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PubMed1992

Measurement of oxybutynin and its N-desethyl metabolite in plasma, and its application to pharmacokinetic studies in young, elderly and frail elderly volunteers.

1. A quantitative h.p.l.c. plasma assay for oxybutynin (OB) and its active metabolite, N-desethyl oxybutynin (DEOB) is described. The method is linear with coefficients of variation ranging between 4 and 11.8% for OB and 4.6-9.1% for DEOB over the typical concentration range measured. Minimum detectable levels were 0.5 and 5 ng/ml for OB and DEOB respectively from a 2 ml sample. 2. Pharmacokinetic parameters were obtained after a single oral dose of OB and after administration two or three times daily to frail elderly and elderly volunteer groups respectively. Single dose results were also compared with data from young healthy volunteers. 3. There was a wide range in peak blood levels and high levels of parent drug were matched by high DEOB metabolite levels. Plasma levels on repeated administration were as would be predicted from the single dose kinetics. 4. Area under the plasma time course curve for DEOB metabolite was less than or equal to 5 than that of the parent drug. 5. A trend of increasing peak plasma levels and bioavailability was observed with increasing age and frailty, with the differences more apparent between the active elderly and frail elderly groups than between the active elderly and young volunteers. 6. Results indicate that for frail elderly patients a lower initial starting dose of 2.5 mg OB given two or three times a day may provide adequate therapeutic blood levels of the drug.

Administration, Oral↗
PubMed2006

Erythromycin breath test results in elderly, very elderly, and frail elderly persons.

BACKGROUND AND OBJECTIVE: Although increasing age is often thought to be associated with slower oxidative drug clearance, limited data from old, very old, and frail patients exist. Our objective was to determine the effects of very old age and frailty on erythromycin breath test (ERBT) results in patients and, secondarily, to determine the effects of sex and comedications on ERBT results. METHODS: ERBTs were performed in 60 individuals aged 65 to 101 years, 27 of whom were classified as frail (mean age [+/-SD], 86 +/- 6 years; mean weight, 66 +/- 17.4 kg; 8 men and 19 women; 24 living in a nursing home and 3 living in the community) and 33 of whom were classified as nonfrail (mean age, 79 +/- 8 years; mean weight, 78.5 +/- 14.5 kg; 16 men and 17 women; 17 living in a nursing home and 16 living in the community). RESULTS: ERBT results were faster in women versus men (3.53% +/- 1.15% carbon 14 [14C] excreted/h versus 2.59% +/- 0.99% 14C excreted/h, respectively; ANOVA, P < .002), faster in frail versus nonfrail patients (3.58% +/- 1.2% 14C excreted/h versus 2.81% +/- 1.06% (14)C excreted/h, respectively; ANOVA, P = .01), and faster in those receiving cytochrome P450 (CYP) 3A inducers versus those without inducers (5.02% +/- 0.89% 14C excreted/h versus 3.02% +/- 1.08% 14C excreted/h, respectively; ANOVA, P = .0007). When subjects receiving CYP inducers were excluded, sex affected ERBT results (ANOVA, P < .007) but frailty effects were not detected (P = .09). Age from 65 to 101 years did not affect ERBT results (r2 = 0.001). CONCLUSIONS: Old and very old patients in the clinical setting, especially women and those receiving enzyme inducers, may have preserved medication clearance. Frail elderly persons do not have slower ERBT results compared with nonfrail elderly persons.

Aged↗
PubMed1997

A study of the effects of tamoxifen in the frail elderly: difficulties encountered in nursing home research.

OBJECTIVE: This study was conducted in order to determine whether the effects of tamoxifen in elderly, frail nursing home residents are similar to those that have been previously reported for younger postmenopausal women. DESIGN: A chart review study. SETTING: The Jewish Home and Hospital for Aged (JHHA), a subacute long-term care facility. PARTICIPANTS: One hundred fifty-eight women who had been at the JHHA at any time since 1986. One hundred ten had a history of breast cancer; 43 of these had been treated with tamoxifen while at the JHHA (Group I), and 66 had not (Group II). The remaining 49 women had no history of breast cancer (Group III). MEASUREMENTS: Data were collected from the time of admission to the JHHA through August, 1994 on: chemistry profiles, bone fractures apparently not a consequence of metastasis, gynecological parameters, and thromboemboli. RESULTS: The lack of pre-admission clinical information presented problems regarding research design and the interpretation of our findings. Nevertheless, compared to women who had not been treated with tamoxifen, treated women had a significantly elevated incidence of vaginal discharge (P = 0.01) and a lower prevalence of elevated total cholesterol (P = 0.04). Although not statistically significant, they also had decreased levels of low density lipoprotein cholesterol and an increased incidence of thromboemboli and bone fractures. CONCLUSIONS: While some of the effects of tamoxifen in elderly, frail women are similar to those observed in younger, postmenopausal women, others may be different. Our results suggest a need for further innovative studies that focus on the consequences of tamoxifen treatment in the elderly, frail population.

Age Factors↗
PubMedDate not supplied

Prescribing exercise for frail elders.

BACKGROUND: Frail elders often have chronic illnesses, such as osteoarthritis, hypertension, diabetes, and peripheral vascular disease, for which exercise is a proven means of achieving nonpharmacologic benefits, even at advanced age. Exercise has been shown to enhance the quality of life for these elders. METHODS: A literature search of exercise literature applied to older adults and lifestyle modifications was conducted, summarized, and then reviewed with practicing colleagues. RESULTS AND CONCLUSIONS: Exercise continues to be an underused therapeutic intervention for frail elders as a result of barriers created by patients themselves, their caregivers, and their health care providers. Family physicians can overcome these barriers by prescribing appropriate exercises and by tailoring the exercise to the functional needs and preferences of their patients. An exercise prescription for frail elders is based on a pragmatic strategy that makes therapeutic exercise both sustainable and safe. Such a strategy incorporates motivational elements and knowledge of achievable benefits.

Aged↗
PubMed2000

The effect of oral nutritional supplements on habitual dietary quality and quantity in frail elders.

BACKGROUND: Frail institutionalized elders have a high prevalence of nutritional risk factors, undernutrition, weight loss, and nutrition-related morbidity and excess mortality. Little information is available on effective means to intervene in this setting. HYPOTHESES: We tested the hypothesis that addition of multinutrient oral supplements to the diet of frail elders would improve their overall nutritional status and functional level. METHODS: Fifty nursing home residents aged 88+/-1 yr. were followed for 10 weeks in the course of a randomized controlled trial of supplementation with a multinutrient liquid supplement vs. a non-nutritive placebo drink. Three-day food weighing was used to analyze their habitual dietary intake before and during the final week of the intervention. Nutritional status was further assessed with nutritional biochemistries, anthropometric measurements, and body composition analysis as well as physical and functional performance tests. RESULTS: The nutritional supplement was consumed with high compliance, but did not significantly augment total caloric intake. Supplementation was associated with significant reductions in total energy, protein, fat, water, fiber, and many vitamins and minerals in the habitual diet of these nursing home residents. Nutritional status improved in terms of folate levels in serum, but no other measured vitamin or mineral indices. Body composition analysis revealed a small gain in weight, increases in fat stores, but no improvement in lean tissue mass associated with supplemention. No physical performance or functional gains were associated with supplementation. CONCLUSION: Short-term nutritional supplementation in elders at nutritional risk is offset by simultaneous reduction in voluntary food intake. It seems likely that changing other components of energy expenditure such as physical activity levels or basal metabolism may be required to produce overall improvements in nutritional intake in this setting.

Aged↗
PubMed1989

Steady state pharmacokinetics of nortriptyline in the frail elderly.

The frail elderly, for whom chronic disease and disability are essentially universal, are at high risk for depression and are specifically vulnerable to the adverse effects of antidepressant medication. There have, however, been few investigations of either the pharmacokinetics or the clinical investigations of either the pharmacokinetics or the clinical response to antidepressants in such patients. We report on the pharmacokinetics of nortriptyline at steady state in a group of 22 patients, average age 84, living within an institutional setting. Comparison of our findings with those previously reported for younger and healthier subjects suggests that there are no clinically significant group differences in nortriptyline kinetics. Plasma levels of nortriptyline and those of both the trans- and cishydroxylated metabolites are linear with daily dose. Mean (and SD) for the parameter (plasma level/dose) was 1.21 (0.63) ng/ml/mg/day for the parent compound, 1.41 (0.86) for the trans metabolite, and 0.30 (0.16) for the cis metabolite. There was no significant correlation across individuals between the accumulation of the parent compound and the metabolites. Based upon these data, the average dose of nortriptyline required to achieve a plasma level of 100 ng/ml is 80 mg/day. Dose requirements, however, vary between individuals by a factor of 20. Plasma levels measured 24 hours after a 25-mg test dose of nortriptyline can allow early identification of slow metabolizers. Twenty-four-hour plasma levels (mean 8.8 ng/ml, SD 3.2) were significantly correlated with steady state levels at 25 mg/day (r = 0.71), steady state levels at 50 mg/day (r = 0.73), and each individual's average (plasma level/dose) (r = 0.57).

Aged↗
PubMed1988

Loop diuretics cause less postural hypotension than thiazide diuretics in the frail elderly.

Seventy frail elderly patients attending a day hospital were studied to investigate the incidence of postural hypotension in control patients on no diuretic treatment (n = 30), patients on loop diuretics (frusemide) for mild cardiac failure (n = 20) and patients on thiazide diuretics for mild cardiac failure (n = 20). The results showed that patients on thiazide diuretics had a higher incidence of postural hypotension (reduction in systolic blood pressure greater than 20 mmHg on standing after 2 minutes) than patients on loop diuretics (12 out of 20 vs 4 out of 20, p less than 0.05). Mean plasma potassium levels were lower in the thiazide group than in the frusemide group (p less than 0.05) and this correlated significantly with change in systolic blood pressure from supine to standing position (r = -0.56, p less than 0.01). These findings indicate that a loop diuretic (frusemide) is as safe if not safer than thiazides in older patients and the latter have an unjustified reputation of being safer first-line drugs for the treatment of cardiac failure.

Aged↗
PubMed2006

Fatigue in frail elderly people.

Many frail older people are likely to suffer from fatigue, but tools to measure fatigue in this population are lacking. Stage one of this study explored and described the experiences of fatigue of 12 older people from Australian residential aged care facilities. Themes identified were pacing yourself, battling on, hitting rock bottom, feeling safe, and moving on. Findings indicated that, with support, frail elders may be able to manage fatigue effects themselves. A measure of fatigue was developed from stage one findings, with reference to the literature. In stage two of the study, the Frail Elder Fatigue Assessment Tool was subjected to panel review, piloting, and refinement. The refined tool comprises 20 items in three subscales: fatigue effects; fatigue resources; and adaptation to fatigue. Further work is required to establish the tool's psychometric properties, but it should then be useful for both research and clinical assessment purposes.

Activities of Daily Living↗
PubMedDate not supplied

PACE (Program of All-Inclusive Care for the Elderly): innovative care for the frail elderly. Comprehensive services enable most participants to remain at home.

PACE--the Program of All Inclusive Care for the Elderly--provides integrated comprehensive healthcare services to the frail elderly on a capitated basis. Begun in the early 1970s in San Francisco's Chinatown, PACE today comprises many individual programs across the nation. PACE's goal is to provide participants with the healthcare services they need for the highest possible level of functioning and autonomy. A typical PACE program is divided into sites, each of which serves 120 to 150 participants. Most participants come several times a week to the site's adult day care center, where they see members of an interdisciplinary team that includes physicians, nurses, social workers, therapists, and others. Home care is provided to participants unable to attend the center. PACE is financed by capitated payments from Medicare and Medicaid, which put providers at full risk for the services used by participants. The flexibility provided by this funding enables PACE to offer a wide variety of services, including supportive housing, which help keep participants out of institutions. Estimates of Medicare savings attributed to PACE are 12 percent and higher.

Activities of Daily Living↗
PubMedDate not supplied

The effect of supplementation with an enriched drink on indices of immune function in frail elderly.

Ageing induces a change in immune responses. Besides this, impaired nutritional status is considered to have a critical influence on immune function, which may be reversed by nutritional supplementation. We evaluated the effect of an enriched drink on immune function in the elderly. 33 frail elderly subjects (aged > or = 65 years and body mass index < or = 25) received two 125 ml packages of either an enriched drink (n=20) or placebo (n=13) daily for 6 months. The enriched drink contained macro- and micronutrients. At baseline and after 6 months blood samples were drawn and PBMC's were isolated. ConA stimulated proliferation and IL-2 production of PBMC's were measured. There was a significant difference between groups in proliferation over the study period. The supplement group remained stable whereas the placebo group showed a reduction in proliferation over the 6-month period. There was no significant difference in IL-2 production between groups. Our study adds to the evidence that nutritional supplementation can affect immune function in the elderly.

Aged↗
PubMed2004

Serum parathyroid hormone predicts time to fall independent of vitamin D status in a frail elderly population.

Very frail older people constitute an increasing proportion of ageing populations and often have vitamin D deficiency. Falls are frequent in this population and have usually been associated with vitamin D deficiency. In this prospective study we measured serum 25-hydroxyvitamin D (25OHD), serum PTH, and falls in 637 ambulatory subjects living in institutional aged care facilities (intermediate-care hostels or nursing homes). The study sample comprised 121 men (mean age, 82.1 yr) and 516 women (mean age, 86.7 yr). Two hundred and seventy-four subjects fell one or more times over a mean duration of follow-up of 10.2 months. Vitamin D deficiency, defined as a serum 25OHD level below 39 nmol/liter was present in 73.6%. Baseline serum 25OHD and PTH were significantly associated with falls in univariate analyses. In multivariate analyses that also corrected for balance and health status, PTH remained a significant predictor of falls independent of 25OHD. Serum PTH is a predictor of time to first fall in the frail elderly independent of vitamin D status and measures of general health.

Accidental Falls↗
PubMed2004

Inappropriate medication use among frail elderly inpatients.

BACKGROUND: Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients. OBJECTIVE: To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients. METHODS: The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score. RESULTS: Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores. CONCLUSIONS: Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Aged↗
PubMed2003

[Functional status of community-dwelling frail elderly in the Japanese long-term care insurance system].

OBJECTIVE: To clarify exercise habits, self-rated functional fitness, activities of daily living (ADL) and fear of falling in community-dwelling elderly who are classified as frail by the eligibility decision process of the Japanese long-term care insurance system. METHODS: Subjects aged 75 years and older were classified into a frail elderly group (n = 126; male = 29, female = 97) and a healthy elderly group (n = 262; male = 114, female = 148). We had carried out an interview survey using questionnaire asking about exercise habits, self-rated functional fitness, ADL, fear of falling and activity curtailment. The survey was carried out by door-to-door method and data were collected from November to December 2000. RESULTS: Respondents who answered no practice of exercise were more likely to be in the frail elderly group. Among the self-rated functional fitness items, endurance, muscular strength and flexibility were comparatively low in the frail elderly group. The rates of basic ADL dependence were higher for bathing (males = 34.5%, females = 15.5%) and walking (males = 27.6%, females = 20.6%), for both sexes of the frail elderly group. Also, the rate of instrumental ADL dependence was much higher in the frail elderly group than in the healthy elderly group. Among frail elderly, 93.1% of males and 93.8% of females had fear of falling. Of those who were afraid, 66.7% of males and 60.4% of females curtailed going out due to this fear. CONCLUSIONS: Our findings suggest that intervention programs are needed to improve bathing and walking ability as well as to provide social support for the frail elderly. Self-rated fear of falling is significantly associated with activity curtailment in this population.

Activities of Daily Living↗
PubMed1989

Feeding the frail elderly.

1. Frail older adults need to be fed carefully and observed closely while eating to prevent choking and aspiration of food and fluids. They choke more easily on clear liquids than on soft foods with some texture. 2. The licensed nurse is responsible for evaluating the physical status of frail older adults before feeding them and for assuring that less qualified personnel are aware of the dangers and specific precautions in feeding these types of patients. 3. The use of nutritious finger foods allows frail older people some degree of independence by encouraging them to feed themselves whenever possible. Careful menu planning can result in a variety of nutritious foods for older people. 4. Soft-cooked vegetables and fruits are more appetizing and acceptable to frail edentulous older adults than pureed or ground foods. Making mealtime special may be one of their few pleasures. 5. Frail older adults should remain in a sitting or semi-Fowler's position for at least one to two hours after eating to prevent possible regurgitation and aspiration of food or fluids.

Aged↗
PubMed1993

The role of anthropometry in the assessment of malnutrition in the hospitalized frail elderly.

Although common among the hospitalized frail elderly, malnutrition is often unrecognized by clinicians, and its identification is fought with difficulty due to inadequate nutritional assessment methods and standards. This study compared the use of percent ideal body weight (%IBW) and anthropometry in the assessment of malnutrition in the hospitalized frail elderly. Approximaty 45% of patients studied had at least two anthropometric measurements below the 5th percentile, a level reflecting severe malnutrition. However, only 28% of patients were found to be less than 90% IBW, a level reflecting only mild to severe changes in body weight. Serum albumin was below normal (< 35 g/l) in 30% of patients. The total lymphocyte count was below normal (< 1,500 cells/mm3) in 53%, and was severely depressed (< 800 cells/mm3) in 24%. Thus, despite the use of stringent anthropometric criteria indicating severe malnutrition, anthropometry appeared more sensitive than %IBW as a measure of malnutrition in the hospitalized frail elderly. Furthermore, acute illness causes changes in commonly employed blood measures which make them unreliable in the assessment of malnutrition in this population. Anthropometry may prove to be the most stable, easily performed, and sensitive measure of malnutrition in the hospitalized frail elderly. However, further studies are clearly needed, including the development of appropriate anthropometric reference standards for the very old, a population that commonly suffers malnutrition.

Aged↗
PubMed2001

Needs of frail elderly people in informal settlements.

The frail elderly in informal settlements find themselves in an extremely vulnerable position due to a number of factors, namely, their increasing dependency status, limited resources and adverse physical environment. Various aspects that influence the aged in their present environment will be highlighted. A survey method was used to explore and to describe the world in which they live in informal areas. The attitude, expectation and needs of the elderly in respect of their care was also determined. A random cluster sample was taken. Data was collected by means of interviews in terms of a semi-structured questionnaire. It appears that the frail elderly were happy in the environment in which they received care in spite of their unfavourable physical environment and limited resources. The communities where the frail elderly lived were largely unaware of the valuable inputs they can make regarding the care of the aged. This necessitates the development of programs in the heart of communities, owned by communities, where all role players in the care of the aged participate.

Aged↗
PubMed1993

Decisions regarding services for the frail elderly.

The care of the frail elderly will become a progressive challenge in the decades to come. There are presently validated and standardized measures for assessing the frail elderly, as well as a number of options for their care. The challenge for the physician will be the proper selection of assessment instruments and care options.

Activities of Daily Living↗
PubMed2001

Progressive resistance muscle strength training of hospitalized frail elderly.

OBJECTIVE: To determine whether frail elderly patients recuperating from acute illnesses could safely participate in and gain appreciable improvement in muscle strength from progressive resistance muscle strength training. DESIGN: Muscle strength (one repetition maximum), functional abilities (sit-to-stand maneuver and 20-sec maximal safe gait speed), and body composition were measured before and at the conclusion of a 10-wk program of lower limb progressive resistance muscle strength training. The nonrandomized study was conducted in a 30-bed geriatric rehabilitation unit of a university-affiliated Veterans Affairs hospital and a 28-bed transitional care unit of a community nursing home. Participants included 19 recuperating elderly subjects (14 male, 5 female; 13 ambulatory, 6 nonambulatory) >64 yr (mean age, 82.8+/-7.9 yr). RESULTS: The one repetition maximum increased an average of 74%+/-49% (median, 70%; interquartile range, 38%-95%, and an average of 20+/-13 kg (P = 0.0001). Sit-to-stand maneuver times improved in 15 of 19 cases (79%). Maximum safe gait speeds improved in 10 of 19 cases (53%). Four of the six nonambulatory subjects progressed to ambulatory status. No subject experienced a complication. CONCLUSIONS: A carefully monitored program of progressive resistance muscle strength training to regain muscle strength is a safe and possibly effective method for frail elderly recuperating from acute illnesses. A randomized control study is needed to examine the degree to which progressive resistance muscle strength training offers advantages, if any, over routine posthospital care that includes traditional low-intensity physical therapy.

Activities of Daily Living↗