Hormone therapy in elderly women; a comparative study with alendronate of the effects on bone, cardiovascular risk factors, periodontal conditions and quality of life

Thirty percent of 70-year-old women have osteoporosis; after age of 80 its prevalence is up to 70%. Postmenopausal women with osteoporosis seem to be at an increased risk for cardiovascular events, and deterioration of oral health, as shown by attachment loss of teeth, which is proportional to the severity of osteoporosis. Osteoporosis can be treated with many different medication, e.g. estrogen and alendronate. We randomized 90 elderly osteoporotic women (65-80 years of age) to receive hormone therapy (HT)(2mg E2+NETA), 10mg alendronate, and their combination for two years and compared their effects on bone mineral density (BMD) and turnover, two surrogate markers of the risk of cardiovascular diseases, C-reactive protein (CRP) and E-selectin, as well as oral health. The effect of HT on health-related quality of life (HRQoL) was studied in the population-based cohort of 1663 postmenopausal women (mean age 68 yr) (585 estrogen users and 1078 non-users). BMD was measured with dual-energy X-ray absorptiometry (DXA) at 0, 12 and 24 months. Urinary N-telopeptide (NTX) of type I collagen, a marker of bone resorption, and serum aminoterminal propeptide of human type I procollagen (PINP), a marker of bone formation, were measured every six months of treatment. Serum CRP and E-selectin, were measured at 0, 6, and 12 months. Dental, and periodontal conditions, and gingival crevicular fluid (GCF) matrix metalloproteinase (MMP)-8 levels were studied to evaluate the oral health status and for the mouth symptoms a structured questionnaire was used. The HRQoL was measured with 15D questionnaire. Lumbar spine BMD increased similarly in all treatment groups (6.8-8.4% and 9.1-11.2%). Only HT increased femoral neck BMD at both 12 (4.9%) and 24 months (5.8%), at the latter time point the HT group differed significantly from the other groups. HT reduced bone marker levels of NTX and PINP significantly less than other two groups.Oral HT significantly increased serum CRP level by 76.5% at 6 and by 47.1% (NS) at 12 months, and decreased serum E-selectin level by 24.3% and 30.0%. Alendronate had no effect on these surrogate markers. Alendronate caused a decrease in the resting salivary flow rate and tended to increase GCF MMP-8 levels. Otherwise, there was no effect on the parameters of oral health. HT improved the HRQoL of elderly women significantly on the dimensions of usual activities, vitality and sexual activity, but the overall improvement in HRQoL was neither statistically significant nor clinically important. In conclusion, bisphosphonates might be the first option to start the treatment of postmenopausal osteoporosis in the old age.

Visual Impairment and Falls Risk in the Elderly

Vision is highly important for balance and gait and visual impairments are significantly associated with locomotion problems and falls in older people. There is now a large body of research linking falls and fall-related injuries with visual problems, some of which are easily remedied by surgery or refractive correction. However there is also evidence that the kind of refractive correction provided (in terms of single-vision or multifocal correction) can also have an effect on fall risk. This chapter provides an overview of the major findings in this area.

Middle-aged and elderly Finnish households considering moving, their preferences, and potential downsizing amidst changing life course and housing careers

We examine the moving and housing preferences of middle-aged and older in Finland, a country where population composition and movement through the life course are changing. A logistic regression reveals that middle-aged, moderate income residents, renters, those who have lived in their houses only a short time, and residents who are generally dissatisfied are most likely to consider moving. Downsizing appeals to residents with lower incomes who live alone, and who have been in their current houses longer. All potential movers agree on the importance of transportation access and a neighborhood grocery store; however, those preferring to downsize are also interested in house and neighborhood design as well as services that will allow aging in place. Income limitations may create affordability problems for some potential movers.

Probiotics in the prevention of clinical manifestations of common infectious diseases in children and in the elderly

Infectious diseases put an enormous burden on both children and the elderly in the forms of respiratory, gastrointestinal and oral infections. There is evidence suggesting that specific probiotics may be antagonistic to pathogens and may enhance the immune system, but the clinical evidence is still too sparce to make general conclusions on the disease-preventive effects of probiotics. This thesis, consisting of four independent, double-blind, placebo-controlled clinical trials, investigated whether Lactobacillus GG (LGG) or a specific probiotic combination containing LGG would reduce the risk of common infections or the prevalence of pathogens in healthy and infection-prone children and in independent and institutionalised elderly people. In healthy day-care children, the 7-month consumption of probiotic milk containing Lactobacillus GG appeared to postpone the first acute respiratory infection (ARI) by one week (p=0.03, adjusted p=0.16), and to reduce complicated infections (39% vs. 47%, p<0.05, adjusted p=0.13), as well as the need for antibiotic treatment (44% vs. 54%, p=0.03, adjusted p=0.08) and day-care absences (4.9 vs. 5.8 days, p=0.03, adjusted p=0.09) compared to the placebo milk. In infection-prone children, the 6-month consumption of a combination of four probiotic bacteria (LGG, L. rhamnosus LC705, Propionibacterium freudenreichii JS, Bifidobacterium breve 99) taken in capsules appeared to reduce recurrent ARIs (72% vs. 82%, p<0.05; adjusted p=0.06), and the effect was particularly noticeable in a subgroup of children with allergic diseases (12% vs. 33%, p=0.03), although no effect on the presence of nasopharyngeal rhinovirus or enterovirus was seen. The 5-month consumption of the same probiotic combination did not show any beneficial effects on the respiratory infections in frail, institutionalised elderly subjects. In healthy children receiving Lactobacillus GG, the reduction in complications resulted in a marginal reduction in the occurrence of acute otitis media (AOM) (31% vs. 39%, p=0.08; adjusted p=0.19), and the postponement of the first AOM episode by 12 days (p=0.04; adjusted p=0.09). However, in otitis-prone children, a probiotic combination did not reduce the occurrence of AOM or the total prevalence of common AOM pathogens (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), except in the case of children with allergic diseases, in whom probiotics reduced recurrent AOM episodes (0% vs. 14%, p=0.03). In addition, interaction between probiotics and bacterial carriage was seen: probiot-ics reduced AOM in children who did not carry any bacterial pathogens (63% vs. 83%), but the effect was the reverse in children carrying bacteria in the nasopharynx (74% vs 62%) (p<0.05). Long-term probiotic treatment, either LGG given in milk to healthy children for 7 months or a combination of probiotics given in capsules to institutionalised elderly subjects for 5 months, did not reduce the occurrence of acute diarrhoea. However, when the probiotic combination (LGG, L. rhamnosus LC705, Propionibacterium JS) was given in cheese to independent elderly subjects for 4 months, the oral carriage of high Candida counts was reduced in the probiotic group vs. the placebo group (21% vs. 34%, p=0.01, adjusted p=0.004). The risk of hyposalivation was also reduced in the probiotic group (p=0.05). In conclusion, probiotics appear to slightly alleviate the severity of infections by postponing their appearance, by reducing complications and the need for antimicrobial treatments. In addition, they appear to prevent recurrent infections in certain subgroups of children, such as in infection-prone children with allergic diseases. Alleviating ARI by probiotics may lead to a marginal reduction in the occurrence of AOM in healthy children but not in infection-prone children with disturbed nasopharyngeal microbiota. On the basis of these results it could be supposed that Lactobacillus GG or a specific combination containing LGG are effective against viral but not against bacterial otitis, and the mechanism is probably mediated through the stimulation of the immune system. A specific probiotic combination does not reduce respiratory infections in frail elderly subjects. Acute diarrhoea, either in children or in the elderly, is not prevented by the continuous, long-term consumption of probiotics, but the consumption of a specific probiotic combination in a food matrix is beneficial to the oral health of the elderly, through the reduction of the carriage of Candida.

Ikääntyminen maalaiskylässä

Aging in a country village This dissertation examines what kind of environment of aging a small country village is, who elderly villagers are and what kind of everyday life they have. The qualitative material gathered through ethnographic field work at a village situated in Southern Finland consists of a field work diary and 34 interviews of elderly villagers. The dissertation is based on social gerontology and village research. The key concepts are: the environment of aging; locality and local identity; and way of life. The village is examined as a social and physical environment of aging. Difficulties regarding mobility are the biggest challenges for elderly villagers in their everyday life. The social environment of aging is constructed by historical, cultural and local factors. The village community is formed by many small sub-communities. An elderly villager s status in a village community and her/his social competence affect the formation of her/his social network and the quality of her/his environment of aging. The dissertation examines the local identities of older villagers and their relationships to the village. The local identities can be based on the village, memories or on many places, or a place and places may not be of great importance for a person s identity. The local identity of an older villager affects her/his experiences of living in the village and her/his future plans to move away from the village. The everyday life of an older villager is constructed by rhythms, routines and repetitions. However, there are differences between how everyday lives are arranged among elderly villagers, which are explained by the concept of a way of life. Four ways of life were found. Nature and its importance are a background to all four ways of life. A traditional way of life is based on continuity and hard work, a family-oriented way of life on family members and relatives. A mobile way of life is characterized by symbolic and concrete mobility. An original way of life is marked by independent loneliness . In practice, a person s way of life is always constructed by two or many ways of life.

The relationships between work stressors and organizational performance in long-term care for elderly residents

This study investigates the relationships between work stressors and organizational performance in terms of the quality of care provided by the long-term care facilities. Work stressors are first examined in relation to the unit's structural factors, resident characteristics, and to the unit specialization. The study is completed by an investigation into the associations of work stressors such as job demands or time pressure, role ambiguity, resident-related stress, and procedural injustice to organizational performance. Also the moderating effect of job control in the job demands organizational performance relationship is examined. The study was carried out in the National Research and Development Centre for Welfare and Health (STAKES). Survey data were drawn from 1194 nursing employees in 107 residential-home and health-center inpatient units in 1999 and from 977 employees in 91 units in 2002. Information on the unit resident characteristics and the quality of care was provided by the Resident Assessment Instrument (RAI). The results showed that large unit size or lower staffing levels were not consistently related to work stressors, whereas the impairments in residents' physical functioning in particular initiated stressful working conditions for employees. However, unit specialization into dementia and psychiatric residents was found to buffer the effects that the resident characteristics had on employee appraisals of work stressors, in that a high proportion of behavioral problems was related to less time pressure and role conflicts for employees in specialized units. Unit specialization was also related to improved team climates and the organizational commitment of employees. Work stressors associated with problems in care quality. Time pressure explained most of the differences between units in how the employees perceived the quality of physical and psychosocial care they provide for the residents. A high level of job demands in the unit was also found to be related to some increases in all clinical quality problems. High job control buffered the effects of job demands on the quality of care in terms of the use of restraints on elderly residents. Physical restraint and especially antipsychotic drug use were less prevalent in units that combined both high job demands and high control for employees. In contrast, in high strain units where heavy job demands coincided with a lack of control for employees, quality was poor in terms of the frequent use of physical restraints. In addition, procedural injustice was related to the frequent use of antianxiety of hypnotic drugs for elderly residents. The results suggest that both job control and procedural justice may have improved employees' abilities to cope when caring for the elderly residents, resulting in better organizational performance.

Adnominal Person in the Morphological System of Erzya : Adnominaalinen persoona ersän kielen morfologisessa järjestelmässä

This dissertation is a synchronic description of adnominal person in the highly synthetic morphological system of Erzya as attested in extensive Erzya-language written-text corpora consisting of nearly 140 publications with over 4.5 million words and over 285,000 unique lexical items. Insight for this description have been obtained from several source grammars in German, Russian, Erzya, Finnish, Estonian and Hungarian, as well as bounteous discussions in the understanding of the language with native speakers and grammarians 1993 2010. Introductory information includes the discussion of the status of Erzya as a lan- guage, the enumeration of phonemes generally used in the transliteration of texts and an in-depth description of adnominal morphology. The reader is then made aware of typological and Erzya-specifc work in the study of adnominal-type person. Methods of description draw upon the prerequisite information required in the development of a two-level morphological analyzer, as can be obtained in the typological description of allomorphic variation in the target language. Indication of original author or dialect background is considered important in the attestation of linguistic phenomena, such that variation might be plotted for a synchronic description of the language. The phonological description includes the establishment of a 6-vowel, 29-consonant phoneme system for use in the transliteration of annotated texts, i.e. two phonemes more than are generally recognized, and numerous rules governing allophonic variation in the language. Erzya adnominal morphology is demonstrated to have a three-way split in stem types and a three-layer system of non-derivative affixation. The adnominal-affixation layers are broken into (a) declension (the categories of case, number and deictic marking); (b) nominal conjugation (non-verb grammatical and oblique-case items can be conjugated), and (c) clitic marking. Each layer is given statistical detail with regard to concatenability. Finally, individual subsections are dedicated to the matters of: possessive declension compatibility in the distinction of sublexica; genitive and dative-case paradigmatic defectivity in the possessive declension, where it is demonstrated to be parametrically diverse, and secondary declension, a proposed typology modifiers without nouns , as compatible with adnominal person.

Solution concepts in two-person multicriteria games

In this paper, we propose new solution concepts for multicriteria games and compare them with existing ones. The general setting is that of two-person finite games in normal form (matrix games) with pure and mixed strategy sets for the players. The notions of efficiency (Pareto optimality), security levels, and response strategies have all been used in defining solutions ranging from equilibrium points to Pareto saddle points. Methods for obtaining strategies that yield Pareto security levels to the players or Pareto saddle points to the game, when they exist, are presented. Finally, we study games with more than two qualitative outcomes such as combat games. Using the notion of guaranteed outcomes, we obtain saddle-point solutions in mixed strategies for a number of cases. Examples illustrating the concepts, methods, and solutions are included.

Pain measurement and management in elderly patients : Clinical studies in long term hospital care and after cardiac surgery

The proportion of patients over 75 years of age, receiving all different types of healthcare, is constantly increasing. The elderly undergo surgery and anaesthetic procedures more often than middle-aged patients. Poor pain management in the elderly is still an issue. Although the elderly consumes the greatest proportion of prescribed medicines in Western Europe, most clinical pharmacological studies have been performed in healthy volunteers or middle-aged patients. The aim of this study was to investigate pain measurement and management in cognitively impaired patients in long term hospital care and in cognitively normal elderly patients after cardiac surgery. This thesis incorporated 366 patients, including 86 home-dwelling or hospitalized elderly with chronic pain and 280 patients undergoing cardiac surgery with acute pain. The mean age of patients was 77 (SD ± 8) years and approximately 8400 pain measurements were performed with four pain scales: Verbal Rating Scale (VRS), the Visual Analogue Scale (VAS), the Red Wedge Scale (RWS), and the Facial Pain Scale (FPS). Cognitive function, depression, functional ability in daily life, postoperative sedation and postoperative confusion were assessed with MMSE, GDS, Barthel Index, RASS, and CAM-ICU, respectively. The effects and plasma concentrations of fentanyl and oxycodone were measured in elderly (≥ 75 years) and middle-aged patients (≤ 60 years) and the opioid-sparing effect of pregabalin was studied after cardiac surgery. The VRS pain scores after movement correlated with the Barthel Index. The VRS was most successful in the groups of demented patients (MMSE 17-23, 11-16 and ≤ 10) and in elderly patients on the first day after cardiac surgery. The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients. The plasma concentrations of oxycodone were comparable between the groups. Pain intensity on the VRS was lower and the sedation scores were higher in the elderly. Total oxycodone consumption during five postoperative days was reduced by 48% and the CAM-ICU scores were higher on the first postoperative day in the pregabalin group. The incidence of postoperative pain during movement was lower in the pregabalin group three months after surgery. This investigation demonstrates that chronic pain did not seem to impair daily activities in home-dwelling Finnish elderly. The VRS appeared to be applicable for elderly patients with clear cognitive dysfunction (MMSE ≤17) and it was the most feasible pain scale for the early postoperative period after cardiac surgery. After cardiac surgery, plasma concentrations of fentanyl in elderly were elevated, although oxycodone concentrations were at similar level compared to middle-aged patients. The elderly had less pain and were more sedated after doses of oxycodone. Therefore, particular attention must be given to individual dosing of the opioids in elderly surgical patients, who often need a smaller amount for adequate analgesia than middle-aged patients. The administration of pregabalin reduced postoperative oxycodone consumption after cardiac surgery. Pregabalin-treated patients had less confusion, and additionally to less postoperative pain on the first postoperative day and during movement at three months post-surgery. Pregabalin might be a new alternative as analgesic for acute postoperative and chronic pain management in the elderly. Its clinical role and safety remains to be verified in large-scale randomized and controlled studies. In the future, many clinical trials in the older category of patients will be needed to facilitate improvements in health care methods.

On the origin and foundation of the concept “The Person” metaphysical realism on interpersonal recognition

Resumen: De acuerdo con el autor, la capacidad del alma de conocerse a sí misma está en la raíz del problema de la persona. Más aún, el entendimiento deber ser interpretado antológicamente como una actividad del alma. Se lleva a cabo un análisis del concepto de persona en algunos filósofos medievales y modernos. También hay referencias a pensadores contemporáneos. El autor sostiene que la noción que Spaemann introduce, considerando la intencionalidad como meramente un sentimiento o negatividad, es insuficiente. El mencionado sentimiento subjetivo es idéntico al concepto de ‘intuición experienciante’ en la fenomenología; pero es insuficiente para permitirnos comprender la esencia de la persona como una entidad espiritual. El autor afirma que cada ser humano debería ser reconocido, no sólo como una creatura racional, sino también como persona, en especial cuando nos referimos a este ser humano o a esta alma. Agrega que las consecuencias prácticas de esta perspectiva son de gran importancia.