Heidi Splete

WASHINGTON — A history of type 2 diabetes was associated with a 34% higher risk of new-onset Parkinson's disease in older men, but diabetes did not seem to cause Parkinson's.

Data from epidemiology studies have suggested a link between diabetes and Parkinson's disease (PD), but there have been few prospective studies of the association.

To evaluate the relationship between new-onset PD and diabetes, Ashley E. Smith, a medical student at Northeastern Ohio Universities, Rootstown, and colleagues reviewed data from 21,841 men aged 40–84 years who were enrolled in the Physicians' Health Study. Those with a history of PD at baseline, with type 1 diabetes or unknown diabetes status, and who developed dementia before PD were excluded. They reported the findings in a poster presentation at the annual meeting of the American Geriatrics Society.

They identified 423 diabetes cases at baseline, 1,987 incident cases of diabetes, and 556 cases of PD over a median follow-up of 23.1 years. Mean baseline age was 55 years for men with diabetes and 52 years for men without diabetes. Mean age for PD diagnosis was 73 years.

Diabetes was associated with an increased risk of PD, but the risk did not increase with the duration or severity of diabetes. Instead, after adjustment for multiple factors including age, smoking, alcohol use, body mass index, hypertension, physical activity, and high cholesterol, the risk of PD was greatest in those with a normal baseline body mass index, older age at onset of diabetes, and a shorter duration of diabetes.

In the proportional hazard model, a diagnosis of diabetes was clustered around the diagnosis of PD, which supports a biological link between the two conditions. “Dopaminergic neurons are involved in glucose regulation and extensive damage to these neurons might lead to impaired peripheral glucose metabolism,” the investigators wrote.

More studies are needed to determine whether the increased risk of PD in adults with diabetes is because of detection bias or an underlying biological mechanism.

The study was supported in part by grants from the National Cancer Institute and the National Heart, Lung, and Blood Institute, in Bethesda, Md.

WASHINGTON — A history of type 2 diabetes was associated with a 34% higher risk of new-onset Parkinson's disease in older men, but diabetes did not seem to cause Parkinson's.

Data from epidemiology studies have suggested a link between diabetes and Parkinson's disease (PD), but there have been few prospective studies of the association.

To evaluate the relationship between new-onset PD and diabetes, Ashley E. Smith, a medical student at Northeastern Ohio Universities, Rootstown, and colleagues reviewed data from 21,841 men aged 40–84 years who were enrolled in the Physicians' Health Study. Those with a history of PD at baseline, with type 1 diabetes or unknown diabetes status, and who developed dementia before PD were excluded. They reported the findings in a poster presentation at the annual meeting of the American Geriatrics Society.

They identified 423 diabetes cases at baseline, 1,987 incident cases of diabetes, and 556 cases of PD over a median follow-up of 23.1 years. Mean baseline age was 55 years for men with diabetes and 52 years for men without diabetes. Mean age for PD diagnosis was 73 years.

Diabetes was associated with an increased risk of PD, but the risk did not increase with the duration or severity of diabetes. Instead, after adjustment for multiple factors including age, smoking, alcohol use, body mass index, hypertension, physical activity, and high cholesterol, the risk of PD was greatest in those with a normal baseline body mass index, older age at onset of diabetes, and a shorter duration of diabetes.

In the proportional hazard model, a diagnosis of diabetes was clustered around the diagnosis of PD, which supports a biological link between the two conditions. “Dopaminergic neurons are involved in glucose regulation and extensive damage to these neurons might lead to impaired peripheral glucose metabolism,” the investigators wrote.

More studies are needed to determine whether the increased risk of PD in adults with diabetes is because of detection bias or an underlying biological mechanism.

The study was supported in part by grants from the National Cancer Institute and the National Heart, Lung, and Blood Institute, in Bethesda, Md.

WASHINGTON — A history of type 2 diabetes was associated with a 34% higher risk of new-onset Parkinson's disease in older men, but diabetes did not seem to cause Parkinson's.

Data from epidemiology studies have suggested a link between diabetes and Parkinson's disease (PD), but there have been few prospective studies of the association.

To evaluate the relationship between new-onset PD and diabetes, Ashley E. Smith, a medical student at Northeastern Ohio Universities, Rootstown, and colleagues reviewed data from 21,841 men aged 40–84 years who were enrolled in the Physicians' Health Study. Those with a history of PD at baseline, with type 1 diabetes or unknown diabetes status, and who developed dementia before PD were excluded. They reported the findings in a poster presentation at the annual meeting of the American Geriatrics Society.

They identified 423 diabetes cases at baseline, 1,987 incident cases of diabetes, and 556 cases of PD over a median follow-up of 23.1 years. Mean baseline age was 55 years for men with diabetes and 52 years for men without diabetes. Mean age for PD diagnosis was 73 years.

Diabetes was associated with an increased risk of PD, but the risk did not increase with the duration or severity of diabetes. Instead, after adjustment for multiple factors including age, smoking, alcohol use, body mass index, hypertension, physical activity, and high cholesterol, the risk of PD was greatest in those with a normal baseline body mass index, older age at onset of diabetes, and a shorter duration of diabetes.

In the proportional hazard model, a diagnosis of diabetes was clustered around the diagnosis of PD, which supports a biological link between the two conditions. “Dopaminergic neurons are involved in glucose regulation and extensive damage to these neurons might lead to impaired peripheral glucose metabolism,” the investigators wrote.

More studies are needed to determine whether the increased risk of PD in adults with diabetes is because of detection bias or an underlying biological mechanism.

The study was supported in part by grants from the National Cancer Institute and the National Heart, Lung, and Blood Institute, in Bethesda, Md.

WASHINGTON — A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, a geriatrician at the University of California, Los Angeles, and director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and more need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. Several screening tools for mood disorders are in use, but they haven't been compared with one another or to any validated psychiatric-assessment tool, said Dr. Saliba.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard; this study used the newer version of the test, which is made up of 15 yes/no questions. But studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

The investigators selected 418 nursing home residents scheduled to receive mandatory MDS 2.0 assessments. Nearly half the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, “gold standard” tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” she said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba. The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

WASHINGTON — A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, a geriatrician at the University of California, Los Angeles, and director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and more need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. Several screening tools for mood disorders are in use, but they haven't been compared with one another or to any validated psychiatric-assessment tool, said Dr. Saliba.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard; this study used the newer version of the test, which is made up of 15 yes/no questions. But studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

The investigators selected 418 nursing home residents scheduled to receive mandatory MDS 2.0 assessments. Nearly half the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, “gold standard” tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” she said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba. The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

WASHINGTON — A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, a geriatrician at the University of California, Los Angeles, and director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and more need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. Several screening tools for mood disorders are in use, but they haven't been compared with one another or to any validated psychiatric-assessment tool, said Dr. Saliba.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard; this study used the newer version of the test, which is made up of 15 yes/no questions. But studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

The investigators selected 418 nursing home residents scheduled to receive mandatory MDS 2.0 assessments. Nearly half the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, “gold standard” tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” she said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba. The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

WASHINGTON — Fluoroquinolone resistance rose significantly over an 8-year period in hospitalized adults aged 65 years and older with gram-negative bacterial infections.

The safety and bioavailability of fluoroquinolones (FQs) have made them a popular choice for treating infections—especially urinary tract and intra-abdominal infections—in older adults. But increased fluoroquinolone resistance in gram-negative bacteria may have a significant impact on the use of these agents in this population, wrote Jon P. Furuno, Ph.D., of the University of Maryland, Baltimore, and his colleagues in a poster presented at the annual meeting of the American Geriatrics Society.

They collected microbiology data from all cultures that tested positive for gram-negative bacteria in patients aged 65 years and older who were admitted to the University of Maryland Medical Center between January 1998 and December 2005.

During that period, they analyzed a total of 1,839 Escherichia coli, 554 Proteus mirabilis, 1,044 Pseudomonas aeruginosa, 1,068 Klebsiella, and 480 Enterobacter cloacae isolates.

FQ resistance increased significantly across all species, from 8% in 1998 to almost 27% in 2005. But resistance varied by species and within years. Species-specific significant increases in the percentage of resistant isolates were observed from 1998 to 2005 for E. coli (3% vs. 31%), P. mirabilis (7 % vs. 39%), and Klebsiella (1.7% vs. 9.3%). Resistance rates in P. aeruginosa and E. cloacae increased from 1998 to 2005, but the differences were not statistically significant.

The researchers defined FQ resistance as resistance to all FQ drugs against which the isolates were tested, including ciprofloxacin, levofloxacin, and gatifloxacin.

They urged that prescribers consider the evidence of rising FQ resistance when choosing antibiotics for hospitalized older adults, although they conceded that more data are needed to determine the impact on treatment failure and subsequent outcomes in this population.

The study was supported in part by funding from the National Institutes of Health, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America. Dr. Furuno did not disclose any financial conflicts.

WASHINGTON — Fluoroquinolone resistance rose significantly over an 8-year period in hospitalized adults aged 65 years and older with gram-negative bacterial infections.

The safety and bioavailability of fluoroquinolones (FQs) have made them a popular choice for treating infections—especially urinary tract and intra-abdominal infections—in older adults. But increased fluoroquinolone resistance in gram-negative bacteria may have a significant impact on the use of these agents in this population, wrote Jon P. Furuno, Ph.D., of the University of Maryland, Baltimore, and his colleagues in a poster presented at the annual meeting of the American Geriatrics Society.

They collected microbiology data from all cultures that tested positive for gram-negative bacteria in patients aged 65 years and older who were admitted to the University of Maryland Medical Center between January 1998 and December 2005.

During that period, they analyzed a total of 1,839 Escherichia coli, 554 Proteus mirabilis, 1,044 Pseudomonas aeruginosa, 1,068 Klebsiella, and 480 Enterobacter cloacae isolates.

FQ resistance increased significantly across all species, from 8% in 1998 to almost 27% in 2005. But resistance varied by species and within years. Species-specific significant increases in the percentage of resistant isolates were observed from 1998 to 2005 for E. coli (3% vs. 31%), P. mirabilis (7 % vs. 39%), and Klebsiella (1.7% vs. 9.3%). Resistance rates in P. aeruginosa and E. cloacae increased from 1998 to 2005, but the differences were not statistically significant.

The researchers defined FQ resistance as resistance to all FQ drugs against which the isolates were tested, including ciprofloxacin, levofloxacin, and gatifloxacin.

They urged that prescribers consider the evidence of rising FQ resistance when choosing antibiotics for hospitalized older adults, although they conceded that more data are needed to determine the impact on treatment failure and subsequent outcomes in this population.

The study was supported in part by funding from the National Institutes of Health, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America. Dr. Furuno did not disclose any financial conflicts.

WASHINGTON — Fluoroquinolone resistance rose significantly over an 8-year period in hospitalized adults aged 65 years and older with gram-negative bacterial infections.

The safety and bioavailability of fluoroquinolones (FQs) have made them a popular choice for treating infections—especially urinary tract and intra-abdominal infections—in older adults. But increased fluoroquinolone resistance in gram-negative bacteria may have a significant impact on the use of these agents in this population, wrote Jon P. Furuno, Ph.D., of the University of Maryland, Baltimore, and his colleagues in a poster presented at the annual meeting of the American Geriatrics Society.

They collected microbiology data from all cultures that tested positive for gram-negative bacteria in patients aged 65 years and older who were admitted to the University of Maryland Medical Center between January 1998 and December 2005.

During that period, they analyzed a total of 1,839 Escherichia coli, 554 Proteus mirabilis, 1,044 Pseudomonas aeruginosa, 1,068 Klebsiella, and 480 Enterobacter cloacae isolates.

FQ resistance increased significantly across all species, from 8% in 1998 to almost 27% in 2005. But resistance varied by species and within years. Species-specific significant increases in the percentage of resistant isolates were observed from 1998 to 2005 for E. coli (3% vs. 31%), P. mirabilis (7 % vs. 39%), and Klebsiella (1.7% vs. 9.3%). Resistance rates in P. aeruginosa and E. cloacae increased from 1998 to 2005, but the differences were not statistically significant.

The researchers defined FQ resistance as resistance to all FQ drugs against which the isolates were tested, including ciprofloxacin, levofloxacin, and gatifloxacin.

They urged that prescribers consider the evidence of rising FQ resistance when choosing antibiotics for hospitalized older adults, although they conceded that more data are needed to determine the impact on treatment failure and subsequent outcomes in this population.

The study was supported in part by funding from the National Institutes of Health, the Centers for Disease Control and Prevention, and the Infectious Diseases Society of America. Dr. Furuno did not disclose any financial conflicts.

WASHINGTON – A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, who is a geriatrician at the University of California, Los Angeles, and the director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and increased need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. There are several screening tools for mood disorders in use, but they have not been compared with one another or to any validated psychiatric-assessment tool, Dr. Saliba explained.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard–this study used the newer version of the test, which is made up of 15 yes/no questions–but other studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

She and her associates selected 418 nursing home residents who were scheduled to receive mandatory MDS 2.0 assessments. Nearly half of the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, standard tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” Dr. Saliba said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba.

The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

WASHINGTON – A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, who is a geriatrician at the University of California, Los Angeles, and the director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and increased need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. There are several screening tools for mood disorders in use, but they have not been compared with one another or to any validated psychiatric-assessment tool, Dr. Saliba explained.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard–this study used the newer version of the test, which is made up of 15 yes/no questions–but other studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

She and her associates selected 418 nursing home residents who were scheduled to receive mandatory MDS 2.0 assessments. Nearly half of the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, standard tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” Dr. Saliba said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba.

The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

WASHINGTON – A nine-item questionnaire of self-reported symptoms was more reliable and efficient than the widely used Geriatric Depression Scale and the Minimum Data Set 2.0 scale at assessing mood disorders in nursing home patients, according to a study in 71 facilities across eight states.

Accurate detection of mood disorders in the long-term care population remains a constant challenge, said Dr. Debra Saliba, who is a geriatrician at the University of California, Los Angeles, and the director of the Borun Center for Gerontological Research there. She reported the results at the annual meeting of the American Geriatrics Society.

Identifying depression in nursing home patients is important, she emphasized, because the condition is associated with poor functional status; increased perception of pain; stress; suicide; and increased need for medical services. “In fact, a disproportionate number of successful suicides occur in people over the age of 65,” said Dr. Saliba.

Treating depression can be effective in reducing poor outcomes in long-term care residents, but depression often goes unnoticed in this population. There are several screening tools for mood disorders in use, but they have not been compared with one another or to any validated psychiatric-assessment tool, Dr. Saliba explained.

The new study compared the effectiveness of the nine-item Patient Health Questionnaire (PHQ-9), the Geriatric Depression Scale (GDS), Minimum Data Set version 2.0 (MDS 2.0) assessment by staff, and one of two validated tools for identifying mood disorders in a long-term care population.

The GDS was designed for older adults and has become a geriatric standard–this study used the newer version of the test, which is made up of 15 yes/no questions–but other studies have suggested that the test may be overly influenced by somatic symptoms when individuals answer questions such as, “Have you stopped many of your activities and interests?” without being able to elaborate.

By contrast, PHQ-9 questions prompt open-ended responses to topics including sleep problems, feeling bad about oneself, and having trouble concentrating. The tool may be administered either as a self-reported survey or as part of an interview. The MDS 2.0 observer-rated scale avoids an interview or self-report.

“Some people have said that the PHQ-9 is too symptom driven or too complicated,” Dr. Saliba said, leading to questions of the survey's validity for assessing mood disorders in frail old people.

She and her associates selected 418 nursing home residents who were scheduled to receive mandatory MDS 2.0 assessments. Nearly half of the study participants were older than 85 years.

In addition to the MDS 2.0 assessment for each resident, one nurse administered the PHQ-9 and GDS, and a second nurse administered either the modified Schedule for Affective Disorders and Schizophrenia (mSADS) or the Cornell Scale for Depression.

The Cornell tool was used for residents whose cognition was too low to allow assessment by mSADS, but both of these tests are validated, standard tools, said Dr. Saliba.

About 80% of study participants were assessed by at least one of the screening tools as well as one of the validated tools. Overall, the GDS screen found 41% of residents with probable depression, PHQ-9 found 42%, and MDS 2.0 found 17%.

When the investigators used a measure of agreement adjusted for chance (kappa scores), the PHQ-9 had significantly higher agreement with the validated standard than either the GDS or the MDS 2.0 did. In fact, the MDS 2.0 assessment was less accurate than if the results had happened by chance, Dr. Saliba said.

“Contrary to the expectations of many, the PHQ-9 did not lead to more classification with depression,” Dr. Saliba said.

Not only was the PHQ-9 tool more accurate than the GDS screen, but it also took less time to complete: 4.9 minutes for the PHQ-9 vs. 11.4 minutes for the GDS.

Most of the residents, including the large number with cognitive impairment, could complete the PHQ-9, said Dr. Saliba.

The findings suggest that standardized mood assessment of older adults could be performed more effectively with the PHQ-9 than with the GDS or MDS 2.0, although more research is needed to confirm the results.

“We hadn't expected it to be quite so favorable for PHQ-9,” she said. “But it is often difficult for older adults to reduce their life experiences to yes or no questions.”

A complex mixture of biologic, psychological, and social evidence suggests that alcohol consumption in children and adolescents is a developmental issue, based on data from several studies published in a supplement in the journal Pediatrics.

The supplement, sponsored by the National Institute on Alcohol Abuse and Alcoholism, is intended as a clinicians' reference for current research on the developmental factors that may play a role in when and whether children and adolescents use and abuse alcohol. Contributors to the articles include experts in child and adolescent health and development, along with specialists in behavior, prevention research, neuroscience, brain imaging, and genetics.

Studying the developmental components of underage drinking at all developmental stages may help clinicians and public health officials intervene with children, families, and communities to prevent and treat alcohol problems in children and reduce the risk of long-term problems, wrote Ann S. Masten, Ph.D., of the University of Minnesota, Minneapolis, and her colleagues in an article that introduced the concept of a developmental framework for underage drinking (Pediatrics 2008;121:S235-51).

Data from animal studies show that adolescence is a time of particular sensitivity to alcohol, and chronic exposure to alcohol during adolescence promotes cell death and may have negative effects that last into adulthood. Similarly, limited studies in human adolescents suggest that severe alcohol use disorders may be associated with a reduced hippocampal volume, although the results are not definitive, the investigators noted.

Developmental changes throughout childhood and adolescence include changes in form, function, organization, and context, they wrote. Several studies presented in the supplement highlight the connections between these changes and alcohol use and abuse at different developmental stages. Developmental pathways that can steer children toward or away from alcohol appear when they are younger than 10 years old, based on data reported by Robert A. Zucker, Ph.D., of the University of Michigan, Ann Arbor, and his colleagues.

Many factors that have an impact on alcohol use and abuse by children and teens are not specific to alcohol, the investigators noted. Instead, the development of both internalizing and externalizing behaviors can become either risk factors or protective factors with regard to a child's early experiences with alcohol. The nonspecific risk factors are as important as the alcohol-specific factors in affecting how a child responds to alcohol, they explained.

Findings from studies of infants have shown that some infants respond more quickly than others to stimuli. Their abilities to focus on an object or shift focus in response to new stimuli reflect the beginnings of self-regulation and control systems that will ultimately affect how well the individual can plan, reflect, and decide whether to proceed with a particular action. In addition, data from longitudinal studies of young children suggest that externalizing behaviors including aggression, impulsivity, and lack of control, as well as internalizing behaviors including anxiety, sadness, and depression, not only appear in early childhood but predict an increased risk of substance abuse problems. These traits tend to persist throughout childhood and adolescence, Dr. Zucker and his associates noted.

“Despite the preponderance of evidence, it is still rare for clinicians to recognize that drinking problems of youths have their beginnings well before alcohol use is initiated,” they said.

More research is needed to understand the factors that influence initial alcohol use in children, and the data are not conclusive as to whether children who first experiment with drinking when they are younger than age 12 years are at greater risk than those who initiate alcohol use at age 13–14 years. Social contexts, including drinking habits in the child's home and the child's exposure to alcohol through mass media, contribute to children's attitudes toward alcohol and expectations of its effects.

Children in alcoholic families are at increased risk for developing alcohol-related problems. Based on data from the National Longitudinal Alcohol Epidemiologic Survey published in 2000, 15% of children aged 17 years and younger in the United States were living with at least one adult who met criteria for alcohol abuse or dependence within a year of the survey. Although alcohol use at a young age is a problem, some parents opt to introduce children to responsible drinking patterns within a family context, and any public or school-based alcohol abuse prevention programs must take family and cultural considerations into account in order to be effective, Dr. Zucker and his associates said.

Changes in family and peer relationships, as well as developmental and cognitive changes related to puberty, have an impact on the onset and escalation of alcohol use in youth between 10 and 15 years of age, according to a report by Michael Windle, Ph.D., of Emory University, Atlanta, and colleagues (Pediatrics 2008;121:S273-89). Early adolescents begin spending less time with parents and families and more time alone or with peers.

In addition, early adolescents become more aware of societal influences, and they become more like adults in their active consumption of cultural messages from the mass media and their peers. Studies have shown that third-graders tend to associate drinking alcohol with negative outcomes such as acting wild, rude, or silly, the investigators noted. By contrast, by age 10 most children have formed response-outcome expectancies about drinking alcohol that are more positive. Early adolescents are increasingly sensitive to peer behaviors, and the mass media could serve as a “superpeer” in forming their thinking, they said. Movies and television aimed at adolescents often show teenagers drinking and rarely show them suffering any negative consequences.

The biologic effects of puberty also have an impact on alcohol use in early adolescence, although the mechanism of these effects has not been well studied, Dr. Windle and associates noted. But data from multiple studies have shown that the changes that occur in the brain during early and middle adolescence include changes in neurocognitive functions (such as decision making and risk taking) that are linked to alcohol use.

“Family history of alcoholism, parents' drinking levels, perceptions of peer drinking, and prototypes of typical adolescent drinkers all seem to help shape expectancies,” the investigators wrote. But learning and personality factors play a role, too. It also must be understood that each human is an active agent in determining developmental pathways and that resilience (resistance to moving down problematic pathways) is as important to understand as are processes leading to maladaptation and disease,” they emphasized.

Alcohol-specific risk factors and protective factors have a significant impact at this age. Data from multiple prediction studies have shown that the number of alcohol-using friends can account for up to 50% of the variance in teen and preteen alcohol use. And parents and older siblings continue to influence adolescent alcohol use and contribute to alcohol expectancies that formed during early childhood. Protective factors that deter early adolescents from alcohol use include an affectionate temperament, high levels of religiosity, and nurturing, supportive parents, based on data from prospective studies.

By late adolescence, aged 16–20 years, alcohol use tends to escalate and youth are increasingly vulnerable to alcohol use problems and alcohol use disorders. The increased vulnerability stems from a combination of the ongoing early adolescent risk factors and the unique neurologic, social, and cognitive changes that occur in late adolescence, wrote Sandra A. Brown, Ph.D., of the University of California, San Diego, and her colleagues (Pediatrics 2008;121:S290-310).

“Adolescence is now realized as a period of continued neurologic development, and the adolescent brain may be especially vulnerable to the neurotoxic effects of alcohol, especially given the typical ways in which youths drink,” the investigators wrote.

Data from behavioral genetics research show that the genetic factors that can affect adolescent alcohol use appear to have greater impact during the transition from middle to late adolescence. In addition, genetic influences that have an impact on problem drinking appear to overlap with other disinhibited behaviors that are influenced by genetics. But that doesn't mean that genetics alone contribute to the tendency toward alcohol abuse in some adolescents and not others. In fact, more evidence suggests that genetic influences on such complex behaviors as problem drinking result from a mix of environmental and inherited factors, they noted.

Problems with alcohol in late adolescence have proven links not only to problem drinking but also to an increased risk for mental health problems and poor social function in adulthood. Findings from longitudinal studies of alcohol use enhance the developmental picture by showing how individuals and subgroups of adolescents differ in their patterns of alcohol use over time.

The trajectory groups most often used to characterize adolescent drinking patterns include abstainers/light stable moderate drinkers, fling drinkers, decreasers, chronic heavy drinkers, and late-onset heavy drinkers. The proportion of adolescents who fall within these groups varies among different studies, but in general the abstainers/light drinkers account for 20%–65% of the adolescent population, while stable moderate drinkers account for approximately 30%, fling drinkers and decreasers each account for approximately 10%, and chronic heavy drinkers and late-onset heavy drinkers each account for less than 10%.

Risk factors and protective factors associated with alcohol use and abuse in late adolescents have been well studied. Risk factors include a family history of alcoholism, history of mental health problems, and history of physical or sexual abuse. Protective factors include long-term educational or job goals and positive family and social relationships. The timing of other life transitions such as getting a job and getting married also can have an impact on alcohol use and abuse in late adolescence.

“It is increasingly clear that the emergence and progression of drinking behavior are influenced by development, that underage drinking has developmental consequences, that alcohol use disorders are developmental in nature, and that efforts to prevent or to reduce underage drinking behavior must be developmentally informed to be strategic, sensitive, and effective,” Dr. Masten and colleagues wrote in the introduction.

The authors of the studies in the supplement had no relevant financial relationships to disclose.

Chronic exposure to alcohol during adolescence may have negative effects that last into adulthood. ©Ivonne

A complex mixture of biologic, psychological, and social evidence suggests that alcohol consumption in children and adolescents is a developmental issue, based on data from several studies published in a supplement in the journal Pediatrics.

The supplement, sponsored by the National Institute on Alcohol Abuse and Alcoholism, is intended as a clinicians' reference for current research on the developmental factors that may play a role in when and whether children and adolescents use and abuse alcohol. Contributors to the articles include experts in child and adolescent health and development, along with specialists in behavior, prevention research, neuroscience, brain imaging, and genetics.

Studying the developmental components of underage drinking at all developmental stages may help clinicians and public health officials intervene with children, families, and communities to prevent and treat alcohol problems in children and reduce the risk of long-term problems, wrote Ann S. Masten, Ph.D., of the University of Minnesota, Minneapolis, and her colleagues in an article that introduced the concept of a developmental framework for underage drinking (Pediatrics 2008;121:S235-51).

Data from animal studies show that adolescence is a time of particular sensitivity to alcohol, and chronic exposure to alcohol during adolescence promotes cell death and may have negative effects that last into adulthood. Similarly, limited studies in human adolescents suggest that severe alcohol use disorders may be associated with a reduced hippocampal volume, although the results are not definitive, the investigators noted.

Developmental changes throughout childhood and adolescence include changes in form, function, organization, and context, they wrote. Several studies presented in the supplement highlight the connections between these changes and alcohol use and abuse at different developmental stages. Developmental pathways that can steer children toward or away from alcohol appear when they are younger than 10 years old, based on data reported by Robert A. Zucker, Ph.D., of the University of Michigan, Ann Arbor, and his colleagues.

Many factors that have an impact on alcohol use and abuse by children and teens are not specific to alcohol, the investigators noted. Instead, the development of both internalizing and externalizing behaviors can become either risk factors or protective factors with regard to a child's early experiences with alcohol. The nonspecific risk factors are as important as the alcohol-specific factors in affecting how a child responds to alcohol, they explained.

Findings from studies of infants have shown that some infants respond more quickly than others to stimuli. Their abilities to focus on an object or shift focus in response to new stimuli reflect the beginnings of self-regulation and control systems that will ultimately affect how well the individual can plan, reflect, and decide whether to proceed with a particular action. In addition, data from longitudinal studies of young children suggest that externalizing behaviors including aggression, impulsivity, and lack of control, as well as internalizing behaviors including anxiety, sadness, and depression, not only appear in early childhood but predict an increased risk of substance abuse problems. These traits tend to persist throughout childhood and adolescence, Dr. Zucker and his associates noted.

“Despite the preponderance of evidence, it is still rare for clinicians to recognize that drinking problems of youths have their beginnings well before alcohol use is initiated,” they said.

More research is needed to understand the factors that influence initial alcohol use in children, and the data are not conclusive as to whether children who first experiment with drinking when they are younger than age 12 years are at greater risk than those who initiate alcohol use at age 13–14 years. Social contexts, including drinking habits in the child's home and the child's exposure to alcohol through mass media, contribute to children's attitudes toward alcohol and expectations of its effects.

Children in alcoholic families are at increased risk for developing alcohol-related problems. Based on data from the National Longitudinal Alcohol Epidemiologic Survey published in 2000, 15% of children aged 17 years and younger in the United States were living with at least one adult who met criteria for alcohol abuse or dependence within a year of the survey. Although alcohol use at a young age is a problem, some parents opt to introduce children to responsible drinking patterns within a family context, and any public or school-based alcohol abuse prevention programs must take family and cultural considerations into account in order to be effective, Dr. Zucker and his associates said.

Changes in family and peer relationships, as well as developmental and cognitive changes related to puberty, have an impact on the onset and escalation of alcohol use in youth between 10 and 15 years of age, according to a report by Michael Windle, Ph.D., of Emory University, Atlanta, and colleagues (Pediatrics 2008;121:S273-89). Early adolescents begin spending less time with parents and families and more time alone or with peers.

In addition, early adolescents become more aware of societal influences, and they become more like adults in their active consumption of cultural messages from the mass media and their peers. Studies have shown that third-graders tend to associate drinking alcohol with negative outcomes such as acting wild, rude, or silly, the investigators noted. By contrast, by age 10 most children have formed response-outcome expectancies about drinking alcohol that are more positive. Early adolescents are increasingly sensitive to peer behaviors, and the mass media could serve as a “superpeer” in forming their thinking, they said. Movies and television aimed at adolescents often show teenagers drinking and rarely show them suffering any negative consequences.

The biologic effects of puberty also have an impact on alcohol use in early adolescence, although the mechanism of these effects has not been well studied, Dr. Windle and associates noted. But data from multiple studies have shown that the changes that occur in the brain during early and middle adolescence include changes in neurocognitive functions (such as decision making and risk taking) that are linked to alcohol use.

“Family history of alcoholism, parents' drinking levels, perceptions of peer drinking, and prototypes of typical adolescent drinkers all seem to help shape expectancies,” the investigators wrote. But learning and personality factors play a role, too. It also must be understood that each human is an active agent in determining developmental pathways and that resilience (resistance to moving down problematic pathways) is as important to understand as are processes leading to maladaptation and disease,” they emphasized.

Alcohol-specific risk factors and protective factors have a significant impact at this age. Data from multiple prediction studies have shown that the number of alcohol-using friends can account for up to 50% of the variance in teen and preteen alcohol use. And parents and older siblings continue to influence adolescent alcohol use and contribute to alcohol expectancies that formed during early childhood. Protective factors that deter early adolescents from alcohol use include an affectionate temperament, high levels of religiosity, and nurturing, supportive parents, based on data from prospective studies.

By late adolescence, aged 16–20 years, alcohol use tends to escalate and youth are increasingly vulnerable to alcohol use problems and alcohol use disorders. The increased vulnerability stems from a combination of the ongoing early adolescent risk factors and the unique neurologic, social, and cognitive changes that occur in late adolescence, wrote Sandra A. Brown, Ph.D., of the University of California, San Diego, and her colleagues (Pediatrics 2008;121:S290-310).

“Adolescence is now realized as a period of continued neurologic development, and the adolescent brain may be especially vulnerable to the neurotoxic effects of alcohol, especially given the typical ways in which youths drink,” the investigators wrote.

Data from behavioral genetics research show that the genetic factors that can affect adolescent alcohol use appear to have greater impact during the transition from middle to late adolescence. In addition, genetic influences that have an impact on problem drinking appear to overlap with other disinhibited behaviors that are influenced by genetics. But that doesn't mean that genetics alone contribute to the tendency toward alcohol abuse in some adolescents and not others. In fact, more evidence suggests that genetic influences on such complex behaviors as problem drinking result from a mix of environmental and inherited factors, they noted.

Problems with alcohol in late adolescence have proven links not only to problem drinking but also to an increased risk for mental health problems and poor social function in adulthood. Findings from longitudinal studies of alcohol use enhance the developmental picture by showing how individuals and subgroups of adolescents differ in their patterns of alcohol use over time.

The trajectory groups most often used to characterize adolescent drinking patterns include abstainers/light stable moderate drinkers, fling drinkers, decreasers, chronic heavy drinkers, and late-onset heavy drinkers. The proportion of adolescents who fall within these groups varies among different studies, but in general the abstainers/light drinkers account for 20%–65% of the adolescent population, while stable moderate drinkers account for approximately 30%, fling drinkers and decreasers each account for approximately 10%, and chronic heavy drinkers and late-onset heavy drinkers each account for less than 10%.

Risk factors and protective factors associated with alcohol use and abuse in late adolescents have been well studied. Risk factors include a family history of alcoholism, history of mental health problems, and history of physical or sexual abuse. Protective factors include long-term educational or job goals and positive family and social relationships. The timing of other life transitions such as getting a job and getting married also can have an impact on alcohol use and abuse in late adolescence.

“It is increasingly clear that the emergence and progression of drinking behavior are influenced by development, that underage drinking has developmental consequences, that alcohol use disorders are developmental in nature, and that efforts to prevent or to reduce underage drinking behavior must be developmentally informed to be strategic, sensitive, and effective,” Dr. Masten and colleagues wrote in the introduction.

The authors of the studies in the supplement had no relevant financial relationships to disclose.

Chronic exposure to alcohol during adolescence may have negative effects that last into adulthood. ©Ivonne

A complex mixture of biologic, psychological, and social evidence suggests that alcohol consumption in children and adolescents is a developmental issue, based on data from several studies published in a supplement in the journal Pediatrics.

The supplement, sponsored by the National Institute on Alcohol Abuse and Alcoholism, is intended as a clinicians' reference for current research on the developmental factors that may play a role in when and whether children and adolescents use and abuse alcohol. Contributors to the articles include experts in child and adolescent health and development, along with specialists in behavior, prevention research, neuroscience, brain imaging, and genetics.

Studying the developmental components of underage drinking at all developmental stages may help clinicians and public health officials intervene with children, families, and communities to prevent and treat alcohol problems in children and reduce the risk of long-term problems, wrote Ann S. Masten, Ph.D., of the University of Minnesota, Minneapolis, and her colleagues in an article that introduced the concept of a developmental framework for underage drinking (Pediatrics 2008;121:S235-51).

Data from animal studies show that adolescence is a time of particular sensitivity to alcohol, and chronic exposure to alcohol during adolescence promotes cell death and may have negative effects that last into adulthood. Similarly, limited studies in human adolescents suggest that severe alcohol use disorders may be associated with a reduced hippocampal volume, although the results are not definitive, the investigators noted.

Developmental changes throughout childhood and adolescence include changes in form, function, organization, and context, they wrote. Several studies presented in the supplement highlight the connections between these changes and alcohol use and abuse at different developmental stages. Developmental pathways that can steer children toward or away from alcohol appear when they are younger than 10 years old, based on data reported by Robert A. Zucker, Ph.D., of the University of Michigan, Ann Arbor, and his colleagues.

Many factors that have an impact on alcohol use and abuse by children and teens are not specific to alcohol, the investigators noted. Instead, the development of both internalizing and externalizing behaviors can become either risk factors or protective factors with regard to a child's early experiences with alcohol. The nonspecific risk factors are as important as the alcohol-specific factors in affecting how a child responds to alcohol, they explained.

Findings from studies of infants have shown that some infants respond more quickly than others to stimuli. Their abilities to focus on an object or shift focus in response to new stimuli reflect the beginnings of self-regulation and control systems that will ultimately affect how well the individual can plan, reflect, and decide whether to proceed with a particular action. In addition, data from longitudinal studies of young children suggest that externalizing behaviors including aggression, impulsivity, and lack of control, as well as internalizing behaviors including anxiety, sadness, and depression, not only appear in early childhood but predict an increased risk of substance abuse problems. These traits tend to persist throughout childhood and adolescence, Dr. Zucker and his associates noted.

“Despite the preponderance of evidence, it is still rare for clinicians to recognize that drinking problems of youths have their beginnings well before alcohol use is initiated,” they said.

More research is needed to understand the factors that influence initial alcohol use in children, and the data are not conclusive as to whether children who first experiment with drinking when they are younger than age 12 years are at greater risk than those who initiate alcohol use at age 13–14 years. Social contexts, including drinking habits in the child's home and the child's exposure to alcohol through mass media, contribute to children's attitudes toward alcohol and expectations of its effects.

Children in alcoholic families are at increased risk for developing alcohol-related problems. Based on data from the National Longitudinal Alcohol Epidemiologic Survey published in 2000, 15% of children aged 17 years and younger in the United States were living with at least one adult who met criteria for alcohol abuse or dependence within a year of the survey. Although alcohol use at a young age is a problem, some parents opt to introduce children to responsible drinking patterns within a family context, and any public or school-based alcohol abuse prevention programs must take family and cultural considerations into account in order to be effective, Dr. Zucker and his associates said.

Changes in family and peer relationships, as well as developmental and cognitive changes related to puberty, have an impact on the onset and escalation of alcohol use in youth between 10 and 15 years of age, according to a report by Michael Windle, Ph.D., of Emory University, Atlanta, and colleagues (Pediatrics 2008;121:S273-89). Early adolescents begin spending less time with parents and families and more time alone or with peers.

In addition, early adolescents become more aware of societal influences, and they become more like adults in their active consumption of cultural messages from the mass media and their peers. Studies have shown that third-graders tend to associate drinking alcohol with negative outcomes such as acting wild, rude, or silly, the investigators noted. By contrast, by age 10 most children have formed response-outcome expectancies about drinking alcohol that are more positive. Early adolescents are increasingly sensitive to peer behaviors, and the mass media could serve as a “superpeer” in forming their thinking, they said. Movies and television aimed at adolescents often show teenagers drinking and rarely show them suffering any negative consequences.

The biologic effects of puberty also have an impact on alcohol use in early adolescence, although the mechanism of these effects has not been well studied, Dr. Windle and associates noted. But data from multiple studies have shown that the changes that occur in the brain during early and middle adolescence include changes in neurocognitive functions (such as decision making and risk taking) that are linked to alcohol use.

“Family history of alcoholism, parents' drinking levels, perceptions of peer drinking, and prototypes of typical adolescent drinkers all seem to help shape expectancies,” the investigators wrote. But learning and personality factors play a role, too. It also must be understood that each human is an active agent in determining developmental pathways and that resilience (resistance to moving down problematic pathways) is as important to understand as are processes leading to maladaptation and disease,” they emphasized.

Alcohol-specific risk factors and protective factors have a significant impact at this age. Data from multiple prediction studies have shown that the number of alcohol-using friends can account for up to 50% of the variance in teen and preteen alcohol use. And parents and older siblings continue to influence adolescent alcohol use and contribute to alcohol expectancies that formed during early childhood. Protective factors that deter early adolescents from alcohol use include an affectionate temperament, high levels of religiosity, and nurturing, supportive parents, based on data from prospective studies.

By late adolescence, aged 16–20 years, alcohol use tends to escalate and youth are increasingly vulnerable to alcohol use problems and alcohol use disorders. The increased vulnerability stems from a combination of the ongoing early adolescent risk factors and the unique neurologic, social, and cognitive changes that occur in late adolescence, wrote Sandra A. Brown, Ph.D., of the University of California, San Diego, and her colleagues (Pediatrics 2008;121:S290-310).

“Adolescence is now realized as a period of continued neurologic development, and the adolescent brain may be especially vulnerable to the neurotoxic effects of alcohol, especially given the typical ways in which youths drink,” the investigators wrote.

Data from behavioral genetics research show that the genetic factors that can affect adolescent alcohol use appear to have greater impact during the transition from middle to late adolescence. In addition, genetic influences that have an impact on problem drinking appear to overlap with other disinhibited behaviors that are influenced by genetics. But that doesn't mean that genetics alone contribute to the tendency toward alcohol abuse in some adolescents and not others. In fact, more evidence suggests that genetic influences on such complex behaviors as problem drinking result from a mix of environmental and inherited factors, they noted.

Problems with alcohol in late adolescence have proven links not only to problem drinking but also to an increased risk for mental health problems and poor social function in adulthood. Findings from longitudinal studies of alcohol use enhance the developmental picture by showing how individuals and subgroups of adolescents differ in their patterns of alcohol use over time.

The trajectory groups most often used to characterize adolescent drinking patterns include abstainers/light stable moderate drinkers, fling drinkers, decreasers, chronic heavy drinkers, and late-onset heavy drinkers. The proportion of adolescents who fall within these groups varies among different studies, but in general the abstainers/light drinkers account for 20%–65% of the adolescent population, while stable moderate drinkers account for approximately 30%, fling drinkers and decreasers each account for approximately 10%, and chronic heavy drinkers and late-onset heavy drinkers each account for less than 10%.

Risk factors and protective factors associated with alcohol use and abuse in late adolescents have been well studied. Risk factors include a family history of alcoholism, history of mental health problems, and history of physical or sexual abuse. Protective factors include long-term educational or job goals and positive family and social relationships. The timing of other life transitions such as getting a job and getting married also can have an impact on alcohol use and abuse in late adolescence.

“It is increasingly clear that the emergence and progression of drinking behavior are influenced by development, that underage drinking has developmental consequences, that alcohol use disorders are developmental in nature, and that efforts to prevent or to reduce underage drinking behavior must be developmentally informed to be strategic, sensitive, and effective,” Dr. Masten and colleagues wrote in the introduction.

The authors of the studies in the supplement had no relevant financial relationships to disclose.

Chronic exposure to alcohol during adolescence may have negative effects that last into adulthood. ©Ivonne

WASHINGTON — A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that builds and operates retirement communities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015-22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition.

The “memory care exercise program” developed for residents with dementia and used at Touchmark communities rests on four fundamentals—deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia residents include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower lungs.

The program then addresses posture, which is important for balance and stability. Chest muscles tend to become weak with age, so it's hard for many older long-term care residents to draw the shoulder blades together and sit up straight.

A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck, bending the head forward and towards each shoulder (never tilting it back), which promotes range of motion in the neck. Shoulder range of motion exercises include “pick an apple,” which is reaching up and across the body and back down to the opposite side, and “swing the bat,” in which the person holds an imaginary baseball bat on one shoulder and swings it down and across the body.

To strengthen the lower body, residents make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

The exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised.

A small ball is placed behind the patient's back to help her sit upright and attain maximum movement. Touchmark

WASHINGTON — A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that builds and operates retirement communities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015-22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition.

The “memory care exercise program” developed for residents with dementia and used at Touchmark communities rests on four fundamentals—deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia residents include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower lungs.

The program then addresses posture, which is important for balance and stability. Chest muscles tend to become weak with age, so it's hard for many older long-term care residents to draw the shoulder blades together and sit up straight.

A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck, bending the head forward and towards each shoulder (never tilting it back), which promotes range of motion in the neck. Shoulder range of motion exercises include “pick an apple,” which is reaching up and across the body and back down to the opposite side, and “swing the bat,” in which the person holds an imaginary baseball bat on one shoulder and swings it down and across the body.

To strengthen the lower body, residents make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

The exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised.

A small ball is placed behind the patient's back to help her sit upright and attain maximum movement. Touchmark

WASHINGTON — A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that builds and operates retirement communities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015-22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition.

The “memory care exercise program” developed for residents with dementia and used at Touchmark communities rests on four fundamentals—deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia residents include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower lungs.

The program then addresses posture, which is important for balance and stability. Chest muscles tend to become weak with age, so it's hard for many older long-term care residents to draw the shoulder blades together and sit up straight.

A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck, bending the head forward and towards each shoulder (never tilting it back), which promotes range of motion in the neck. Shoulder range of motion exercises include “pick an apple,” which is reaching up and across the body and back down to the opposite side, and “swing the bat,” in which the person holds an imaginary baseball bat on one shoulder and swings it down and across the body.

To strengthen the lower body, residents make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

The exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised.

A small ball is placed behind the patient's back to help her sit upright and attain maximum movement. Touchmark

Modafinil significantly improved symptoms in children with inattentive and combined subtypes of attention-deficit/hyperactivity disorder, based on data from 638 children aged 6–17 years.

Pooled results from one 7-week study and two 9-week studies showed that modafinil was well tolerated and improved attention-deficit hyperactivity disorder (ADHD) symptoms both at home and in school. The studies were funded by Cephalon Inc., which markets modafinil as Provigil in the United States.

Dr. Joseph Biederman of Massachusetts General Hospital, Boston, and Dr. Steven R. Pliszka of the University of Texas Health Science Center, San Antonio, reviewed the pooled data to analyze the effectiveness of modafinil on three ADHD subtypes: inattentive, combined, and hyperactive impulsive (J. Pediatr. 2008;152:394-9). Few studies have examined the effectiveness of drug treatments for ADHD by subtype.

In the 7-week study, children were randomized to receive 340 mg or 425 mg of modafinil or a placebo daily. In the 9-week studies, children were randomized to receive a flexible dose from 170 mg to 425 mg or a placebo daily. A total of 423 children received modafinil and 215 received a placebo.

The researchers used the ADHD-RS-IV School Version, which includes teacher and investigator ratings to assess symptoms.

Children in the inattentive and combined subgroups who received modafinil showed significant improvements in the ADHD-RS-IV School Version total scores, compared with placebo patients. Children in the hyperactive-impulsive subgroup who received modafinil showed a greater improvement in total scores (demonstrated by lower numbers) than placebo patients, but this difference was not statistically significant.

The average score for modafinil patients across all subgroups was 57 at the study's end versus 73 for placebo patients. Results were similar for scores on the ADHD-RS-IV Home Version, which were detailed in a separate analysis.

Forty-eight percent of the inattentive subgroup who received modafinil versus 15% of those who were given a placebo received “much improved” or “very much improved” ratings from investigators. Similarly, 44% of the combined subgroup who received modafinil versus 18% of those who received placebo were rated “much improved” or “very much improved” by the investigators.

Children in the inattentive and combined subtype groups who received modafinil showed significant improvements in subscale scores for cognitive problems/inattention, hyperactivity, and the ADHD index, compared with placebo patients.

The combined subtype of ADHD is the most commonly diagnosed and is most often associated with psychiatric comorbidity and other behavioral, social, and academic problems, the researchers noted. A total of 65% of the children met criteria for the combined ADHD subtype, and this group had the largest percentage (18%) of children who were ranked “severely ill” or “extremely ill” at baseline.

Dr. Biederman receives research support from multiple drug companies, including this study's sponsor, Cephalon (for whom he also serves as a speaker and a member of the advisory board). He also serves as a speaker and advisory board member for many other pharmaceutical companies.

Dr. Pliszka receives research support from Cephalon and Eli Lilly & Co., and serves on speakers bureaus sponsored by Shire Pharmaceuticals and McNeil.

Modafinil significantly improved symptoms in children with inattentive and combined subtypes of attention-deficit/hyperactivity disorder, based on data from 638 children aged 6–17 years.

Pooled results from one 7-week study and two 9-week studies showed that modafinil was well tolerated and improved attention-deficit hyperactivity disorder (ADHD) symptoms both at home and in school. The studies were funded by Cephalon Inc., which markets modafinil as Provigil in the United States.

Dr. Joseph Biederman of Massachusetts General Hospital, Boston, and Dr. Steven R. Pliszka of the University of Texas Health Science Center, San Antonio, reviewed the pooled data to analyze the effectiveness of modafinil on three ADHD subtypes: inattentive, combined, and hyperactive impulsive (J. Pediatr. 2008;152:394-9). Few studies have examined the effectiveness of drug treatments for ADHD by subtype.

In the 7-week study, children were randomized to receive 340 mg or 425 mg of modafinil or a placebo daily. In the 9-week studies, children were randomized to receive a flexible dose from 170 mg to 425 mg or a placebo daily. A total of 423 children received modafinil and 215 received a placebo.

The researchers used the ADHD-RS-IV School Version, which includes teacher and investigator ratings to assess symptoms.

Children in the inattentive and combined subgroups who received modafinil showed significant improvements in the ADHD-RS-IV School Version total scores, compared with placebo patients. Children in the hyperactive-impulsive subgroup who received modafinil showed a greater improvement in total scores (demonstrated by lower numbers) than placebo patients, but this difference was not statistically significant.

The average score for modafinil patients across all subgroups was 57 at the study's end versus 73 for placebo patients. Results were similar for scores on the ADHD-RS-IV Home Version, which were detailed in a separate analysis.

Forty-eight percent of the inattentive subgroup who received modafinil versus 15% of those who were given a placebo received “much improved” or “very much improved” ratings from investigators. Similarly, 44% of the combined subgroup who received modafinil versus 18% of those who received placebo were rated “much improved” or “very much improved” by the investigators.

Children in the inattentive and combined subtype groups who received modafinil showed significant improvements in subscale scores for cognitive problems/inattention, hyperactivity, and the ADHD index, compared with placebo patients.

The combined subtype of ADHD is the most commonly diagnosed and is most often associated with psychiatric comorbidity and other behavioral, social, and academic problems, the researchers noted. A total of 65% of the children met criteria for the combined ADHD subtype, and this group had the largest percentage (18%) of children who were ranked “severely ill” or “extremely ill” at baseline.

Dr. Biederman receives research support from multiple drug companies, including this study's sponsor, Cephalon (for whom he also serves as a speaker and a member of the advisory board). He also serves as a speaker and advisory board member for many other pharmaceutical companies.

Dr. Pliszka receives research support from Cephalon and Eli Lilly & Co., and serves on speakers bureaus sponsored by Shire Pharmaceuticals and McNeil.

Modafinil significantly improved symptoms in children with inattentive and combined subtypes of attention-deficit/hyperactivity disorder, based on data from 638 children aged 6–17 years.

Pooled results from one 7-week study and two 9-week studies showed that modafinil was well tolerated and improved attention-deficit hyperactivity disorder (ADHD) symptoms both at home and in school. The studies were funded by Cephalon Inc., which markets modafinil as Provigil in the United States.

Dr. Joseph Biederman of Massachusetts General Hospital, Boston, and Dr. Steven R. Pliszka of the University of Texas Health Science Center, San Antonio, reviewed the pooled data to analyze the effectiveness of modafinil on three ADHD subtypes: inattentive, combined, and hyperactive impulsive (J. Pediatr. 2008;152:394-9). Few studies have examined the effectiveness of drug treatments for ADHD by subtype.

In the 7-week study, children were randomized to receive 340 mg or 425 mg of modafinil or a placebo daily. In the 9-week studies, children were randomized to receive a flexible dose from 170 mg to 425 mg or a placebo daily. A total of 423 children received modafinil and 215 received a placebo.

The researchers used the ADHD-RS-IV School Version, which includes teacher and investigator ratings to assess symptoms.

Children in the inattentive and combined subgroups who received modafinil showed significant improvements in the ADHD-RS-IV School Version total scores, compared with placebo patients. Children in the hyperactive-impulsive subgroup who received modafinil showed a greater improvement in total scores (demonstrated by lower numbers) than placebo patients, but this difference was not statistically significant.

The average score for modafinil patients across all subgroups was 57 at the study's end versus 73 for placebo patients. Results were similar for scores on the ADHD-RS-IV Home Version, which were detailed in a separate analysis.

Forty-eight percent of the inattentive subgroup who received modafinil versus 15% of those who were given a placebo received “much improved” or “very much improved” ratings from investigators. Similarly, 44% of the combined subgroup who received modafinil versus 18% of those who received placebo were rated “much improved” or “very much improved” by the investigators.

Children in the inattentive and combined subtype groups who received modafinil showed significant improvements in subscale scores for cognitive problems/inattention, hyperactivity, and the ADHD index, compared with placebo patients.

The combined subtype of ADHD is the most commonly diagnosed and is most often associated with psychiatric comorbidity and other behavioral, social, and academic problems, the researchers noted. A total of 65% of the children met criteria for the combined ADHD subtype, and this group had the largest percentage (18%) of children who were ranked “severely ill” or “extremely ill” at baseline.

Dr. Biederman receives research support from multiple drug companies, including this study's sponsor, Cephalon (for whom he also serves as a speaker and a member of the advisory board). He also serves as a speaker and advisory board member for many other pharmaceutical companies.

Dr. Pliszka receives research support from Cephalon and Eli Lilly & Co., and serves on speakers bureaus sponsored by Shire Pharmaceuticals and McNeil.

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

Social anxiety stemming from acne or other skin conditions might keep people from exercising, say results of a survey of 50 adults selected from an acne support group.

Exercise is important for overall health and skin health, but data from previous studies have shown that people are often inclined to avoid participating in sports and other activities because of anxiety about their appearance.

To examine the link between skin-related social anxiety and the intention to play sports or exercise, Tom Loney, a Ph.D. student at the University of Bath (England) and his colleagues surveyed 20 men and 30 women with an average age of 33 years (J. Health Psychol. 2008;13:47–54).

The participants responded to questionnaires that addressed dermatologic social anxiety, intention to participate in sports and exercise, self-esteem, and quality of life related to skin conditions.

Based on responses to dermatologic social anxiety statements such as, “When in a bathing suit, I often feel nervous about the appearance of my skin,” the average score was 3.97 on a scale of 1 (not at all) to 5 (extremely).

The average score for intent-to-exercise statements such as “I am determined to exercise/play sport at least three times a week during the next month” was 4.04 on a scale of 1 (very unlikely) to 7 (very likely). For self-esteem statements such as “I feel that I have a number of good qualities,” the average response was 1.56 on a scale of 1 (strongly disagree) to 4 (strongly agree).

Finally, the average score on the Dermatology Life Quality Index, which includes 10 items such as, “Over the last week, how much has your skin affected any social or leisure activities?” was 0.99 on a scale of 3 (very much) to 0 (not at all).

Statistical analyses of the responses yielded significant negative relationships between skin-related social anxiety and each of three variables: intention to exercise, self-esteem, and dermatologic-related quality of life.

“Participants who experience greater levels of skin-related social anxiety report lower intention to participate in sport and exercise, experience lower self-esteem,” and have a poorer quality of life related to skin conditions, Mr. Loney and his associates wrote.

The extent to which people are apprehensive about having their skin evaluated by others has implications for the intention to participate in sports and exercise and for self-perception, but more studies are needed to determine the impact of skin-related social anxiety within specific sports and exercise settings, they said. For example, team sports or group exercise settings might cause more anxiety than exercising alone, and people with high skin-related social anxiety might avoid those situations.

Although the results were limited by the use of a global perception of acne severity rather than symptom-specific ratings, the data support findings from previous studies and contribute to the limited field of research involving both physical and psychological health, Mr. Loney and his colleagues said. None of the researchers disclosed any conflicts of interest.

WASHINGTON – A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that operates a range of retirement communities including nursing homes and skilled nursing facilities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015–22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition. “There's so little hope you can hold out to people with this diagnosis,” Dr. Coalman said. “Something as simple as a predictable exercise routine makes a huge difference.”

The “memory care exercise program” developed for residents with dementia and used at Touchmark facilities rests on four fundamentals–deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia patients include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower parts of the lungs.

The program then addresses posture, which is important for balance and stability. A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck and bends the head toward each shoulder, promoting range of motion in the neck.

To strengthen the lower body, residents are instructed to make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

Finally, the exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. A caregiver should stand next to each resident and assist the person slightly, as needed.

To stand, residents are encouraged to scoot to the fronts of their chairs and use the chair's armrests to push themselves up. To sit, they are reminded to simply reverse the process. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised. The primary goal of any exercise program for people with dementia is “to keep [them] away from assistive devices as long as possible,” said Dr. Coalman. Greater independence promotes a better quality of life, she said.

An inflatable ball behind the back helps the person attain maximum movement. Touchmark

WASHINGTON – A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that operates a range of retirement communities including nursing homes and skilled nursing facilities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015–22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition. “There's so little hope you can hold out to people with this diagnosis,” Dr. Coalman said. “Something as simple as a predictable exercise routine makes a huge difference.”

The “memory care exercise program” developed for residents with dementia and used at Touchmark facilities rests on four fundamentals–deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia patients include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower parts of the lungs.

The program then addresses posture, which is important for balance and stability. A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck and bends the head toward each shoulder, promoting range of motion in the neck.

To strengthen the lower body, residents are instructed to make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

Finally, the exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. A caregiver should stand next to each resident and assist the person slightly, as needed.

To stand, residents are encouraged to scoot to the fronts of their chairs and use the chair's armrests to push themselves up. To sit, they are reminded to simply reverse the process. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised. The primary goal of any exercise program for people with dementia is “to keep [them] away from assistive devices as long as possible,” said Dr. Coalman. Greater independence promotes a better quality of life, she said.

An inflatable ball behind the back helps the person attain maximum movement. Touchmark

WASHINGTON – A regular exercise program not only promotes flexibility, balance, and strength in elderly people with dementia, but it also might improve their mental function.

“You won't get oxygen to the brain if you don't get air down into the alveoli,” said Marge A. Coalman, Ed.D., vice president of wellness and programs at Touchmark, an Oregon-based company that operates a range of retirement communities including nursing homes and skilled nursing facilities in the United States and Canada. She spoke at a joint conference of the American Society on Aging and the National Council on Aging.

The World Health Organization and the President's Council on Physical Fitness and Sport endorse exercise for people with Alzheimer's disease (AD) and other dementias, Dr. Coalman pointed out. The first research confirming that stand came 5 years ago in a randomized, controlled trial of 153 AD patients, she added. Those who participated in supervised exercise for at least 60 minutes per week had significantly better physical function and less depression than did patients who didn't exercise (JAMA 2003;290:2015–22). Since then, studies in mice and people have suggested that exercise creates new cells in areas of the brain that are affected by age-related memory loss.

If nothing else, exercise offers hope to people with dementia that they can improve their condition. “There's so little hope you can hold out to people with this diagnosis,” Dr. Coalman said. “Something as simple as a predictable exercise routine makes a huge difference.”

The “memory care exercise program” developed for residents with dementia and used at Touchmark facilities rests on four fundamentals–deep breathing, posture, range of motion, and strength. The degree of participation varies according to the resident's condition. Some patients continue exercising for as long as 30 minutes, but the average is 7 minutes.

Dr. Coalman's tips for conducting an exercise program with elderly dementia patients include keeping the movements slow but smooth, using straight-backed chairs with good back support, and invoking visual imagery such as marching in place to make the movements purposeful and fun.

Dr. Coalman described one exercise program developed by a physical therapist for Touchmark that starts with participants taking one to three deep breaths while raising their arms overhead. This promotes airflow into the lower parts of the lungs.

The program then addresses posture, which is important for balance and stability. A caregiver places a rolled-up towel or small inflatable ball behind a resident's back to help the person sit upright and attain maximum movement. The resident then rotates his or her neck and bends the head toward each shoulder, promoting range of motion in the neck.

To strengthen the lower body, residents are instructed to make circles with their ankles and to straighten one knee at a time and hold the lower leg up for a few seconds.

Finally, the exercise class ends with “stand-up sit-down” exercises for residents who are willing and able to rise from a sitting position with little or no assistance. A caregiver should stand next to each resident and assist the person slightly, as needed.

To stand, residents are encouraged to scoot to the fronts of their chairs and use the chair's armrests to push themselves up. To sit, they are reminded to simply reverse the process. Start patients with one repetition and work toward five rounds of stand-up sit-down, Dr. Coalman advised. The primary goal of any exercise program for people with dementia is “to keep [them] away from assistive devices as long as possible,” said Dr. Coalman. Greater independence promotes a better quality of life, she said.

An inflatable ball behind the back helps the person attain maximum movement. Touchmark

Frequent nighttime leg movements were significantly associated with sleep disturbance and less total sleep in a study of 102 elderly people with cognitive impairment.

Previous research had shown that sleep time varies from approximately 6 to 10 hours in nursing home residents who have moderate to severe cognitive impairment, and that this sleep is quite fragmented.

However, an association between periodic limb movements in sleep and total sleep time in older people with cognitive impairment hadn't been established.

The nature of the association–which emerged both among people living in nursing homes and in those in the community–remains unclear.

Kathy C. Richards, Ph.D., of the Polisher Research Institute, Horsham, Pa., and her colleagues measured sleep variables in 58 men and 44 women of average age 82 years. Of those, 66 people lived in nursing homes or assisted-living facilities and the rest resided at home.

The participants scored an average of 17.3 on the Mini-Mental State Examination (MMSE), in which a score of 30 signifies the highest cognitive function.

The exam rated seven people as having profound cognitive impairment, 14 with severe cognitive impairment, and 33 within the criteria for moderate cognitive impairment. The test rated 21 people as mildly impaired and 27 with early cognitive impairment.

The researchers then used polysomnography to collect data on variables including leg movement, oxygen saturation, time spent in bed, total sleep time, and the apnea-hypopnea index. The team conducted the test during 1 night in each person's usual sleep setting.

The study participants averaged 5.5 hours of total sleep time, ranging from less than 1 hour to nearly 9 hours. Although the average time spent in bed was 8 hours, only 67% of that time was spent sleeping, and nonrapid eye movement sleep made up 87% of the total sleep time. The study subjects awoke an average of 34 times during the night, but only an average of 1.8 awakenings was related to leg movements (Sleep 2008;31:224–30).

Participants' scores on the Periodic Leg Movement Index (PLMI) ranged from 0 to 112, with an average of 17. A total of 34 persons (33%) had PLMI scores greater than 15, which is the cutoff point for a diagnosis of periodic limb movement disorder.

Overall, people with a PLMI greater than 15 experienced significantly more minutes awake; less total sleep time and nonrapid eye movement sleep; less sleep efficiency; and a lower apnea-hypopnea index than did study participants with lower PLMI.

When the researchers controlled for multiple variables, a combination of time spent in bed, older age, and higher PLMI accounted for 44% of the study population's variance in total sleep time.

On the other hand, the analysis found no relationship between PLMI and other sleep variables or participants' age or MMSE scores.

The study showed no significant difference in total sleep time between people in private homes and those in nursing homes or assisted-living facilities.

“This was surprising considering the pervasive nursing care practices in nursing homes of awakening residents for incontinence and other care and the noise from other residents and staff,” the researchers noted.

“An elevated PLMI was associated with a consistent pattern of sleep disturbance, suggesting that [periodic leg movements] or other related comorbidities, such as restless leg syndrome, may be a cause for poor sleep in elders with cognitive impairment,” Dr. Richards and her colleagues wrote.

In a statement, Dr. Richards called that finding “important because treatment of periodic leg movements may result in improved nighttime sleep and improved quality of life in this vulnerable population.”

The study was limited by a lack of data on the potential role of upper airway resistance as a cause of nighttime leg movement, according to Dr. Richards and her colleagues.

Dr. Richards has received research support from Beverly Healthcare Corp., but the study had no industry sponsorship.

Frequent nighttime leg movements were significantly associated with sleep disturbance and less total sleep in a study of 102 elderly people with cognitive impairment.

Previous research had shown that sleep time varies from approximately 6 to 10 hours in nursing home residents who have moderate to severe cognitive impairment, and that this sleep is quite fragmented.

However, an association between periodic limb movements in sleep and total sleep time in older people with cognitive impairment hadn't been established.

The nature of the association–which emerged both among people living in nursing homes and in those in the community–remains unclear.

Kathy C. Richards, Ph.D., of the Polisher Research Institute, Horsham, Pa., and her colleagues measured sleep variables in 58 men and 44 women of average age 82 years. Of those, 66 people lived in nursing homes or assisted-living facilities and the rest resided at home.

The participants scored an average of 17.3 on the Mini-Mental State Examination (MMSE), in which a score of 30 signifies the highest cognitive function.

The exam rated seven people as having profound cognitive impairment, 14 with severe cognitive impairment, and 33 within the criteria for moderate cognitive impairment. The test rated 21 people as mildly impaired and 27 with early cognitive impairment.

The researchers then used polysomnography to collect data on variables including leg movement, oxygen saturation, time spent in bed, total sleep time, and the apnea-hypopnea index. The team conducted the test during 1 night in each person's usual sleep setting.

The study participants averaged 5.5 hours of total sleep time, ranging from less than 1 hour to nearly 9 hours. Although the average time spent in bed was 8 hours, only 67% of that time was spent sleeping, and nonrapid eye movement sleep made up 87% of the total sleep time. The study subjects awoke an average of 34 times during the night, but only an average of 1.8 awakenings was related to leg movements (Sleep 2008;31:224–30).

Participants' scores on the Periodic Leg Movement Index (PLMI) ranged from 0 to 112, with an average of 17. A total of 34 persons (33%) had PLMI scores greater than 15, which is the cutoff point for a diagnosis of periodic limb movement disorder.

Overall, people with a PLMI greater than 15 experienced significantly more minutes awake; less total sleep time and nonrapid eye movement sleep; less sleep efficiency; and a lower apnea-hypopnea index than did study participants with lower PLMI.

When the researchers controlled for multiple variables, a combination of time spent in bed, older age, and higher PLMI accounted for 44% of the study population's variance in total sleep time.

On the other hand, the analysis found no relationship between PLMI and other sleep variables or participants' age or MMSE scores.

The study showed no significant difference in total sleep time between people in private homes and those in nursing homes or assisted-living facilities.

“This was surprising considering the pervasive nursing care practices in nursing homes of awakening residents for incontinence and other care and the noise from other residents and staff,” the researchers noted.

“An elevated PLMI was associated with a consistent pattern of sleep disturbance, suggesting that [periodic leg movements] or other related comorbidities, such as restless leg syndrome, may be a cause for poor sleep in elders with cognitive impairment,” Dr. Richards and her colleagues wrote.

In a statement, Dr. Richards called that finding “important because treatment of periodic leg movements may result in improved nighttime sleep and improved quality of life in this vulnerable population.”

The study was limited by a lack of data on the potential role of upper airway resistance as a cause of nighttime leg movement, according to Dr. Richards and her colleagues.

Dr. Richards has received research support from Beverly Healthcare Corp., but the study had no industry sponsorship.

Frequent nighttime leg movements were significantly associated with sleep disturbance and less total sleep in a study of 102 elderly people with cognitive impairment.

Previous research had shown that sleep time varies from approximately 6 to 10 hours in nursing home residents who have moderate to severe cognitive impairment, and that this sleep is quite fragmented.

However, an association between periodic limb movements in sleep and total sleep time in older people with cognitive impairment hadn't been established.

The nature of the association–which emerged both among people living in nursing homes and in those in the community–remains unclear.

Kathy C. Richards, Ph.D., of the Polisher Research Institute, Horsham, Pa., and her colleagues measured sleep variables in 58 men and 44 women of average age 82 years. Of those, 66 people lived in nursing homes or assisted-living facilities and the rest resided at home.

The participants scored an average of 17.3 on the Mini-Mental State Examination (MMSE), in which a score of 30 signifies the highest cognitive function.

The exam rated seven people as having profound cognitive impairment, 14 with severe cognitive impairment, and 33 within the criteria for moderate cognitive impairment. The test rated 21 people as mildly impaired and 27 with early cognitive impairment.

The researchers then used polysomnography to collect data on variables including leg movement, oxygen saturation, time spent in bed, total sleep time, and the apnea-hypopnea index. The team conducted the test during 1 night in each person's usual sleep setting.

The study participants averaged 5.5 hours of total sleep time, ranging from less than 1 hour to nearly 9 hours. Although the average time spent in bed was 8 hours, only 67% of that time was spent sleeping, and nonrapid eye movement sleep made up 87% of the total sleep time. The study subjects awoke an average of 34 times during the night, but only an average of 1.8 awakenings was related to leg movements (Sleep 2008;31:224–30).

Participants' scores on the Periodic Leg Movement Index (PLMI) ranged from 0 to 112, with an average of 17. A total of 34 persons (33%) had PLMI scores greater than 15, which is the cutoff point for a diagnosis of periodic limb movement disorder.

Overall, people with a PLMI greater than 15 experienced significantly more minutes awake; less total sleep time and nonrapid eye movement sleep; less sleep efficiency; and a lower apnea-hypopnea index than did study participants with lower PLMI.

When the researchers controlled for multiple variables, a combination of time spent in bed, older age, and higher PLMI accounted for 44% of the study population's variance in total sleep time.

On the other hand, the analysis found no relationship between PLMI and other sleep variables or participants' age or MMSE scores.

The study showed no significant difference in total sleep time between people in private homes and those in nursing homes or assisted-living facilities.

“This was surprising considering the pervasive nursing care practices in nursing homes of awakening residents for incontinence and other care and the noise from other residents and staff,” the researchers noted.

“An elevated PLMI was associated with a consistent pattern of sleep disturbance, suggesting that [periodic leg movements] or other related comorbidities, such as restless leg syndrome, may be a cause for poor sleep in elders with cognitive impairment,” Dr. Richards and her colleagues wrote.

In a statement, Dr. Richards called that finding “important because treatment of periodic leg movements may result in improved nighttime sleep and improved quality of life in this vulnerable population.”

The study was limited by a lack of data on the potential role of upper airway resistance as a cause of nighttime leg movement, according to Dr. Richards and her colleagues.

Dr. Richards has received research support from Beverly Healthcare Corp., but the study had no industry sponsorship.