The feasibility of self-report advance directives among elderly patients with cognitive impairment

The central objective of this dissertation was to determine the feasibility of self-completed advance directives (AD) in older persons suffering from mild and moderate stages of dementia. This was accomplished by identifying differences in ability to complete AD among elderly subjects with increasing degrees of dementia and cognitive incompetence. Secondary objectives were to describe and compare advance directives completed by elders and identified proxy decision makers. Secondary objectives were accomplished by measuring the agreement between advance directives completed by proxy and elder, and comparing that agreement across groups defined by the elder's cognitive status. This cross-sectional study employed a structured interview to elicit AD, followed by a similar interview with a proxy decision maker identified by the elder. A stratified sampling scheme recruited elders with normal cognition, mild, and moderate forms of dementia using the Mini Mental-State Exam (MMSE). The Hopkins Competency Assessment Test (HCAT) was used for evaluation of competency to make medical decisions. Analysis was conducted on "between group" (non-demented $\leftrightarrow$ mild dementia $\leftrightarrow$ moderate dementia, and competent $\leftrightarrow$ incompetent) and "within group" (elder $\leftrightarrow$ family member) variation.^ The 118 elderly subjects interviewed were generally male, Caucasian, and of low socioeconomic status. Mean age was 77. Overall, elders preferred a "trial of therapy" regarding AD rather than to "always receive the therapy". No intervention was refused outright more often than it was accepted. A test-retest of elders' AD revealed stable responses. Eleven logic checks measured appropriateness of AD responses independent of preference. No difference was found in logic error rates between elders grouped by MMSE or HCAT. Agreement between proxy and elder responses showed significant dissimilarity, indicating that proxies were not making the same medical decisions as the elders.^ Conclusions based on these data are: (1) Self reporting AD is feasible among elders showing signs of cognitive impairment and they should be given all opportunities to complete advance directives, (2) variation in preferences for advance directives in cognitively impaired elders should not be assumed to be the effects of their impairment alone, (3) proxies do not appear to forego life-prolonging interventions in the face of increasing impairment in their ward, however, their advance directives choices are frequently not those of the elder they represent. ^

Assessment of executive function before and after vitamin D replacement in vulnerable adults who self-neglect

Purpose: Self-neglect (SN) is the inability to maintain self-care needs. It is thought that older adults who have impaired executive function (EF) develop the inability to do self-care and to protect themselves. The specific aims were to (1) determine the feasibility of using multiple EF measures with community-dwelling elders with SN, (2) identify changes in EF between baseline and 5-months in community-dwelling elders with SN who receive 50,000 IU or 400 IU of oral vitamin D monthly and (2) explore changes in specific dimensions of EF between the groups. ^ Methods: Fifty adults, 65 years of age and older, were recruited from Adult Protective Services with confirmed SN. A research nurse administered the following tests at baseline and five-months: Delis-Kaplan Card Sort Test (D-KEFS), Executive Interview (EXIT 25), CLOX Drawing Test (CLOX I, II), Trails Making Test A and B (TMT A & B) and the Mini-Mental State Examination (MMSE). Demographic data was collected at baseline and serum 25-OHD levels were collected at baseline and five-months. ^ Results: Older adults with SN were more likely to fail the CLOX1 and D-KEFS, while passing the MMSE, CLOX II, TMT A & B and the EXIT 25. At five-months, the only statistically significant difference between groups was in the TMT A & B test scores; the control group did better than the treatment group. There was a non-significant increase in serum vitamin D levels for both groups and no difference between groups. ^ Conclusions: Results from this study provide support that individuals who SN will complete a battery of EF tests and that they exhibit the following impairments consistent with executive dysfunction: 'concept generation', 'planning', 'inhibition', and 'spatial working memory'. Utilizing only one EF measure in individuals with intact cognition may result in unidentification of individuals with executive dysfunction, thus delaying necessary treatment. Future studies should attempt to determine different etiologies of executive dysfunction and determine if early treatment can prevent or reverse SN. ^ Key Words: Self-neglect, Executive Dysfunction, Executive Function, Adult Protective Services, Community-dwelling, Vitamin D ^

Quiero detenerme en la palabra... A propósito del hueso duro de Gauguin

El artículo aborda una lectura e interpretación del campo literario puertorriqueño actual, a través de la relación establecida entre los autores más jóvenes y sus modelos literarios, especialmente a través del vínculo establecido, a modo de ejemplo, entre Juan Carlos Quiñones y Luis Rafael Sánchez. El concepto de influencia según la propuesta de Harold Bloom se complejiza en términos de lectura y escritura, puesto que los jóvenes se distancian y desmarcan de los mandatos programáticos en torno a la ambivalente identidad nacional puertorriqueña, pero a su vez reconocen gestos filiativos de aproximación respecto de sus mayores.

Desafíos actuales del envejecer

Presentamos hallazgos sobre el envejecer en la actualidad y su entrecruzamiento con la participación en grupos. Señalamos la importancia de la educación permanente en la producción de subjetividad. Se destaca la contribución de las investigaciones referidas a la: docencia, extensión universitaria y formación de investigadores. Partimos del marco teórico de la psicología, se revisan los aportes interdisciplinarios que enriquecen el campo gerontológico. A partir de la longevidad se busca identificar las transformaciones del envejecer, el proceso de revisión identificatoria y el trabajo psíquico de revisar, cuestionar y transformar las significaciones simbólicas, a la par que hacer lugar a lo nuevo en relación con sus funciones: hombre/mujer; esposo/esposa; abuelo/abuela. Se emplea metodología cualitativa: entrevistas en profundidad, historias de vida, crónicas del funcionamiento grupal. Surge la preocupación constante y conciente de los mayores, por preservar su capacidad de desear, crear, producir y gozar, la búsqueda de realización personal y la interrelación con el medio, con los otros y con sus pares. Se observan lógicas propias que promueven la horizontalidad de los vínculos y presentan representaciones, sentidos y conductas que modifican el concepto tradicional del viejo. Se destaca la riqueza del encuentro intersubjetivo entre investigadores y entrevistados, en la elaboración de los cambios.

Quiero detenerme en la palabra... A propósito del hueso duro de Gauguin

El artículo aborda una lectura e interpretación del campo literario puertorriqueño actual, a través de la relación establecida entre los autores más jóvenes y sus modelos literarios, especialmente a través del vínculo establecido, a modo de ejemplo, entre Juan Carlos Quiñones y Luis Rafael Sánchez. El concepto de influencia según la propuesta de Harold Bloom se complejiza en términos de lectura y escritura, puesto que los jóvenes se distancian y desmarcan de los mandatos programáticos en torno a la ambivalente identidad nacional puertorriqueña, pero a su vez reconocen gestos filiativos de aproximación respecto de sus mayores.

Desafíos actuales del envejecer

Presentamos hallazgos sobre el envejecer en la actualidad y su entrecruzamiento con la participación en grupos. Señalamos la importancia de la educación permanente en la producción de subjetividad. Se destaca la contribución de las investigaciones referidas a la: docencia, extensión universitaria y formación de investigadores. Partimos del marco teórico de la psicología, se revisan los aportes interdisciplinarios que enriquecen el campo gerontológico. A partir de la longevidad se busca identificar las transformaciones del envejecer, el proceso de revisión identificatoria y el trabajo psíquico de revisar, cuestionar y transformar las significaciones simbólicas, a la par que hacer lugar a lo nuevo en relación con sus funciones: hombre/mujer; esposo/esposa; abuelo/abuela. Se emplea metodología cualitativa: entrevistas en profundidad, historias de vida, crónicas del funcionamiento grupal. Surge la preocupación constante y conciente de los mayores, por preservar su capacidad de desear, crear, producir y gozar, la búsqueda de realización personal y la interrelación con el medio, con los otros y con sus pares. Se observan lógicas propias que promueven la horizontalidad de los vínculos y presentan representaciones, sentidos y conductas que modifican el concepto tradicional del viejo. Se destaca la riqueza del encuentro intersubjetivo entre investigadores y entrevistados, en la elaboración de los cambios.

Desafíos actuales del envejecer

Presentamos hallazgos sobre el envejecer en la actualidad y su entrecruzamiento con la participación en grupos. Señalamos la importancia de la educación permanente en la producción de subjetividad. Se destaca la contribución de las investigaciones referidas a la: docencia, extensión universitaria y formación de investigadores. Partimos del marco teórico de la psicología, se revisan los aportes interdisciplinarios que enriquecen el campo gerontológico. A partir de la longevidad se busca identificar las transformaciones del envejecer, el proceso de revisión identificatoria y el trabajo psíquico de revisar, cuestionar y transformar las significaciones simbólicas, a la par que hacer lugar a lo nuevo en relación con sus funciones: hombre/mujer; esposo/esposa; abuelo/abuela. Se emplea metodología cualitativa: entrevistas en profundidad, historias de vida, crónicas del funcionamiento grupal. Surge la preocupación constante y conciente de los mayores, por preservar su capacidad de desear, crear, producir y gozar, la búsqueda de realización personal y la interrelación con el medio, con los otros y con sus pares. Se observan lógicas propias que promueven la horizontalidad de los vínculos y presentan representaciones, sentidos y conductas que modifican el concepto tradicional del viejo. Se destaca la riqueza del encuentro intersubjetivo entre investigadores y entrevistados, en la elaboración de los cambios.

Quiero detenerme en la palabra... A propósito del hueso duro de Gauguin

El artículo aborda una lectura e interpretación del campo literario puertorriqueño actual, a través de la relación establecida entre los autores más jóvenes y sus modelos literarios, especialmente a través del vínculo establecido, a modo de ejemplo, entre Juan Carlos Quiñones y Luis Rafael Sánchez. El concepto de influencia según la propuesta de Harold Bloom se complejiza en términos de lectura y escritura, puesto que los jóvenes se distancian y desmarcan de los mandatos programáticos en torno a la ambivalente identidad nacional puertorriqueña, pero a su vez reconocen gestos filiativos de aproximación respecto de sus mayores.

Radiocarbon dates of Mytilus shells and peat and wood samples collected on Drayton Island

A multidisciplinary study was undertaken at the Qijurittuq Site (IbGk-3) on Drayton Island in Low-Arctic Quebec (Canada) to document the relationships between climatic, environmental, and cultural changes and the choice of Thule/Inuit dwelling style in the eastern Arctic. Several marine terraces were 14C-dated with shells in order to reconstruct the area's uplift (glacioisostatic rebound) curve. Plant macrofossil analysis of peat was conducted to reconstruct past vegetation and, indirectly, past climate. Archaeological surveys and excavations characterized the structure of subterranean sod houses at the Qijurittuq Site and were supplemented with open interviews with Inuit elders for a better understanding of site location and the use of household space. The sites selected for habitation were well-drained sandy marine terraces in a valley sheltered from prevailing winds. Sod houses were in turn made possible by the abundance of driftwood on the island and the presence of nearby peatland. Thule/Inuit people used semi-subterranean houses rather than igloos at the Qijurittuq Site during the dry, cold conditions toward the end of the Little Ice Age. Stable environmental conditions and food supply during winter possibly explain the use of those semipermanent houses on Drayton Island. However, it does not exclude the use of igloos during short expeditions on ice.

(Table 2) Number of identified specimens and individuals from bones and bone fragments at site IbGk-3, Drayton Island

An interdisciplinary study was conducted at Qijurittuq (IbGk-3), an archaeological site located on Drayton Island along the eastern shore of Hudson Bay, Nunavik. Local Inuit made important contributions to the research. High school students participated in the field school, and elders shared their traditional knowledge. The elders expressed an interest in the source of the wood used to construct Qijurittuq's semi-subterranean dwellings, and this inspired us to expand our research in that direction. This interdisciplinary study included a reconstruction of the geomorphological and environmental history of Drayton Island, wood provenance and dendrochronology studies, research on house architecture and settlement patterns, and a zooarchaeological analysis. This paper synthesizes the preliminary results of this interdisciplinary investigation within the context of climate change. We discuss the persistence of semi-subterranean dwellings in eastern Hudson Bay long after they had been abandoned elsewhere. At Qijurittuq, their abandonment corresponds with the end of Little Ice Age. However, at the same time, the development of more permanent contact with Euro-Canadians was having a strong impact upon Inuit culture.

Evolution and treatment of vitamin B12 deficiency as a risk factor for (cognitive and functional) neurodegenerative diseases in institutionalized elderly = Evolución y tratamiento de la deficiencia de vitamina B12 como factor de riesgo de enfermedades neurodegenerativas (cognitivas y funcionales) en las personas mayores institucionalizadas.

Prevalence of vitamin B12 deficiency is very common in elderly people and can reach values as high as 40.5% of the population. It can be the result of the interaction among several factors. Vitamin B12 deficiencies have been associated with neurological, cognitive deterioration, haematological abnormalities and cardiovascular diseases that have an important influence on the health of the elderly and their quality of life. It is necessary to approach the problems arisen from the lack of data relative to them. The main objective of this thesis was to analyse the evolution of vitamin B12 status and related parameters, lipid and haematological profiles and their relationship to health risk factors, and to functional and cognitive status over one year and to determine the effect of an oral supplementation of 500 μg of cyanocobalamin for a short period of 28 days. An additional objective was to analyze the possible effects of medicine intakes on vitamin B status. Three studies were performed: a) a one year longitudinal follow-up with four measure points; b) an intervention study providing an oral liquid supplement of 500 μg of cyanocobalamin for a 28 days period; and c) analysis of the possible effect of medication intake on vitamin B status using the ATC classification of medicines. The participants for these studies were recruited from nursing homes for the elderly in the Region of Madrid. Sixty elders (mean age 84 _ 7y, 19 men and 41 women) were recruited for Study I and 64 elders (mean age 82 _ 7y, 24 men and 40 women) for Study II. For Study III, baseline data from the initially recruited participants of the first two studies were used. An informed consent was obtained from all participants or their mentors. The studies were approved by the Ethical Committee of the University of Granada. Blood samples were obtained at each examination date and were analyzed for serum cobalamin, holoTC, serum and RBC folate and total homocysteine according to laboratory standard procedures. The haematological parameters analyzed were haematocrit, haemoglobin and MCV. For the lipid profile TG, total cholesterol, LDL- and HDLcholesterol were analyzed. Anthropometric measures (BMI, skinfolds [triceps and subscapular], waist girth and waist to hip ratio), functional tests (hand grip, arm and leg strength tests, static balance) and MMSE were obtained or administered by trained personal. The vitamin B12 supplement of Study II was administered with breakfast and the medication intake was taken from the residents’ anamnesis. Data were analyzed by parametric and non-parametric statistics depending on the obtained data. Comparisons were done using the appropriate ANOVAs or non-parametric tests. Pearsons’ partial correlations with the variable “time” as control were used to define the association of the analyzed parameters. XIII The results showed that: A) Over one year, in relationship to vitamin B status, serum cobalamin decreased, serum folate and mean corpuscular volumen increased significantly and total homocysteine concentrations were stable. Regarding blood lipid profile, triglycerides increased and HDL-cholesterol decreased significantly. Regarding selected anthropometric measurements, waist circumference increased significantly. No significant changes were observed for the rest of parameters. B) Prevalence of hyperhomocysteinemia was high in the elderly studied, ranging from 60% to 90 % over the year depending on the cut-off used for the classification. LDL-cholesterol values were high, especially among women, and showed a tendency to increase over the year. Results of the balance test showed a deficiency and a tendency to decrease; this indicates that the population studied is at high risk for falls. Lower extremity muscular function was deficient and showed a tendency to decrease. A highly significant relationship was observed between the skinfold of the triceps and blood lipid profile. C) Low cobalamin concentrations correlated significantly with low MMSE scores in the elderly studied. No correlations were observed between vitamin B12 status and functional parameters. D) Regarding vitamin B12 status, holo-transcobalamin seems to be more sensitive for diagnosis; 5-10% of the elderly had a deficiency using serum cobalamin as a criterion, and 45-52% had a deficiency when using serum holotranscobalamin as a criterion. E) 500 μg of cyanocobalamin administered orally during 28 days significantly improved vitamin B12 status and significantly decreased total homocysteine concentrations in institutionalized elderly. No effect of the intervention was observed on functional and cognitive parameters. F) The relative change (%) of improvement of vitamin B12 status was higher when using serum holo-transcobalamin as a criterion than serum cobalamin. G) Antiaenemic drug intake normalized cobalamin, urologic drugs and corticosteroids serum folate, and psychoanaleptics holo-transcobalamin levels. Drugs treating pulmonary obstruction increased total homocysteine concentration significantly. H) The daily mean drug intake was 5.1. Fiftynine percent of the elderly took medication belonging to 5 or more different ATC groups. The most prevalent were psycholeptic (53%), antiacid (53%) and antithrombotic (47%) drugs.

White matter damage disorganizes brain functional networks in amnestic mild cognitive impairment

Although progressive functional brain network disruption has been one of the hallmarks of Alzheimer?s Dis- ease, little is known about the origin of this functional impairment that underlies cognitive symptoms. We in- vestigated how the loss of white matter (WM) integrity disrupts the organization of the functional networks at different frequency bands. The analyses were performed in a sample of healthy elders and mild cognitive im- pairment (MCI) subjects. Spontaneous brain magnetic activity (measured with magnetoencephalography) was characterized with phase synchronization analysis, and graph theory was applied to the functional networks. We identified WM areas (using diffusion weighted magnetic resonance imaging) that showed a statistical de- pendence between the fractional anisotropy and the graph metrics. These regions are part of an episodic mem- ory network and were also related to cognitive functions. Our data support the hypothesis that disruption of the anatomical networks influences the organization at the functional level resulting in the prodromal dementia syndrome of MCI.

Avaliação dos efeitos de um programa de caminhada nos fatores de risco de queda em idosos: equilíbrio, força e agilidade.

Dissertação apresentada para a obtenção do grau de Mestre em Desporto com especialização em Condição Física e Saúde

UMA ECOLOGIA REFÉM DO PODER ECONÔMICO: Leitura exegética sócio-econômica de Deuteronômio 5,12-15

Com esse trabalho, visamos discutir a tentativa de estabelecer um equilíbrio entre o ser humano e natureza na área rural de Judá, pouco antes do reinado de Josias (640-609 a.C.). Nesse caso, pode-se perguntar: seria o mandamento de Deuteronômio 5,12-15 um discurso ecológico? A partir dos estudos de Frank Crüsemann e Haroldo Reimer se admite que partes das leis veterotestamentárias eram destinadas ao assim chamado grupo povo da terra de Judá, visando à manutenção de seu poder. O grupo teria assumido a liderança em Judá mediante um golpe político e, articulando-se, desde então, numa política de aliança para se conservar no poder, mesmo não o assumindo diretamente. Nesse contexto de política de alianças deve-se procurar a implementação do mandamento de Deuteronômio 5,12-15. Ele teria sido escrito por anciãos, um grupo junto ao qual o povo da terra teria se aliado para que ordenassem sentenças jurídicas para a acomodação social. Nesse caso, inicialmente o portão da cidade, espaço oficial para discussões, reclamações e propostas de intermediações, deve ter sido o lugar de elaboração de sentenças jurídicas sobre a utilização de técnicas na agricultura. Sendo elas posteriormente levadas ao tribunal do templo para passar pelas mãos dos sacerdotes, outro braço da coalizão. O uso dos animais de porte, cujo peso prejudicava as pequenas propriedades de terra de Judá, deve ter sido um motivo de incessantes conflitos entre pequenos e grandes proprietários de terra. Ressaltamos assim que apenas os homens mais abastados de Judá tinham acesso a esses animais. Esta solução, segundo se entende, liga o rodízio de culturas ao descanso do campo pertencente ao povo da terra de Judá. Liga-se o termo sábado com a vida da elite rural judaíta do período do reinado de Josias. Uma saída encontrada pelas elites de Judá, a qual nos leva a ponderar uma situação similar que ocorre na América Latina, diante da globalização. Se o texto Deuteronômio 5,12-15 é uma ponderação das elites hegemônicas de Judá que buscam o equilíbrio entre ser o humano e a natureza (ecologia), o discurso ecológico contemporâneo poderá ter neste texto um importante interlocutor. Esse discurso pode ocultar interesses econômicos, completamente diferentes, pois se trata de uma estratégia dominadora e não libertadora, objetivando-se, sobretudo, a reprodução social. O Brasil e os demais países da América Latina vêm sofrendo, há algum tempo, com essa distância entre a elite e o resto da sociedade. Nossas elites utilizam-se, há tempos, do discurso ecológico para se manterem no poder dessas sociedades. Por exemplo, vemos nos noticiários uma quantidade de programas e manchetes ligadas à destruição da natureza. Isso é interessante porque, após terem eles mesmo destruído a natureza, passam agora a defendê-la; controlando as reservas naturais, garantindo sua produtividade e seu status quo no sistema econômico atual.(AU)

UMA ECOLOGIA REFÉM DO PODER ECONÔMICO: Leitura exegética sócio-econômica de Deuteronômio 5,12-15

Com esse trabalho, visamos discutir a tentativa de estabelecer um equilíbrio entre o ser humano e natureza na área rural de Judá, pouco antes do reinado de Josias (640-609 a.C.). Nesse caso, pode-se perguntar: seria o mandamento de Deuteronômio 5,12-15 um discurso ecológico? A partir dos estudos de Frank Crüsemann e Haroldo Reimer se admite que partes das leis veterotestamentárias eram destinadas ao assim chamado grupo povo da terra de Judá, visando à manutenção de seu poder. O grupo teria assumido a liderança em Judá mediante um golpe político e, articulando-se, desde então, numa política de aliança para se conservar no poder, mesmo não o assumindo diretamente. Nesse contexto de política de alianças deve-se procurar a implementação do mandamento de Deuteronômio 5,12-15. Ele teria sido escrito por anciãos, um grupo junto ao qual o povo da terra teria se aliado para que ordenassem sentenças jurídicas para a acomodação social. Nesse caso, inicialmente o portão da cidade, espaço oficial para discussões, reclamações e propostas de intermediações, deve ter sido o lugar de elaboração de sentenças jurídicas sobre a utilização de técnicas na agricultura. Sendo elas posteriormente levadas ao tribunal do templo para passar pelas mãos dos sacerdotes, outro braço da coalizão. O uso dos animais de porte, cujo peso prejudicava as pequenas propriedades de terra de Judá, deve ter sido um motivo de incessantes conflitos entre pequenos e grandes proprietários de terra. Ressaltamos assim que apenas os homens mais abastados de Judá tinham acesso a esses animais. Esta solução, segundo se entende, liga o rodízio de culturas ao descanso do campo pertencente ao povo da terra de Judá. Liga-se o termo sábado com a vida da elite rural judaíta do período do reinado de Josias. Uma saída encontrada pelas elites de Judá, a qual nos leva a ponderar uma situação similar que ocorre na América Latina, diante da globalização. Se o texto Deuteronômio 5,12-15 é uma ponderação das elites hegemônicas de Judá que buscam o equilíbrio entre ser o humano e a natureza (ecologia), o discurso ecológico contemporâneo poderá ter neste texto um importante interlocutor. Esse discurso pode ocultar interesses econômicos, completamente diferentes, pois se trata de uma estratégia dominadora e não libertadora, objetivando-se, sobretudo, a reprodução social. O Brasil e os demais países da América Latina vêm sofrendo, há algum tempo, com essa distância entre a elite e o resto da sociedade. Nossas elites utilizam-se, há tempos, do discurso ecológico para se manterem no poder dessas sociedades. Por exemplo, vemos nos noticiários uma quantidade de programas e manchetes ligadas à destruição da natureza. Isso é interessante porque, após terem eles mesmo destruído a natureza, passam agora a defendê-la; controlando as reservas naturais, garantindo sua produtividade e seu status quo no sistema econômico atual.(AU)