John Roberts, MD, Editor

In 1900, only about 1 million Americans (4% of the population) were older than 65 years of age. Currently, about 14% of Americans are older than 65 years of age; by 2050, that Figure will have increased to more than 20%. This demographic shift has no parallel in history. We have already seen the impact of the increased numbers of older persons on the practice of medicine, and the future of internal medicine will be inextricably linked to this demographic change.

Life expectancy after age 65 years continues to improve. Although the explanation for this finding is unclear, it is probably partly due to the improvement in the management of chronic illness. The improvements continue, as shown by the advances reported in 1996. In reviewing the major clinical advances in geriatrics, I turned mostly to clinical journals that are generally available to practicing internists. Included studies must have reported information that is clinically important to a general internist's practice, and the findings, for the most part, had to be evidence based. In general, every study described in this Update offers observations or strategies that can be put into practice immediately.

Ambulatory Medicine

The past year provided insights into the unique presentation of thyroid disease in the elderly, advances in relieving the pain associated with herpes zoster, a more rational choice in the medical treatment of benign prostatic hyperplasia, and new information on the potential risks of oral hypoglycemic agents.

Hyperthyroidism Presented Like Hypothyroidism

Trivalle C, Doucet J, Chassagne P, Landrin I, Kadri N, Menard JF, et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. J Am Geriatr Soc. 1996; 44:50-3.

The elderly person who reports apathy and mild weakness is familiar to most internists. A major additional consideration in this population is hypothyroidism. Does thyroid disease in the elderly actually match the classic descriptions in textbooks?

These French researchers performed a cohort study of older persons living in the community. Eighty-four patients with new-onset hyperthyroidism that was confirmed chemically were compared with 68 age-matched euthyroid controls. All patients were assessed for "classic" signs of hyperthyroidism. Signs in these elderly hyperthyroid patients were compared with those in a group of hyperthyroid patients who were younger than 50 years of age.

More than 50% of the elderly patients with hyperthyroidism had tachycardia, fatigue, and weight loss. Only anorexia (32% in older patients and 4% in younger patients) and atrial fibrillation (35% and 2%) were found more frequently in older than in younger patients. Seven signs occurred less frequently in elderly patients: hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, polydipsia, and increased appetite. Overall, elderly patients had fewer clinical signs. When older patients with hyperthyroidism were compared with older euthyroid controls, three signs were common in the former group and were highly associated with thyrotoxicosis: tachycardia (odds ratio, 11.2 [95% CI, 4.3 to 29.4]), weight loss (odds ratio, 8.7 [CI, 3.1 to 24.4]), and apathy (odds ratio, 14.8 [CI, 3.8 to 57.5]).

Most of these older persons with hyperthyroidism presented with symptoms that might suggest hypothyroidism. They had fewer classic signs of hyperthyroidism, although anorexia and atrial fibrillation were more common. The most important conclusion is that the most frequent characteristics of hyperthyroidism in older persons can easily be mistaken for other illnesses or can simply be attributed to the aging process itself; this may result in substantial delays in diagnosis and therapy.

Should thyroid function tests be part of a routine prevention examination in older persons? Some have argued that they should [1], but I think that they probably should not. However, because the prevalence of thyroid disease may be as high as 2%, the threshold for testing should be very low. I recommend testing patients who have new atrial fibrillation, difficult-to-control congestive heart failure, unexplained weight change, apathy, and depression and patients who have recently received iodinated contrast agents. Clinicians should also recall that many drugs alter iodine metabolism. In addition, persons who eat a lot of kelp and other health foods that contain high levels of iodine are at higher risk for thyroid disease.

Patients with Subclinical Hypothyroidism Benefited Little from Treatment

Jaeschke R, Guyatt G, Gerstein H, Patterson C, Molloy W, Cook D, et al. Does treatment with L-thyroxine influence health status in middle-aged and older adults with subclinical hypothyroidism? J Gen Intern Med. 1996; 11:744-9.

Internists often encounter patients with elevated thyroid-stimulating hormone levels coupled with normal total thyroid levels-so-called subclinical hypothyroidism. This situation occurs in about 10% of men and 16% of women older than age 60 years [2, 3]. Many such patients are prescribed life-long thyroid replacement therapy, but it has never been clear whether these patients are better off with treatment.

Jaeschke and colleagues assessed the quality of life of patients receiving such therapy. In a clinical trial, 37 patients with subclinical hypothyroidism who were older than 55 years of age were randomly assigned to receive either placebo or L-thyroxine replacement therapy in an amount intended to achieve a normal thyroid-stimulating hormone level. The patients were then followed for 10 months. Memory scores (measured by psychometric testing) in treated patients improved (P = 0.01), but no improvement in other quality-of-life or laboratory variables, including lipid levels, was shown.

The difference in memory scores was probably not clinically significant because it would correlate to no more than a 5-point difference in intelligence quotient score. Jaeschke and colleagues' data support a strategy of watchful waiting in middle-aged and older patients with subclinical hypothyroidism. Such an approach is further strengthened by the finding that no patient receiving placebo developed biochemical or clinically overt hypothyroidism during the 10 months of observation. If patients are seen periodically, no compelling argument supports the use of immediate replacement therapy. If therapy is initiated, the dose should probably be low: In this study, the thyroid-stimulating hormone level returned to normal with a daily L-thyroxine dosage of only 25 µg in 50% of treated patients.

Are there instances in which patients with subclinical hypothyroidism should be treated? Probably yes. For an institutionalized patient with signs of dementia, in whom even tiny improvements in memory could make a difference in lifestyle and prognosis, a prudent case can be made for treatment. Clinicians should remember, however, what they are treating: a patient, not a laboratory test.

Acyclovir plus Prednisone Improved Quality of Life in Patients with Herpes Zoster

Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ, Pappas PG, et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. Ann Intern Med. 1996; 125:376-83.

Herpes zoster occurs in about 500 000 Americans a year and will attack about 10% of persons older than 65 years of age in their lifetime [4]. Infection results in two types of morbid conditions: 1) acute neuritis and sometimes disfigurement, which is usually the problem that prompts a visit to a physician, and 2) persistent, chronic pain (postherpetic neuralgia) that can continue for 6 months or longer. Although acyclovir seems to mitigate the acute pain, studies have had contradictory results on the value of treatment of postherpetic neuralgia.

Whitley and colleagues sought to determine whether a combination of acyclovir and prednisone would affect chronic pain and quality of life in older patients with herpes zoster. In a multicenter clinical trial, 208 immunocompetent patients older than 50 years of age who had localized herpes zoster that had developed less than 72 hours before enrollment were randomly assigned to one of four treatment groups: acyclovir (800 mg five times daily for 21 days) plus placebo, prednisone (60 mg/d for the first 7 days, 30 mg/d for days 8 to 14, and 15 mg/d for days 15 to 21) plus placebo, a combination of acyclovir and prednisone, and placebo only. Patients were monitored daily for the first 28 days and then monthly for 6 months.

Lesions healed earlier in patients who received acyclovir plus prednisone than in those who received placebo (risk ratio [RR], 2.27 [CI, 1.46 to 3.55]). Patients receiving both drugs also reported earlier resolution of the symptoms of acute neuritis (RR, 3.02 [CI, 1.42 to 6.41]). Similar differences in return to uninterrupted sleep and return to usual daily activities were also noted. At 6 months, the four groups did not differ in resolution of pain. No serious adverse events occurred.

Although treatment with acyclovir and prednisone did not seem to affect postherpetic neuralgia, the two drugs did improve quality of life and led to a decreased use of analgesics in these otherwise healthy older persons with localized herpes zoster. One of the most important aspects of treatment was the relatively rapid return to normal daily activities; this prevented deconditioning, which often leads to other clinical problems. Because of these important quality-of-life effects, the use of acyclovir and prednisone is a reasonable treatment in older patients with acute herpes zoster (in the patient with concomitant osteoporosis, diabetes, or hypertension, the potential side effects of prednisone therapy may outweigh any therapeutic benefits). A final clinical point: Because skin lesions did not correlate with pain, patients can be in severe pain even when lesions are relatively minor and after lesions have healed.

-Blocker Was More Effective for Benign Prostatic Hyperplasia

Lepor H, Williford WO, Barry MJ, Brawner MK, Dixon CM, Gormley G, et al. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. Veterans Affairs Cooperative Studies Benign Hyperplasia Study Group. N Engl J Med. 1996; 335:533-9.

Until last year, most options for treatment of symptoms of benign prostatic hyperplasia focused on watchful waiting compared with surgery. In the past 2 years, however, medical treatments—-adrenergic antagonists and agents that inhibit 5-reductase—came into common use. Lepor and colleagues compared the efficacy of these two drugs.

A total of 1229 men 45 to 80 years of age with symptomatic benign prostatic hyperplasia were studied in a multicenter Veterans Affairs trial. All patients received only placebo for an initial 4-week run-in period. The patients assessed their symptoms twice daily using the American Urological Association symptom index [5]. The men were randomly assigned to one of four groups: terazosin (10 mg/d), finasteride (5 mg/d), both drugs, and placebo only. Symptom scores and peak urinary flow rates were monitored for 1 year. Results are presented in Table 1.

Terazosin was an unequivocally effective therapy, but finasteride was not. The combination of terazosin and finasteride was no more effective than terazosin alone. However, an important point was made in the editorial [6] that accompanied this report: Finasteride may have a special role in men with larger prostates. Larger prostates seem to be more androgen dependent and consist of relatively more epithelial cells than muscle cells. Such hormone-sensitive cells should respond to 5-reductase therapy. On the other hand, in patients with symptoms of bladder obstruction who seem to have more normal-size prostates, the problem may well be over-growth of smooth muscle. As a result, one might predict that symptoms would respond better to -adrenergic antagonist therapy. Therefore, digital examination of the prostate may be a critical predictor of which agent will be more effective in a specific patient.

Risk of Oral Hypoglycemic Agents Was Ranked

Schorr RI, Ray WA, Daugherty JR, Griffin MR. Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriatr Soc. 1996; 44:751-5.

Sulfonylurea agents are a well-established cornerstone of therapy for patients with type 2 diabetes. However, older patients who have diabetes and experience hypoglycemic episodes are at high risk for severe complications, especially as a result of falls. Thus, a major clinical question is whether hypoglycemia is a common problem in patients receiving oral hypoglycemic agents.

The first-generation agents, such as chlorpropamide, were associated with severe complications, including disulfiram-like reactions with alcohol, hypernatremia, and probably episodes of prolonged hypoglycemia due to the drugs' long duration of action. In the 1990s, the second-generation agents have predominated, now making up 80% to 90% of the market. Sales of glyburide compose 70% of the sales in this group. The risk for hypoglycemia from sulfonylurea agents in older persons has been unknown. Elderly persons have generally been excluded from studies, in part because of the following confounders: Hypoglycemia can mimic many other problems that affect elderly persons; organ system decline can influence the behavior of the drugs; and the regulatory response to hypoglycemia is blunted, especially if a patient is taking many drugs. For the clinician, however, problems with acute diabetes are common, especially among nursing home residents.

In a retrospective cohort study of patient data from the Tennessee Medicaid Program, Schorr and colleagues compared the risk for serious hypoglycemia associated with the use of individual sulfonylureas in older persons. A total of 13 963 persons 65 years of age and older who had been prescribed any of six sulfonylureas were evaluated. Primary outcome measures were rates of hospitalizations or emergency department visits, death, myocardial infarction, stroke, or injury that could be associated with a blood glucose level less than 50 mg/dL.

During 20 715 person-years of sulfonylurea use, 255 patients were identified as having had a first episode of serious hypoglycemia. Results are shown in Table 2. The clinical presentation of severe hypoglycemia was a loss of consciousness in almost 50% of patients, seizures in 6%, and severe lethargy. In the comparison of second-generation sulfonylureas, the adjusted relative risk for severe hypoglycemia among glyburide recipients compared with glipizide recipients was 1.9 (CI, 1.2 to 2.9).

This study confirms previous findings that chlorpropamide use is associated with a high risk for hypoglycemia. A surprising finding was that among the commonly used second-generation sulfonylureas, the frequency of hypoglycemia was higher with glyburide than with glipizide.

Hospital Medicine

Hospitalization is often necessary for elderly persons, but it does present particular risks, especially for deconditioning, functional decline, and delirium.

Risk Factors for Functional Decline Were Identified

Sager MA, Franke T, Inouye S, Landefeld CS, Morgan TM, Rudberg MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996; 156:645-52.

Older patients are being discharged from hospitals sooner. Several studies of older patients have shown worse functional outcomes in persons discharged early from hospitals, but most of these studies may have been limited by the fact that they focused on institutionalized patients and therefore were not representative of the patients seen in most primary care practices.

Sager and colleagues asked several important questions. First, they sought to develop a way to determine preadmission functional status at the time of admission to an acute care hospital, status at discharge, and status 3 months after discharge. Second, they asked whether they could standardize their findings into a screening strategy suitable for use in primary care. Third, they sought to determine the extent to which patients could eventually recover their preadmission level of function if they lost it during hospitalization. Finally, and perhaps most important, they sought to identify the key risk factors for functional decline associated with hospitalization.

A total of 1279 community-dwelling patients 70 years of age and older were evaluated at the time of hospital admission. Patients were further assessed at discharge and 3 months after discharge to determine any declines in activities of daily living.

At discharge, functional abilities had not changed in 59% of patients, had improved in 10%, and had declined in 31%. Table 3 shows the specific categories of decline. In a related study by the same authors [7], logistic regression analysis identified three patient characteristics that independently predicted functional decline: older age, Mini-Mental Status Examination score less than 22 (total possible score, 30), and preexisting problems with instrumental activities of daily living functions (telephoning, shopping, using transportation, preparing meals, doing housework, taking medications, and managing finances). These factors were incorporated into a screening instrument (the Hospital Admission Risk Profile).

The three risk factors clearly identify patients who should be targeted for more comprehensive discharge planning, early mobilization, and special attention by medical staff. Moreover, these two studies showed that decline was more severe in the activities of daily living that required higher function (such as bathing) than in the more basic activities (such as toileting and eating) (Table 3). These findings suggest that we should consider the risks associated with functional decline in the elderly and pay more attention to the areas in which declines are most likely to occur in order to devise appropriate preventive and therapeutic strategies during hospitalization.

Model Predicted Delirium in the Hospital

Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996; 275:852-7.

Delirium occurs in 14% to 56% of elderly patients during acute care hospitalization. This complication results in higher mortality rates, longer and costlier lengths of stay, and higher rates of discharge to nursing homes. In previous studies, Inouye and colleagues described a predictive model for the occurrence of delirium that was based on characteristics present at hospital admission. In this study, Inouye and Charpentier sought to identify precipitating factors for delirium after admission.

A development cohort of 196 patients 70 years of age and older was used to define the precipitating clinical characteristics most likely to be associated with the onset of delirium after admission. A validation cohort of 312 similar patients was then studied to confirm these findings.

Delirium developed in 18% of patients. Five independent precipitating factors were identified: use of physical restraints (RR, 4.4 [CI, 2.5 to 7.9]), malnutrition (RR, 4.0 [CI, 2.2 to 7.4]), addition of more than three medications (RR, 2.9 [CI, 1.6 to 5.4]), use of a bladder catheter (RR, 2.4 [CI, 1.2 to 4.7]), and any iatrogenic event (RR, 1.9 [CI, 1.1 to 3.2]). Each precipitating factor preceded the onset of delirium by more than 24 hours. The authors developed a risk stratification system, shown in Table 4.

When predictive and precipitating factors were correlated, precise risk stratification was possible; rates increased progressively from low to high risk. These findings are of particular concern because most of the risk factors that predispose patients to delirium are directly influenced by physicians.

Cardiovascular Illnesses

Most cardiovascular illnesses and deaths occur in elderly persons. The following studies are troubling signs that this group, with its great prevalence of cardiac disease, may not be receiving optimal care.

Elderly Patients Received Thrombolytic Agents Less Often

Gurwitz JH, Gore JM, Goldberg RJ, Rubinson M, Chandra N, Rogers WJ. Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction. National Registry of Myocardial Infarction. Ann Intern Med. 1996; 124:283-91.

The risk for death from acute myocardial infarction increases with age. The in-hospital mortality rate among persons younger than 65 years of age who arrive at a hospital with a myocardial infarction is about 3%. Among persons older than 65 years of age, the mortality rate may be as high as 30%. When thrombolytic agents are given, the absolute reductions in mortality rate are actually greater among younger patients, partly because the rate of death from untreated infarction is so much higher in the elderly. Cost-effectiveness analyses of thrombolytic agents show no great fall-off in this trend in patients as old as 85 years of age. The consensus is therefore growing that age alone is probably not an important reason to forego thrombolytic therapy. However, elderly persons do have problems that make thrombolysis difficult to implement. First, many myocardial infarctions in the elderly are initially asymptomatic. Second, the elderly more commonly have non-Q-wave infarctions. Third, elderly patients more often have conduction abnormalities, such as left bundle-branch block. These characteristics make the decision to use thrombolysis in the emergency department more difficult.

Gurwitz and colleagues, as participants in the National Registry of Myocardial Infarction, evaluated the records of 350 755 patients who had had acute myocardial infarction from 1990 to 1994. Trends in the use of thrombolytic therapy were examined according to patients' age and sex.

Use of thrombolytic agents was inversely related to patient age. About 51% of patients younger than 55 years of age received a thrombolytic agent during hospitalization. This proportion progressively decreased with age (33% for patients age 65 to 74 years, 19% for those age 75 to 84 years, and 7.4% for those age 85 years and older). The use of thrombolytic therapy increased during the 4 years of the study, however, and was greatest for patients in the oldest groups. At the beginning of the study, 16% of patients 75 to 84 years of age received thrombolysis. By the last year of the study, this Figure had increased to 21.4%. The use of thrombolytic agents was most increased in older women.

We can conclude, then, that older patients with acute myocardial infarction receive a thrombolytic agent much less often than do younger patients. However, the use of thrombolytic agents in the elderly is increasing as the clinical efficacy of this therapy becomes better understood. Age alone should not be considered an absolute contraindication to the use of thrombolytic agents.

Seventy-Six Percent of Patients Received Aspirin after Myocardial Infarction

Krumholz HM, Radford MJ, Ellerbeck EF, Hennen J, Meehan TP, Petrillo M, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med. 1996; 124:292-8.

Even among the elderly, most patients who have had a myocardial infarction survive hospitalization and are discharged. However, the 6-month mortality rate after myocardial infarction increases dramatically with age. About 4% of persons 66 to 70 years of age die by 6 months; for persons older than 80 years age, the 6-month mortality rate is at least 12% [8]. Antiplatelet agents have been unequivocally shown to improve the long-term prognosis of patients who survive myocardial infarction [9]. The obvious question is, Are elderly persons receiving aspirin?

In all 352 nongovernment acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin, Krumholz and colleagues conducted a survey of 5490 consecutive Medicare beneficiaries who survived an acute myocardial infarction and had no contraindications to aspirin.

At discharge, 76% (n = 4149) of patients had been prescribed aspirin. The use of aspirin was correlated with the factors shown in Table 5. The mortality rate was lower when aspirin was prescribed at discharge (relative risk reduction [RRR], 0.23 [CI, 0.02 to 0.39]).

The authors concluded that about one of every four patients who seem to qualify for aspirin therapy does not receive it; this management failure demonstrably affects 6-month mortality rates. Moreover, Krumholz and colleagues' data suggest that patients are more likely to receive aspirin when seen by a cardiologist. Prescribing aspirin for these patients may provide an excellent opportunity to improve care of older patients after acute myocardial infarction.

Walking Was Effective Prevention of Cardiovascular Disease

LaCroix AZ, Leveille SG, Hecht JA, Grothaus LC, Wagner EH. Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults? J Am Geriatr Soc. 1996; 44:113-20.

Exercise is commonly touted as a primary prevention measure against cardiovascular disease, and evidence on the effectiveness of exercise among the elderly is mounting. Walking is probably the most common exercise undertaken by older persons, and surveys estimate that half of persons older than 65 years of age exercise by walking on a regular basis [10].

In a 4.2-year prospective study, LaCroix and colleagues sought to determine whether walking was associated with hospitalization and death from cardiovascular disease in older persons. A total of 1645 persons older than age 65 years were enrolled in a health maintenance organization's health promotion trial. No participant had severe disabilities or any history of heart disease. Confounding factors-blood pressure, estrogen use, chronic disease scores, smoking, and alcohol intake-were evaluated.

Walking more than 4 hours per week was associated with a dramatically reduced likelihood of hospitalization for cardiovascular disease compared with walking less than 1 hour a week (RRR, 0.31; number needed to treat [NNT] for 1 year to prevent one hospitalization, 52). The mortality rate was lower in participants who walked more than 4 hours per week (RRR, 0.27; NNT, 151).

Although it is difficult to completely exclude confounding factors, these data provide the strongest evidence so far for advising older persons to develop an exercise regimen as part of their routine health habits. The amount of exercise-4 hours of walking per week-is reasonable.

Geriatric Syndromes and Functionality

Functional level has a great impact on quality of life, patient satisfaction, and medical costs. As noted above, it may be more predictive of hospital outcomes than any specific diagnosis. In addition, osteoporosis and falls continue to be major causes of both death and disability in the elderly.

Ten-Minute Test Screened for Function

Moore AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med. 1996; 100:438-43.

Formal comprehensive geriatric assessment focuses on defining the functional status of older persons. However, these strategies are time-consuming and thus are often not considered an essential component of primary care office practice. Moreover, there is some doubt that the behavior of primary care physicians is modified by data obtained through formal assessment. Might it be possible to use specific aspects of geriatric assessment in order to screen older patients rapidly and accurately for functional status in the setting of a primary care office?

Moore and Siu developed and evaluated a screening method that could be used by office staff in a primary care office to screen for functional disability in older persons. After reviewing the literature, they designed a screening instrument that included evaluation of malnutrition, visual impairment, hearing loss, urinary incontinence, depression, physical disability, and reduced mobility. The survey tool was tested on 108 patients at an ambulatory geriatrics clinic and was validated against geriatricians' assessments.

The screening test and operating characteristics determined by the researchers are listed in Table 6. The screening test could be reliably administered by nonphysician, often nonprofessional, staff in 8 to 12 minutes. Cost in a practice setting was estimated to range from $1 to $7 per screened patient.

A more generalizable community-based clinical trial is now being conducted; however, Moore and Siu's validation study strongly indicates that functional assessment screening can be cost-effectively done in a primary care office.

Risk Factors for Falls Were Described

Dargent-Molina P, Favier F, Grandjean H, Baudoin C, Schott AM, Hausherr E, et al. Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet. 1996; 348:145-9.

Osteoporosis and fractures are related and, unfortunately, common problems in geriatric medicine. The evidence supporting the usefulness and safety of bisphosphonate therapy continues to grow and will be described in detail in the upcoming Update in Endocrinology.

About 90% of hip fractures in elderly persons result from falls [11]. One major predictor of hip fractures is osteoporosis, as measured by bone mineral density [12, 13]. However, women who have sustained a hip fracture have only slightly lower bone mineral density than those with no history of fracture. Therefore, other factors must place the elderly at greater risk for hip fracture.

In this French population study, Dargent-Molina and colleagues recruited 7575 women who were 75 years of age or older and had no history of hip fracture. Bone mineral density of the femoral neck was measured, and participants answered questions on physical capacity, neuromuscular function, mobility, visual function, and use of medications.

During 1.9 years of follow-up, 154 women sustained a hip fracture. In an age-adjusted multivariate analysis, four independent fall-related risk factors predicted hip fracture: slower gait speed (RR, 1.4), difficulty in performing a tandem walk (RR, 1.2), reduced visual acuity (RR, 2.0), and small calf circumference (RR, 1.5). The relative risk associated with decreased bone mineral density was 1.8 per SD below the mean for age.

Although low bone mineral density may be only marginally improved by therapy, neuromuscular and visual impairments are often amenable to therapy if they are detected during routine office evaluations. Dargent-Molina and colleagues' data provide more evidence for recommending routine screening for functional assessment in every office visit.

In summary, much geriatrics research published in 1996 focused on patients' function and quality of life. Although much remains to be done, it is encouraging to know how much can already be improved in the primary care setting.

Dr. Roberts (Series Editor): Madroma Medical Group, 5335 Cordata Parkway, Bellingham, WA 98226.