recent studies have described older smokers. The goal of this paper was to test a series of hypotheses about differences between smokers aged 50 years or older (50+) and those younger than age 50 (<50) presenting to the same treatment facility during 2002-2004 for participation in two randomized clinical trials: one exclusively for smokers aged 50+, and a second open to smokers aged 18 or older. As predicted, smokers aged 50+ were more tobacco dependent, had better psychological functioning, and had poorer physical functioning than those aged <50. Contrary to predictions, we found no differences in motivation to quit cigarette smoking or in alcohol use. Women aged 50+ were less likely to report marijuana use than women aged <50, and less likely than men to receive a positive diagnosis for alcohol abuse. Despite higher scores on measures of tobacco dependence, older smokers were less likely to be diagnosed as tobacco dependent or as having tobacco withdrawal using DSM-IV criteria. Rates of DSM-IV alcohol abuse and dependence were high in both age groups but were higher for smokers aged <50. We found no striking differences between studies in reasons for exclusion, but in both the proportion of individuals excluded due to current antidepressant use was high. Implications for the assessment and treatment of older adults are discussed.

Ilomaki J; Korhonen MJ; Enlund H; Hartzema AG; Kauhanen J. Risk drinking behavior among psychotropic drug users in an aging Finnish population: The FinDrink study. Alcohol 42(4): 261-267, 2008. (53 refs.)

Psychotropic drug use and alcohol consumption is increasing among aging Finns. Alcohol use is not recommended with benzodiazepines and some other psychotropic medicines. Concomitant use may lead to accidents and other serious consequences. The aim of this study was to analyze the drinking behavior of psychotropic drug users in an aging Finnish population. This study is part of the ongoing epidemiologic FinDrink study. Self-reported data on alcohol consumption and psychotropic drug use were collected from the Kuopio Ischaemic Heart Disease Risk Factor Study examinations conducted in 1998-2001. Overall, 854 men and 920 women participated in the study. A total of 204 (11.5%) individuals used psychotropic drugs regularly (14.2% of women and 8.5% of men; P <.001). Three quarters of the study population had used alcohol weekly during the preceding year (68.9% of women and 87.5% of men; P <.001). Men who use anxiolytics and sedatives were more likely to drink alcohol at least twice a week (odds ratio=2.42; 95% confidence interval= 1.30-4.51), to be binge drinkers (odds ratio=1.86; 95% confidence interval= 1.01-3.43) and to be heavy alcohol consumers (odds ratio=2.22; 95% confidence interval= 1.13-4.39) than men not using psychotropics. In women, alcohol consumption and drinking patterns were same between the groups. Our results indicate the potential for alcohol-related health risks among aging Finnish men and women using psychotropic drugs..

Johnell K; Fastbom J; Rosen M; Leimanis A. Inappropriate drug use in the elderly: a nationwide register-based study. Annals of Pharmacotherapy 41(7-8): 1243-1248, 2007. (25 refs.)

BACKGROUND: Potentially inappropriate drug use (IDU) is an important and preventable safety concern, in the care of elderly patients and has been associated' with adverse drug reactions, hospitalization, and mortality. OBJECTIVE: To estimate the-prevalence of potentially IDU among the elderly in Sweden and investigate whether age, sex; arid number of dispensed drugs are associated with IDU: METHODS; We analyzed data on age; sex, and dispensed drugs for people aged 75 years and older who-were listed in the Swedish Prescribed Drug Register from October-December 2005 (N = 732 228). The main outcome measures of IDU were prescription of anticholinergics, prescription of long-acting benzodiazepines, concurrent use of 3 or more psychotropic drugs, and an indication of potentially serious drug-drug interactions. RESULTS: Prevalence for IDU was 17%; for anticholinergic drugs 6%, long-acting benzodiazepines 5%, 3 or more psychotropic drugs 5%,. and potentially serious drug-drug interactions 4 %. After adjustment for age and sex, number of dispensed drugs was strongly. associated with all 4 measures of IDU. After adjustment for sex and number of dispensed drugs, increasing age was moderately associated with a higher probability of IDU, long-acting benzodiazepines, and 3 or more psychotropic drugs, After adjustment for age and number of dispensed drugs; women had a slightly increased probability of IDU, anticholinergic drugs, long-acting benzodiazepines, and 3 or more psychotropic drugs. CONCLUSIONS: IDU was fairly common among the elderly in Sweden in 2005 and was strongly connected to the number of dispensed drugs they were taking. Older age and female sex were related to inappropriate use of psychotropic drugs, whereas the opposite relationship prevailed for potentially serious drug-drug interactions. Future research is needed to determine whether IDU will become more common due to increasing use of drugs among elderly persons. The challenge is to balance the problems related to IDU without denying older people potentially valuable drug therapy.

Johnson SD; Striley C; Cottler LB. Comorbid substance use and HIV risk in older African American drug users. Journal of Aging and Health 19(4): 646-658, 2007. (21 refs.)

Objectives: This analysis examines substance abuse/dependence and related HIV risk behaviors among older drug users in comparison to their younger counterparts. Methods: Data related to substance use disorders and HIV-related behaviors were collected from 1,079 African American drug users recruited using a street outreach method. Results: Older users were less likely to have engaged in recent sexual activity, but those who did engage did not vary significantly in their sexual risk behaviors than did drug users aged 25 to 44. Older users were more likely to abuse cocaine and be opiate dependent than younger users were, and this abuse and dependence, along with alcohol abuse, were associated with older users' perception of their risk for HIV/AIDS. Discussion: Although the years 25 to 44 are considered a critical age for HIV risk, older substance users have similar levels of risk for HIV/AIDS. However, older users may not understand how some behaviors contribute to HIV risk.

Kim S; De La Rosa M; Rice CP; Delva J. Prevalence of smoking and drinking among older adults in seven urban cities in Latin America and the Caribbean. Substance Use & Misuse 42(9): 1455-1475, 2007. (40 refs.)

In 2000, a representative sample of the elderly population (60 years or older) was selected from seven urban cities in Latin America and the Caribbean: Buenos Aires (Argentina), Mexico City (Mexico), Santiago (Chile), Havana (Cuba), Montevideo (Uruguay), Bridgetown (Barbados), and Sao Paulo (Brazil). A face-to-face interview was uniformly administered in the respective official languages. A total of 10,577 older adults were included in this study. The elderly in Havana had the highest prevalence of smoking (46.5% of men and 21.5% women). The highest prevalence of daily drinking was in Buenos Aires (19%). In contrast, only 1.5% of respondents in Mexico City, and 2.3% of respondents in Havana consumed alcohol daily. Smoking and daily drinking were highly prevalent among older adults. As the older adult population grows steeply, the health behavior of this population starts carrying important implications for health care systems.

Kintz P; Villain M; Cirimele V. Chemical abuse in the elderly: Evidence from hair analysis. Therapeutic Drug Monitoring 30(2): 207-211, 2008. (13 refs.)

The use of a drug to modify a person's behavior for criminal gain is not a recent phenomenon. However, the recent increase in reports of drug-facilitated crimes (sexual assault, robbery) has caused some alarm in the general public. Drugs involved can be pharmaceuticals such as benzodiazepines (flunitrazepam, lorazepam, clonazepam), hypnotics (zopiclone, zolpidem), sedatives (neuroleptics, some antihistamines), or anesthetics (GHB, ketamine); drugs of abuse such as cannabis, ecstasy, or LSD; or, more often, ethanol. Mistreatment of older people, whether it is abuse or neglect, can be classified as physical, psychologic, or financial/material. Several types of mistreatment may occur simultaneously. Very few data are available in the international literature. It seems that mental abuse and neglect are more frequent, but physical abuse such as beating, pushing, kicking, and possibly sexual abuse have also been reported. Drugs used to facilitate sexual assaults can be difficult to detect (active products at low dosages, chemical instability), can possess amnesic properties, and can be rapidly cleared from the body (short half-life). In these situations, blood, or even urine, can be inadequate. This is the reason why some laboratories have developed an original approach based on hair testing. Hair was suggested as a valuable specimen in situations in which, as a result of a delay in reporting the crime, natural processes have eliminated the drug from typical biologic specimens. Hair analysis may be a useful adjunct to conventional drug testing in sexual assault. It should not be considered as an alternative to blood and urine analyses, but as a complement. Mass spectrometry/mass spectrometry technologies appear to be required for analyses in drug-facilitated cases. The experience of the authors is presented in cases involving the elderly and chemical poisoning.

Koenig TL; Crisp C. Ethical issues in practice with older women who misuse substances. Substance Use & Misuse 43(8/9): 1045-1061, 2008. (73 refs.)

Older women who misuse substances represent a growing population within the United States. Yet, helping professionals lack guidance in addressing ethical issues that arise in working with these older women. The purpose of this article is to (a) examine what we know about older women who misuse substances, (b) address professional ethical dilemmas and other ethical issues that emerge in treating and delivering services to older women, (c) identify barriers for treatment, and (d) propose practice recommendations. Specifically, the authors examine the overarching professional ethical dilemma or tension between client autonomy and professional beneficence that emerges in treating and delivering services to older women. Implications are delineated for professional education, gender-and age-sensitive substance misuse services, and research and policy efforts.

Lester PE; Kohen I. Smoking in the nursing home: A case report and literature review. Journal of the American Medical Directors Association 9(3): 201-203, 2008. (13 refs.)

We report a case of second- and third-degree burns in an elderly nursing home resident with dementia who was smoking in her room. This case highlights the risks of smoking by residents in long-term care settings. It also raises awareness to the issues involving smoking cessation and restriction of smoking privileges in the long-term care setting.

Lim SW; Oh KS; Shin YC; Kang SG; Kim L; Park YM et al. Clinical and temperamental differences between early- and late-onset alcoholism in Korean men. Comprehensive Psychiatry 49(1): 94-97, 2008. (19 refs.)

Objectives: The aims of this study were to elucidate the clinical and temperamental differences between early- and late-onset alcoholism among Korean men and to ascertain the validity of Cloninger's typology model of alcoholism for Koreans. Methods: All of the subjects were screened after a detoxification period of at least 2 weeks using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I Disorders for diagnosing alcohol dependence and identifying psychiatric comorbidities. The Korean version of the tridimensional personality questionnaire was then administered to 173 male alcoholic inpatients; and information regarding their criminality, family history of alcoholism, and age at the onset of alcohol-related problems was gathered. We divided the patients into 2 groups based on the age at the onset of alcoholism: (1) early onset (n = 80), when they were up to 25 years old at the onset, and (2) late onset (n = 93), when they were older than 25 years at the onset. Results: Early-onset patients exhibited more criminality (chi(2) = 15.45, df= 1, P <.00 1, odds ratio [OR] = 3.84, 95% confidence interval [CT] 1.93-7.65), suicide attempts (chi(2) = 7.92, df= 1, P = .005, OR [95% Cl] = 3.14 [1.38-7.15]), and family history of alcoholism (chi(2) = 24.75, df= 1, P <.001, OR [95% CI] = 5.27 [2.67-10.37]). With regard to the tridimensional personality questionnaire profile, the early-onset patients exhibited a higher score of novelty seeking (t = 3.42, P = .001), with the difference still being significant after adjusting for age by analysis of covariance (using age as a covariate) (F = 5.928, P =.016). However, harm avoidance (t = -0. 13, P =.89), reward dependence (t = -0.19, P =.85), and persistence (t = -0.62, P =.54) did not differ between the 2 groups. Conclusions: There were several distinct clinical and temperamental differences between early- and late-onset alcoholism among Korean male alcoholic patients. It is suggested that the age at the onset of alcoholism can be used to discriminate alcoholic subtypes. Our data also partly support Cloninger's typology of 2 types of alcoholic individuals.

Lovheim H; Sandman PO; Kallin K; Karlsson S; Gustafson Y. Symptoms of mental health and psychotropic drug use among old people in geriatric care, changes between 1982 and 2000. International Journal of Geriatric Psychiatry 23(3): 289-294, 2008. (25 refs.)

Background: Some major changes have occurred in the care of older people in institutions providing geriatric care from a few decades ago to today. How these changes regarding organization, diagnosis and pharmacological treatment, have affected the mental health of the population in general remains unclear. Method: The prevalence of symptoms of mental health in two comparable cross-sectional surveys from 1982 and 2000 were studied. The study population consisted of all the people aged 65 years or older living in geriatric care units in the county of Vasterbotten, in northern Sweden. Multivariate regression was used to correct for the effect of change in demographic structure. Results Six out of 14 symptoms showed a significant decrease, correcting for demographical changes. These were, expressed as descriptions of behaviours, Sad (OR 0.72), Crying (OR 0.67), Fearful (OR 0.73), Disturbed and restless (OR 0.84), Lacking initiative (OR 0.67) and Does not cooperate (OR 0.67). Two symptoms showed a significant increase, Overactive/manic (OR 1.44) and Hallucinates visually (OR 1.27). The use of antidepressants had increased from 6.3% 1982 to 39.9% 2000. The use of minor tranquillizers had increased from 13.2% to 39.2% and the prevalence of antipsychotic use had decreased from 25.1% to 20.5%. Conclusion: This article clearly shows that the prevalence of several important symptoms and behaviours in a geriatric care population have decreased over the course of eighteen years, correcting for demographical changes. This might at least partly be accounted for by today's more widespread use of antidepressants and benzodiazepines.

Luijendijk HJ; Tiemeier H; Hofman A; Heeringa J; Stricker BHC. Determinants of chronic benzodiazepine use in the elderly: A longitudinal study. British Journal of Clinical Pharmacology 65(4): 593-599, 2008. (21 refs.)

AIMS: The risk of adverse events due to chronic benzodiazepine use is high in the elderly. Clinicians need to be able to identify those persons who are at risk of chronic benzodiazepine use, but little is known about the determinants. This study determined social and health related factors that predict new-onset chronic benzodiazepine use in community-dwelling elderly. METHODS: This study was embedded in an ongoing cohort study among 5364 persons aged >= 57 years. Drug-dispensing medication records were available for the period between 1991 and 2003. We defined chronic benzodiazepine use as use during at least 180 days in a period of 365 consecutive days. The association of various social, psychiatric and somatic variables with new-onset chronic benzodiazepine use was studied with a Cox proportional hazards analysis. RESULTS: Symptoms of depression, hypertension, pain related joint complaints and the perception of poor physical health predicted new-onset chronic use. In the subsample of participants who had filled at least one prescription in the follow-up period, of these variables only pain related joint complaints increased the risk of new-onset chronic use. Living alone protected against chronic benzodiazepine use. CONCLUSIONS: The elderly with poor mental and physical health are at an increased risk of chronic benzodiazepine use. Living alone was found to decrease the risk of chronic use, which suggests that social factors may determine drug usage patterns. Very few characteristics predicted chronic benzodiazepine use once patients had received their first prescription. For clinicians, identification of patients at high risk is therefore not straightforward.

Martens PJ; Fransoo R; Burland E; Burchill C; Prior HJ; Ekuma O. Prevalence of mental illness and its impact on the use of home care and nursing homes: A population-based study of older adults in Manitoba. Canadian Journal of Psychiatry 52(9): 581-590, 2007. (27 refs.)

Objectives: To determine the prevalence of mental illness in older adults and its effect on home care and personal care home (PCH) use. Methods: Using nonidentifying administrative records (fiscal years 1997-1998 to 2001-2002) from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy, we determined the 5-year period prevalence for individuals aged 14 55 years and over (119 539 men and 145 752 women) for 3 mental illness categories: cumulative mental disorders (those having a diagnosis of depression, anxiety disorder, personality disorder, schizophrenia, and [or] substance abuse), any mental illness, and dementia. We calculated age-specific and age-adjusted rates of home care and PCH use and the prevalence of mental illness in PCH residents. Results: From the group aged 55 to 59 years to the group aged 90 years or older, the prevalence of mental illness increased with the population's age. The prevalence of any mental illness rose from 32.4% to 45.0% in men and from 42.6% to 51.9% in women, and dementia prevalence rose from 2.0% to 33.6% in men and from 1.3% to 40.3% in women. The age-adjusted annual rates of open home care cases per 1000 population aged 55 and older varied by mental illness grouping (no mental disorder, 57 for men and 91 for women; cumulative mental disorders, 162 for men and 191 for women; dementia, 300 for men and 338 for women). The age-adjusted rates of PCH use per 1000 population aged 75 years and older also varied by mental illness grouping (no mental disorder, 53 for men and 78 for women; cumulative mental disorders, 305 for men and 373 for women; dementia, 542 for men and 669 for women). Among patients admitted to (or resident in) a PCH in 2002-2003, 74.6% (87.1%) had a mental illness, and 46.0% (69.0%) had dementia. Conclusions: Mental illness affects the use of home care and nursing homes profoundly. Individuals with dementia used home care at 3 times the rate of those having no mental illness diagnosis, and they used PCHs at 8 times the rate.

McGhee SM; Schooling CM; Wong LC; Leung GM; Ho LM; Thomas GN et al. Does smoking affect hospital use before death? A comparison of ever- and never-smokers in the last years of life. Medical Care 46(6): 614-619, 2008. (38 refs.)

Background: Given the apparent greater use of health care services by smokers and predictions of higher costs for a never-smoking population, we aimed in this study to determine whether the acute hospital costs in the last years of life of never- and ever-smokers differed before death using a database of the decedents in 1 year in Hong Kong. Objectives: To compare the acute hospital use of ever- and never-smoker decedents. Methods: The data on cause of death, personal characteristics, and public hospital discharges were linked for all decedents in 1998 in Hong Kong. The incidence rate ratio was used to compare, for ever- and never-smokers, the number of days spent in an acute hospital over the prior 7 years. Analyses were done using specific and all cause mortality, adjusted for sex, lifestyle factors, and life expectancy. Results: Compared with never-smokers who died of the same condition, ever-smokers who died of chronic obstructive pulmonary disease used 28% more acute hospital bed days and those dying of smoking-related cancer 9% fewer. These differences cancelled out over the case-mix of deaths with no net difference in acute bed day use by smoking status for all-cause mortality. Conclusions: There was no difference in acute hospital bed days in the last years of life of ever- and never-smokers but some differences by cause of death. Reducing smoking in this population will not increase acute hospital use.

Meier P; Seitz HK. Age, alcohol metabolism and liver disease. Current Opinion in Clinical Nutrition and Metabolic Care 11(1): 21-26, 2008. (43 refs.)

Purpose of review: Alcohol consumption among the elderly has increased. Alcohol metabolism changes with age and the elderly are more sensitive to the toxic effects; this increased consumption is therefore of great clinical relevance. Recent findings: Metabolism of ethanol changes with advancing age because activity of the enzymes involved, such as alcohol and acetalclehyde dehydrogenase and cytochrome P-4502E1, diminish with age. The water distribution volume also decreases with age. Both lead to increased blood concentrations of ethanol. Also, elderly people take more drugs, and ethanol and these drugs may interact; therefore, alcohol consumption can modify serum drug concentrations and their toxicity. Finally, elderly people may suffer more frequently from other types of liver disease, and alcohol may exacerbate these. Summary: Over recent decades alcohol consumption has increased among those who are older than 65 years. Alcohol is more toxic in the ageing organism because of changes in its metabolism, distribution and elimination, which lead to central nervous system effects at lower levels of intake; also, ageing organs such as brain and liver are more sensitive to the toxicity of alcohol. For these reasons, alcohol should be used in moderation, especially among those of older age.

Merrick EL; Horgan CM; Hodgkin D; Garnick DW; Houghton SF; Panas L et al. Unhealthy drinking patterns in older adults: Prevalence and associated characteristics. Journal of the American Geriatrics Society 56(2): 214-223, 2008. (42 refs.)

OBJECTIVES: To examine the prevalence of unhealthy drinking patterns in community-dwelling older adults and its association with sociodemographic and health characteristics. DESIGN: Cross-sectional analysis of nationally representative survey data. SETTING: The data source was the 2003 Access to Care file of the Medicare Current Beneficiary Survey, which represents the continuously enrolled Medicare population. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=12,413). MEASUREMENTS: The prevalence of unhealthy alcohol use by older adults defined in relation to two parameters of recommended limits: monthly use exceeding 30 drinks per typical month and "heavy episodic" drinking of four or more drinks in any single day during a typical month in the previous year. Sociodemographic and health status variables were also included. RESULTS: Nine percent of elderly Medicare beneficiaries reported unhealthy drinking, with higher prevalence in men (16%) than women (4%). In logistic regression analyses with the full sample, higher education and income; better health status; male sex; younger age; smoking; being white; and being divorced, separated, or single were associated with higher likelihood of unhealthy drinking. Among drinkers, in addition to sociodemographic variables, self-reported depressive symptoms were positively associated with unhealthy drinking. Among unhealthy drinkers, race and ethnicity variables were associated with likelihood of heavy episodic drinking. CONCLUSION: Almost one in 10 elderly Medicare beneficiaries report exceeding recommended drinking limits. Several distinct unhealthy drinking patterns were identified and associated with sociodemographic and health characteristics, suggesting the value of additional targeted approaches within the context of universal screening to reduce alcohol misuse by older adults.

Nace EP; Tinsley JA. Patients with Substance Abuse Problems: Effective Identification, Diagnosis, and Treatment. New York: W.W. Norton, 2007. (Chapter refs.)

The diagnosis and treatment of substance-abuse disorders are gaining the attention of physicians, with, in a given year, approximately 9% of the U.S. population is found to be dependent on or to abuse alcohol, and almost 4% are dependent on illicit drugs. Nicotine dependence affects some 20% of the population. The book is intended to provide a relatively brief concise overview of the field of substance abuse for the busy practitioner. It reviews the medical literature concerning the basics of addiction and details specific procedures such as detoxification schedules for alcohol, anxiolytic and hypnotic agents, and opioids. Each chapter uses brief vignettes to illustrate concepts, and tables or figures to clarify material. Two special populations are featured in this book: adolescence and late life. It is organized into 10 chapters: (1) Facing the Challenge: Patients with Substance Abuse Problems; (2) Addiction: A Disease of the Reward Pathway; (3) Does the Patient Know Something is Wrong?; (4) Steps to Identification; (5) Making a Diagnosis; (6) Treatment Options; (7) Adolescence (8) Substance Abuse in Late Life; (9) Smoking; and (10) Pharmacologic Treatment.

Nicita-Mauro V; Lo Balbo C; Mento A; Nicita-Mauro C; Maltese G; Basile G. Smoking, aging and the centenarians. (review). Experimental Gerontology 43(2): 95-101, 2008. (73 refs.)

The smoke of cigarettes represents an important accelerator of the aging process, both directly through complex mechanisms mediated prevalently by excessive formation of free radicals, and indirectly by favoring the appearance of various pathologies in which smoke is a recognized risk factor. This means that smoke compromises not only life expectancy, but also the quality of the life, favoring the occurrence of non-autosufficiency. Smoking is an important risk factor for many diseases, such as cancer, cardiovascular and respiratory diseases. These are also the main causes of death in the industrialized Countries, where the habit of smoking is also largely diffused. Non-smokers have a much higher life expectancy than smokers, and the suspension of smoking is accompanied, even in the elderly, by an increase in the survival time due to the reduction of smoke-induced biological damage. Therefore, cigarette smoking is opposing the longevity, particularly the extreme one, as it is confirmed by the observations obtained on centenarians. Among them, smoking is extremely rare, and even when it occurs among them, it is correlated almost exclusively to bad health conditions and non-autosufficiency, indicating that it compromises health status and the quality of life even in extremely long living subjects. Considering the demonstrated beneficial effects of suspension of smoking, all practitioners and geriatricians in particular, should promote the abstinence from smoking as a behavioral norm for a correct life style. Non-smokers can delay the appearance of diseases and of the aging process, thus attaining longevity; further, non-smoking habit allows genetically predisposed subjects to reach the extreme longevity and maintain an acceptable health status and autosufficiency.

Nomura K; Nakao M; Sato M; Yano E. The long-term prescription of benzodiazepines, psychotropic agents, to the elderly at a university hospital in Japan. Tohoku Journal of Experimental Medicine 212(3): 239-246, 2007. (26 refs.)

Benzodiazepines are useful and effective psychotropic agents used worldwide. However, the long term use of the drugs can lead to serious adverse health effects such as psychomotor and cognitive impairment, especially in the elderly. In Japan, there are very few reports concerning long-term use of benzodiazepines, and no countermeasures have been instituted. Thus, this study assessed the characteristics of long-term prescription of benzodiazepines at a university hospital in Japan. A cross-sectional study using the database of a computer ordering system examined 4,239 adult outpatients who were prescribed benzodiazepines at a university teaching hospital between July 2002 and June 2003. The patients were divided into two groups: those with long-term (>= 3 months) and short-term (<= 2 months) prescriptions. A logistic regression model was used to analyze the effect of patient age on long-term benzodiazepine prescription. Adjusting for patient gender, pharmacological half-life of the drug, and department group, a logistic regression model showed that long-term benzodiazepine prescription occurred more frequently in older patients (p < 0.0001 in trend tests) and varied according to the physician's specialty (p < 0.0001). Benzodiazepines were more frequently prescribed for long term in the elderly by internal medicine group (p = 0.003). Of the patients older than 71 years (n = 1,105), 86% were assigned to the long-term group and were more likely to have been prescribed benzodiazepines by an internist than a surgeon (p < 0.0001). The appropriate prescription of benzodiazepines in the elderly should be included in the educational programs at teaching hospitals, and rational prescribing needs to be monitored carefully.

Office of Applied Studies, Substance Abuse and Mental Health Administration. The DASIS Report: Adults Aged 65 or Older in Substance Abuse Treatment, 2005. (May 31, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (9 refs.)

Based on SAMHSA's Treatment Episode Data Set (TEDS), the total substance abuse treatment population increased by 10% between 1995 and 2005. At the same time, the number of substance abuse treatment admissions among persons aged 65 or older decreased by 7% from 12,100 to 11,300 admissions. In each year from 1995 to 2005, alcohol was the most frequently reported primary substance of abuse for those aged 65 or older entering treatment. However, the proportion of those aged 65 or older reporting alcohol as their primary substance declined from 84.7% in 1995 to 75.9% in 2005. Between 1995 and 2005, primary opiate admissions increased from 6.6% to 10.6% among adults aged 65 or older. The States with the highest rates of substance abuse treatment admissions aged 65 or older were Colorado (166 admissions per 100,000 population), New York (125 admissions per per 100,000 population), and South Dakota (111 admissions per 100,000 population). States with the lowest rates were Kentucky (35 admissions per 100,000 population), Iowa (36 admissions per 100,000 population), and Washington (37 admissions per 100,000 population).

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Administration. The DASIS Report: Older Adults in Substance Abuse Treatment, 2005. (November 8, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (8 refs.)

Substance abuse treatment admissions aged 50 or older accounted for about 184,400 (10%) of the 1.8 million substance abuse treatment admissions reported to SAMHSA's Treatment Episode Data Set (TEDS) in 2005. Alcohol was the most frequently reported primary substance of abuse for all those aged 50 or older. However, the highest proportions of substance abuse treatment admissions reporting alcohol as their primary substance were among those aged 65 to 69 (76%) and aged 70 or older (76%). In terms of prior treatment, those aged 50 to 64 had more extensive substance abuse treatment histories than those entering treatment who were aged 65 or older.

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The DASIS Report. Adults Aged 65 or Older in Substance Abuse Treatment, 2005. (May 31, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (9 refs.)

Based on SAMHSA's Treatment Episode Data Set (TEDS), the total substance abuse treatment population increased by 10% between 1995 and 2005. At the same time, the number of substance abuse treatment admissions among persons aged 65 or older decreased by 7% from 12,100 to 11,300 admissions. In each year from 1995 to 2005, alcohol was the most frequently reported primary substance of abuse for substance abuse treatment admissions aged 65 or older. However, the proportion of substance abuse treatment admissions aged 65 or older reporting alcohol as their primary substance declined from 84.7% in 1995 to 75.9% in 2005. Between 1995 and 2005, primary opiate admissions increased from 6.6% to 10.6% among adults aged 65 or older. The States with the highest rates of substance abuse treatment admissions aged 65 or older were Colorado (166 admissions per 100,000 population), New York (125 admissions per per 100,000 population), and South Dakota (111 admissions per 100,000 population). States with the lowest rates were Kentucky (35 admissions per 100,000 population), Iowa (36 admissions per 100,000 population), and Washington (37 admissions per 100,000 population).

Public Domain

Office of Applied Studies, Substance Abuse and Mental Health Services Administration. The DASIS Report. Older Adults in Substance Abuse Treatment, 2005. (November 8, 2007). Rockville MD: Substance Abuse and Mental Health Services Administration, 2007. (8 refs.)

Substance abuse treatment admissions aged 50 or older accounted for about 184,400 (10%) of the 1.8 million substance abuse treatment admissions reported to SAMHSA's Treatment Episode Data Set (TEDS) in 2005. Alcohol was the most frequently reported primary substance of abuse for all substance abuse treatment admissions aged 50 or older. However, the highest proportions of substance abuse treatment admissions reporting alcohol as their primary substance were among those aged 65 to 69 (76%) and aged 70 or older (76%). Substance abuse treatment admissions aged 50 to 64 had more extensive substance abuse treatment histories than admissions aged 65 or older.

Public Domain

Pariente A; Dartigues JF; Benichou J; Letenneur L; Moore N; Fourrier-Reglat A. Benzodiazepines and injurious falls in community dwelling elders. Drugs & Aging 25(1): 61-70, 2008. (62 refs.)

Background: Benzodiazepines are frequently used medications in the elderly, in whom they are associated with an increased risk of falling, with sometimes dire consequences. Objective: To estimate the impact of benzodiazepine-associated injurious falls in a population of elderly persons. Method: A nested case-control study was conducted using data collected during 10 years of follow-up of the French PAQUID (Personnel Agees QUID) community-based cohort. The main outcome measure was the occurrence of an injurious fall, which was defined as a fall resulting in hospitalization, fracture, head trauma or death. Controls (3 : 1) were frequency-matched to cases. Benzodiazepine exposure was the use of benzodiazepines over the previous 2 weeks reported at the follow-up visit preceding the fall. Results: Benzodiazepine use was significantly associated with the occurrence of injurious falls, with a significant interaction with age. The adjusted odds ratio for injurious falls in subjects exposed to benzodiazepines was 2.2 (95% CI 1.4, 3.4) in subjects aged >= 80 years and 1.3 (95% CI 0.9, 1.9) in subjects aged <80 years. The population attributable risk for injurious falls in subjects exposed to benzodiazepines was 28.1% (95% CI 16.7, 43.2) for subjects aged >= 80 years. The incidence of injurious falls in subjects aged >= 80 years exposed to benzodiazepines in the PAQUID cohort was 2.8/100 person-years. Over 9% of these falls were fatal. According to these results and to recent population estimates, benzodiazepine use could be held responsible for almost 20 000 injurious falls in subjects aged >= 80 years every year in France, and for nearly 1800 deaths. Conclusion: Given the considerable morbidity and mortality associated with benzodiazepine use and the fact that existing good practice guidelines on benzodiazepines have not been effective in preventing their misuse (possibly because they have not been applied), new methods for limiting use of benzodiazepines in the elderly need to be found.

Pfaff JJ; Almeida OP; Witte TK; Waesche MC; Joiner TE. Relationship between quantity and frequency of alcohol use and indices of suicidal behavior in an elderly Australian sample. Suicide and Life-Threatening Behavior 37(6): 616-626, 2007. (41 refs.)

Relatively little research has been conducted on the relationship between alcohol misuse and suicidal behavior among the elderly. The current study's aim was to examine whether quantity and frequency of alcohol use and the interaction between these variables are related to current suicidal ideation, previous suicidal ideation/intent, and past suicide attempts in a community sample of 1,010 Australian adults over age 60. Results partially supported our hypotheses. The interaction between quantity and frequency of alcohol use was significant, suggesting that those who use alcohol less frequently but in greater quantities (i.e., binge drinking) are more likely to have a history of suicide attempts.

Pollice R; Casacchia M; Bianchini V; Mazza M; Conti CM; Roncone R. Severe tramadol addiction in a 61 year-old woman without a history of substance abuse. International Journal of Immunopathology and Pharmacology 21(2): 475-476, 2008. (9 refs.)

We describe here the first case of Tramadol addiction and withdrawal in an elderly female patient in apparently good physical health. We report successful treatment with mirtazapine and clonidine. We believe that patients must be advised to take Tramadol regularly and to stop gradually especially after long treatment periods; moreover physicians must consider the potential physical dependence when they prescribe Tramadol for pain. Hence, we are observing some patients who continue to take Tramadol in order "to achieve a feeling of well-being," even though their pain is controlled after disease regression. Finally, the establishing of an evidence-based Tramadol detoxification protocol would be highly desirable.

Potenza MN; Steinberg MA; Wu R; Rounsaville BJ; O'Malley SS. Characteristics of older adult problem gamblers calling a gambling helpline. Journal of Gambling Studies 22(2): 241-254, 2006. (31 refs.)

Background Few investigations have characterized groups of older adults with gambling problems, and published reports are currently limited by small samples of older adult problem gamblers. Gambling helplines represent a widespread mechanism for assisting problem gamblers to move into treatment settings. Given data from older adult problem gamblers in treatment, we hypothesized that older as compared with younger adult problem gamblers calling a gambling helpline would be less likely to report gambling-related problems. Design and methods Logistic regression analyses were performed on data obtained from January 1, 2000 to December 31, 2001, inclusive, from callers with gambling problems (N = 1,084) contacting the Connecticut Council on Problem Gambling Helpline. Results Of the 1,018 phone calls used in the logistic regression analyses, 168 (16.5%) were from older adults and 850 (83.5%) from younger adults. Age- related differences were observed in demographic features, types and patterns of gambling reported as problematic, gambling-problematic gambling, and problems with casino slot machine gambling and less likely to report gambling- related anxiety, family problems, illegal behaviors and arrests, drug problems, indebtedness to bookies or acquaintances, family histories of drug abuse, and problems with casino table gambling. Conclusions Older as compared with younger adult problem gamblers calling a gambling helpline differ on many clinically relevant features. The findings suggest the need for improved and unique prevention and treatment strategies for older adults with gambling problems.related problems and psychiatric symptoms, substance use problems, patterns of indebtedness, and family histories of addictive disorders. Older as compared with younger adult problem gamblers were more likely to report having lower incomes, longer durations of gambling, fewer types of

Preston FW; Shapiro PD; Keene JR. Successful aging and gambling: Predictors of gambling risk among older adults in Las Vegas. American Behavioral Scientist 51(1): 102-121, 2007. (32 refs.)

Using a sample of 449 Las Vegas and Clark County, Nevada, residents ages 55 and older, the authors examine predictors of past-year and lifetime risk for problem gambling behavior. They examine the salience of gambling opportunities for the respondents' decision to move to Las Vegas and whether they currently gamble as a significant part of their recreation. Bivariate analyses show the importance of gambling opportunities for predicting at-risk status. Logistic regression analyses demonstrate that those who currently use gambling as a significant part of their recreation are 4 times more likely than others to be at risk. Furthermore, respondents who primarily play video poker are twice as likely as others to be at risk. Respondents' race, income, and length of time living in Las Vegas also predict at-risk behavior. The authors discuss the implications of these findings and their relationships to the aging, gambling, and problem gambling literatures.

Riggs P. Non-medical use and abuse of commonly prescribed medications (review). Current Medical Research and Opinion 24(3): 869-877, 2008. (36 refs.)

Background: The steep escalation in non-medical use and abuse of prescription medications in recent years has begun to seriously affect public health, calling for increased clinician awareness. Effective action and collaborative efforts are required to reduce prescription drug abuse while ensuring that availability of needed prescription medications for the majority of patients who use them appropriately is not inadvertently diminished. Objective: To educate physicians, clinicians, and other healthcare providers about the scope of non-medical prescription drug abuse and effective clinical management strategies to reduce abuse and diversion of prescription medications. Research design and methods: Articles were identified through PubMed and PsycINFO searches (January 2000 to November 2007). Search terms included combinations of I prescription drug abuse', 'substance abuse', and 'non-medical use of prescription drugs'. Government agency Web sites were searched for additional references. Results: Data from recent national surveys and other published reports indicate that the lifetime prevalence of non-medical prescription drug use/abuse in the United States is approximately 20% (48 million persons aged ! 12 years). Public health concern is further heightened by a significant increase in past-month use among adolescents (3.3% of 12-17 year olds) and young adults (6.4% of 18-25 year olds) and the vulnerability of a growing elderly population. Conclusions: Increased clinician awareness of the scope, demographics, and current trends in prescription medication abuse can be used to enhance screening and effective clinical management skills and strategies to reduce abuse and diversion of prescription drugs without compromising access to needed medications for the majority of patients who use them appropriately.

Ritchie K; Carriere I; de Mendonca A; Portet F; Dartigues JF; Rouaud O. The neuroprotective effects of caffeine : A prospective population study (the Three City Study). Neurology 69(6): 536-545, 2007. (29 refs.)

Objective: To examine the association between caffeine intake, cognitive decline, and incident dementia in a community- based sample of subjects aged 65 years and over. Methods: Participants were 4,197 women and 2,820 men from a population- based cohort recruited from three French cities. Cognitive performance, clinical diagnosis of dementia, and caffeine consumption were evaluated at baseline and at 2 and 4 year follow- up. Results: Caffeine consumption is associated with a wide range of sociodemographic, lifestyle, and clinical variables which may also affect cognitive decline. Multivariate mixed models and multivariate adjusted logistic regression indicated that women with high rates of caffeine consumption (over three cups per day) showed less decline in verbal retrieval (OR = 0.67, CI = 0.53, 0.85), and to a lesser extent in visuospatial memory (OR = 0.82, CI = 0.65, 1.03) over 4 years than women consuming one cup or less. The protective effect of caffeine was observed to increase with age (OR = 0.73, CI = 0.53, 1.02 in the age range 65 to 74; OR = 0.3, CI = 0.14, 0.63 in the range 80 +). No relation was found between caffeine intake and cognitive decline in men. Caffeine consumption did not reduce dementia risk over 4 years. Conclusions: The psychostimulant properties of caffeine appear to reduce cognitive decline in women without dementia, especially at higher ages. Although no impact is observed on dementia incidence, further studies are required to ascertain whether caffeine may nonetheless be of potential use in prolonging the period of mild cognitive impairment in women prior to a diagnosis of dementia.

Rosen D; Smith ML; Reynolds CF. The prevalence of mental and physical health disorders among older methadone patients. American Journal of Geriatric Psychiatry 16(6): 488-497, 2008. (41 refs.)

Objectives: The aging opioid-addicted cohort from the 1970s has begun to alter the demographic characteristics of individuals in need of services for heroin addiction. Yet, despite clear trends that indicate the population of older methadone patients is increasing, little is known about their well-being and service needs. The goal of this study was to assess the physical and mental health status of older methadone patients. Design: Face-to-face interviews were conducted with study participants. Setting: This study was conducted at a free-standing methadone clinic in a Midwestern industrial city. Participants: A clinic sample of 140 adult methadone patients over the age of 50 was recruited for face-to-face interviews. Measures: Mental health status was assessed by the Composite International Diagnostic Interview. The SF-12v2 was administered to measure a range of physical health issues. Participants were also asked about a variety of chronic conditions. In addition, respondents provided access to their drug screen results from monthly urine tests for illegal drug use for 1 year before and 1 year after the interview. Results: Findings revealed that over half (57.1%) of respondents had at least one mental health disorder in the past year. In the year before the interview, the most prevalent mental health disorder experienced by older adult patients was major depressive episode (32.9%). The most prevalent anxiety disorders were posttraumatic stress disorder (27.8%) and generalized anxiety disorder (29.7%). Additionally, women experienced significantly higher levels of depression than males (43.8% versus 27.2%), and nearly twice the prevalence rate of agoraphobia and panic disorders. Regarding physical health, respondents reported high rates of health problems in the past year, including arthritis (54.3%) and hypertension (44.9%). The majority of respondents reported having fair to poor physical health (57.7%). When examining the entire 24-month period during which urine data were collected, three quarters (76.4%) of the respondents had at least 1 month where the urine screen detected illegal drug use. Conclusions: In the next decade, the growing and aging substance abusing population will require clinicians trained in both geriatrics and substance abuse. Health and mental health professionals have the opportunity to address the specialized needs of this population and prepare for the shifting service needs these older patients will require.

Rota-Bartelink A; Lipmann B. Causes of homelessness among older people in Melbourne, Australia. Australian and New Zealand Journal of Public Health 31(3): 252-258, 2007. (26 refs.)

Objective: A comparative study of the causes of new episodes of homelessness among people aged 50 years and over has been undertaken in Australia, the United States and England. Semi-structured questionnaires were used to collect information on the circumstances and problems that contributed to homelessness. Methods: This paper presents the findings from Australia, where information was obtained from 125 older homeless people (aged 50+ years) and their key workers in Melbourne. All three participating nations followed identical research methodologies. Results: The factors most frequently reported by respondents as contributing to their homelessness were problems with people with whom they lived, followed by physical and mental ill-health and problems associated with the housing itself. The most frequently reported factors by case workers were problems with alcohol, followed by physical and mental health factors. Conclusions: This study demonstrates a significant under-utilisation of housing and support services among recently homeless older people and provides evidence that people who had previously been homeless appear to be more resigned to their homelessness than do those who had not experienced homelessness before. Significant issues relating to depression and gambling were also noted. The findings support the need for more targeted, specialised services to be developed or improved such that older homeless people can readily gain access to them and for improved collaboration or information exchange among housing providers and welfare agencies.

Sagaspe P; Taillard J; Chaumet G; Moore N; Bioulac B; Philip P. Aging and nocturnal driving: Better with coffee or a nap? A randomized study. Sleep 30(12): 1808-1813, 2007. (40 refs.)

Study Objective: To test the effects of coffee and napping on nocturnal driving in young and middle-aged participants. Design: A cup of coffee (200 mg of caffeine), a placebo (decaffeinated coffee, 15 mg of caffeine), or a 30-minute nap were tested. Participants drove 125 highway miles between 18:00 and 1930 and between 02:00 and 03:30 after coffee, placebo, or a nap. Setting: Sleep laboratory and open French highway. Participants: Twelve young (range, 20-25 years) and 12 middle-aged participants (range, 40-50 years). Measurements: Inappropriate line crossings, self-perceived fatigue and sleepiness, and polysomnographic recordings were analyzed. Results: Compared to daytime, after placebo the number of inappropriate line crossings was significantly increased (2 versus 73 for young participants, P < 0.01 and 0 versus 76 for the middle-aged participants, P < 0.05). Both coffee and napping reduced the risk of inappropriate line crossings, compared with placebo, in young participants (respectively, by three-quarters, incidence rate ratios [IRR] = 0.26 95% confidence interval [CI], 0.09-0.74, P < 0.05 and by two thirds, IRR = 0.34 95% Cl, 0.20-0.58, P < 0.001) and in middle-aged participants (respectively by nine tenths, IRR = 0.1195% Cl, 0.05-0.21, P < 0.001 and by one fifth, IRR = 0.77 95% Cl, 0.63-0.95, P < 0.05). A significant interaction between age and condition (IRR = 2.27 95% Cl, 1.28-4.16 P < 0.01) showed that napping led to fewer inappropriate line crossings in younger participants than in middle-aged participants. During napping, young participants slept more (P < 0.01) and had more delta sleep (P < 0.05) than middle-aged participants. Self-perceived sleepiness and fatigue did not differ in both age groups, but coffee improved sleepiness (P < 0.05), whereas napping did not. Conclusions: Coffee significantly improves performance in young and middle-aged participants. Napping is more efficient in younger than in older participants. Countermeasures to sleepiness should be adapted according to the age of drivers.

Seitz HK; Stickel F. Alcoholic liver disease in the elderly. Clinics in Geriatric Medicine 23(4): 905-+, 2007. (83 refs.)

Although per capita alcohol consumption, and thus the prevalence of alcoholic liver disease, decreases generally with age in Europe and in the United States, recently an increase in alcohol consumption has been reported in individuals over 65 years. Reasons explaining this observation may include an increase in life expectancy or a loss of life partners and, thus, loneliness and depression. Although ethanol metabolism and ethanol distribution change with age, and an elderly person's liver is more susceptible to the toxic effect of ethanol, the spectrum of alcoholic liver diseases and their symptoms and signs is similar to that seen in patients of all ages. However, prognosis of alcoholic liver disease in the elderly is poor. In addition, chronic alcohol consumption may enhance drug associated liver disease and may also act as a cofactor in other liver diseases, such as viral hepatitis and nonalcoholic fatty liver disease.

Shah A. Is there a relationship between elderly suicide rates and smoking? A cross-national study. International Journal of Geriatric Psychiatry 23(3): 308-313, 2008. (32 refs.)

Background: An independent relationship between smoking cigarettes and completed suicides has been reported in several cohort and case-control studies of younger subjects, but this relationship has rarely been examined in the elderly. Methods: The relationship between the prevalence of smoking in males and females and suicide rates in males and females in the age-bands 65-74 years and 75 +years was examined using national-level aggregate data from the World Health Organisation and the United Nations Development Programme websites. In addition to univariate analysis, multivariate analysis were conducted to ascertain an independent relationship between the prevalence of smoking and elderly suicide rates. Results: The main findings were: (i) on univariate analysis, the prevalence of smoking in males was positively correlated with suicide rates in males aged 65-74 years and males aged 75 + years, but this relationship was absent in females and (ii) on multivariate analysis there was no independent relationship between the prevalence of smoking in males and suicide rates in males in both the elderly age-bands. Conclusions: There is a case for examination of the relationship between smoking and elderly suicides in individual-level cohort or case-control studies because of the potential methodological difficulties in cross-national studies using national-level aggregate data, paucity of cohort or case-control studies at an individual-level in the elderly, and the observation of an independent relationship between smoking and completed suicides in individual-level cohort and case-control studies in younger age groups.

Solfrizzi V; D'Introno A; Colacicco AM; Capurso C; Gagliardi G; Santamato A; Baldassarre G; Capurso A. Lifestyle-related factors, alcohol consumption, and mild cognitive impairment. (letter). Journal of the American Geriatrics Society 55(10): 1679-1681, 2007. (10 refs.)

Song HJ; Kim HJ; Choi NK; Hahn S; Cho YJ; Park BJ. Gender differences in gastric cancer incidence in elderly former drinkers. Alcohol 42(5): 363-368, 2008. (19 refs.)

Although numerous studies have been done on gastric cancer and alcohol consumption, results from these studies are inconsistent. We conducted a population-based, prospective cohort study to establish a relationship between alcohol and gastric cancer according to gender. The cohort consisted of elderly (> 64 years of age) subjects at the baseline of 1993-1998. Baseline information was surveyed using a self-administered questionnaire. Gastric cancers were identified by the National Cancer Registry. Cox proportional hazards models were used to calculate relative risks with 95% confidence intervals. A follow up of 116,997.1 person-years of the 13,396 subjects revealed 151 newly diagnosed gastric cancers (80 men and 71 women). The risk of gastric cancer was higher by a factor of three among female former drinkers (adjusted relative risk 2.85 [95% confidence interval 1.11-7.32]) compared to current and nondrinkers. Female former drinkers showed greater alcohol consumption than current drinkers (36.5 g/week vs. 16.4 g/week; P <.0001) and a longer duration of alcohol consumption than did current drinkers (24.5 years vs. 18.46 years; P <.0001). Female subjects with more than 110 g of weekly alcohol consumption had an increased risk of developing gastric cancer (adjusted relative risk 2.23 [95% confidence interval 0.79-6.29]), although the result was statistically insignificant. No relationship was observed for male subjects. The relationship between alcohol and gastric cancer differs according to gender. Alcohol consumption may increase the risk of gastric cancer in women, and the risk elevation may persist for several years after drinking ceases.

Spence JD. Stroke prevention in the high-risk patient. (review). Expert Opinion on Pharmacotherapy 8(12): 1851-1859, 2007. (81 refs.)

Strokes are increasing in number due to an ageing population and are largely preventable. in the highest risk patients, a 90% relative risk reduction for stroke is attainable by appropriately using all the measures proven to reduce stroke: smoking cessation, a Mediterranean diet, control of hypertension, anticoagulants or antiplatelet agents, lipid lowering drugs and appropriate carotid endarterectomy. Vitamin therapy to lower homocysteine and carotid stenting are additional measures that may yet prove beneficial. Diet, smoking cessation and appropriate carotid endarterectomy reduce stroke by more than do pharmacotherapies. Blood pressure control depends more on selecting appropriate therapy individualised for the patient, than on using any particular drug class. This review, therefore, places pharmacotherapy in perspective as part of, but not all of, stroke prevention.

Turvey CL; Schultz SK; Klein DM. Alcohol use and health outcomes in the oldest old. Substance Abuse Treatment, Prevention, and Policy 1(e-article 8), 2006. (36 refs.)

Background: As the United States population ages, an unprecedented proportion of the population will be aged 70 and older. Knowledge of alcohol use and its consequences in this age group is not well known. In light of the disparate findings pointing to negative outcomes with excessive drinking yet also benefits of moderate drinking, the true risk of alcohol use in late life needs more investigation. Methods: This study examined the correlates and 2-year health outcomes related to alcohol use in 7,434 elders aged 70 years or older. Data was collected as part of the Assets and Health Dynamics of the Oldest Old (AHEAD), a nationwide health and economic study of elders. Data from Wave 1 and Wave 2 of AHEAD are presented. Frequency and quantity of drinking was assessed by self-report as was health status, lifetime alcohol or psychiatric problems, presence of chronic illness, functional impairment, and depressive symptoms. Cognitive status was assessed using a brief measure. Results: Approximately 44% of the sample reported any alcohol use in the past three months, with the majority of drinking less than daily. Daily drinking was associated with being Caucasian, married, in relatively good health, and having good affective and cognitive status. Drinking was not associated with negative health outcomes two years later and was protective against stroke and functional impairment. Decline in drinking between Wave 1 and Wave 2 was strongly associated with poor health. Conclusion: This study offers no evidence of negative health outcomes for drinking moderately and confirms the U-shaped curve often found in studies of alcohol and health. Nonetheless, cessation of drinking was associated with poor health suggesting the health benefits of moderate drinking may result from selection of a healthy group of people capable of sustained moderate drinking. Public health recommendations for moderate drinking must take this phenomenon into account.

van der Hooft CS; Schoofs MWCJ; Ziere G; Hofman A; Pols HAP; Sturkenboom MCJM et al. Inappropriate benzodiazepine use in older adults and the risk of fracture. British Journal of Clinical Pharmacology 66(2): 276-282, 2008. (15 refs.)

AIMS: The Beers criteria for prescribing in elderly are well known and used for many drug utilization studies. We investigated the clinical value of the Beers criteria for benzodiazepine use, notably the association between inappropriate use and risk of fracture. METHODS We performed a nested case-control study within the Rotterdam Study, a population-based cohort study in 7983 elderly. The proportion of 'inappropriate' benzodiazepine use according to the Beers criteria was compared between fracture patients and controls. 'Inappropriate' use for elderly implies use of some long-acting benzodiazepines and some intermediate/short-acting ones exceeding a suggested maximum daily dose. Also, alternative criteria were applied to compare the risk of fracture. Cases were defined as persons with incident fracture between 1991 and 2002 who were current benzodiazepine users on the fracture date. Controls were matched on fracture date and were also current benzodiazepine users. RESULTS: The risk of fracture in 'inappropriate' benzodiazepine users according to the Beers criteria was not significantly different from 'appropriate' users [odds ratio (OR) 1.07, 95% confidence interval (CI) 0.72, 1.60]. However, a significantly higher risk of fracture was found in 'high dose' users and a longer duration of use (14-90 days), irrespective of the type of benzodiazepine (OR 3.45, 95% CI 1.38, 8.59). CONCLUSIONS: These findings suggest that inappropriate benzodiazepine use according to the Beers criteria is not associated with increased risk of fracture. Daily dose and longer duration of use (> 14 days) is associated with higher risk of fracture, irrespective of the type of benzodiazepine prescribed.

Voaklander DC; Rowe BH; Dryden DM; Pahal J; Saar P; Kelly KD. Medical illness, medication use and suicide in seniors: A population-based case control study. Journal of Epidemiology and Community Health 62(2): 138-146, 2008. (49 refs.)

Background: Suicide among seniors is a significant health problem in north America, particularly for men in whom the rates rise steadily after 50 years of age. The goal of this study was to examine elder suicides identified from a large population-based database using case control methods to determine disease and medication factors related to suicide. Methods: A population-based 1 : 5 case-control study was conducted comparing seniors aged 66 years and older who had died by suicide with age and sex-matched controls. Case data were obtained through British Columbia (BC) Vital Statistics, whereas controls were randomly selected from the BC Health Insurance Registry. Cases and controls were linked to the provincial PharmaCare database to determine medication use and the provincial Physician Claims and Inpatient Hospitalization databases to determine co-morbidity. Results: Between 1993 and 2002 a total of 602 seniors died by suicide in BC giving an annual rate of 13.2 per 100 000. Firearms were the most common mechanism (28%), followed by hanging/suffocation (25%), self-poisoning (21%), and jumping from height (7%). In the adjusted logistic model, variables related to suicide included: lower socioeconomic status, depression/psychosis, neurosis, stroke, cancer, liver disease, parasuicide, benzodiazepine use, narcotic pain killer use and diuretic use. There was an elevated risk for those prescribed inappropriate benzodiazepines and for those using strong narcotic pain killers. Conclusion: This study is consistent with previous studies that have identified a relationship between medical or psychiatric co-morbidity and suicide in seniors. In addition, new and potentially useful information confirms that certain types and dosages of benzodiazepines are harmful to seniors and their use should be avoided.

Yates LB; Djouss L; Kurth T; Buring JE; Gaziano JM. Exceptional longevity in men - Modifiable factors associated with survival and function to age 90 years. Archives of Internal Medicine 168(3): 284-290, 2008. (30 refs.)

Background: Prospective data on nongenetic determinants of exceptional longevity are limited, and information on long-lived men and their functional status is particularly sparse. We examined modifiable factors associated with a life span of 90 or more years and late-life function in men. Methods: In this prospective cohort study of 2357 healthy men (mean age, 72 years) within the Physicians' Health Study (1981-2006), biological and lifestyle factors and comorbid conditions were assessed by self-report with baseline and annual questionnaires. Mortality and incidence of major diseases were confirmed by medical record review. Late-life function was assessed 16 years after baseline by the Medical Outcomes Study 36-Item Short-Form Health Survey. Results: A total of 970 men (41%) survived to at least age 90 years. Smoking was associated with increased risk of mortality before age 90 years (hazard ratio [HR]; 2. 10; 95% confidence interval [CI], 1.75-2.51), and similar associations were observed with diabetes (HR, 1.86; 95% CI, 1.52-2.26), obesity (HR, 1.44 95% CI, 1.10-1.90), and hypertension (HR 1.28- 95% CI, 1.15-1.43). Regular exercise was associated with a nearly 30% lower mortality risk (HR, 0.72; 95% CI, 0.62-0.83). The probability of a 90-year life span at age 70 years was 54% in the absence of smoking, diabetes, obesity, hypertension, or sedentary lifestyle. It ranged from 36% to 22% with 2 adverse factors and was negligible (4%) with 5. Compared with nonsurvivors, men with exceptional longevity had a healthier lifestyle (67% vs 53% had <= 1 adverse factor), had a lower incidence of chronic diseases, and were 3 to 5 years older at disease onset. They had better late-life physical function (mean SD score [maximum 100], 73 +/- 23 vs 62 +/- 30; P <.001) and mental well-being (mean score, 84 +/- 14 vs 81 +/- 17; P =.03). More than 68% (vs 45%) rated their late-life health as excellent or very good, and less than 8% (vs 22%) reported fair or poor health (P <.001 for trend). Regular exercise was associated with significantly better-and smoking and overweight with significantly worse-late-life physical function. Smoking also was associated with a significant decrement in mental function. Conclusion: Modifiable healthy behaviors during early elderly years, including smoking abstinence, weight management, blood pressure control, and regular exercise, are associated not only with enhanced life span in men but also with good health and function during older age.

Zivin K; Christakis NA. The emotional toll of spousal morbidity and mortality. American Journal of Geriatric Psychiatry 15(9): 772-779, 2007. (61 refs.)

Objective: Spouse caregivers have an increased risk of mental and physical illness during caregiving and widowhood. The authors sought to evaluate whether partners of an ill spouse have a higher likelihood of developing mental health or substance abuse (MHSA) disorders than partners who have healthy spouses, accounting for both spousal illness and death. Methods: The authors used Medicare claims from 1993-2001 for 474,228 married couples. The authors used Cox models to determine the effect of spouse illness on partner MHSA diagnosis, controlling for demographic and clinical characteristics. Results: A wife's hospitalization increased the husband's risk of MHSA diagnosis by 1.29 (95% confidence interval [ CI]: 1.28-1.29) and his risk of depression by 1.49 (95% CI: 1.48-1.51). A husband's hospitalization increased the risk of a wife's MHSA diagnosis by 1.33 (95% CI: 1.32-1.33) and her risk of depression by 1.41 (95% CI: 1.39-1.42). A wife's death increased the risk of the husband's MHSA diagnosis by 1.12 (95% CI: 1.11-1.13) and increased his risk of depression by 1.49 (95% CI: 1.46-1.51). A husband's death increased the risk of the wife's MHSA diagnosis by 1.14 (95% CI: 1.14-1.15) and increased her risk of depression by 1.41 (95% CI: 1.39-1.42). Conclusion: Spouse hospitalizations and spouse death independently increase the risk for partner MHSA and depression diagnoses. These findings can identify which individuals are at greatest risk for emotional distress and should be targeted for interventions to relieve caregiver burden that can arise separately and additively from both spousal illness and death.