bluuebunny/crossref_metadata_2025 huggingface dataset:
Measurement of Drug Compliance by Continuous Electronic Monitoring: A Pilot Study in Elderly Patients Discharged From Hospital
Authors: Kruse Wolfgang , Koch‐Gwinner Peter , Nikolaus Thorsten , Oster Peter , Schlierf Günter , Weber Ellen
Published: April 2015

Objective

A pilot study to assess patient compliance with medication by using a new measurement technique, continuous electronic monitoring.

Design

Survey. Compliance monitors were provided to eligible patients at discharge from the hospital to measure drug intake behavior prospectively for a period of 3 weeks.

Setting

Ambulant patient care after discharge from a geriatric hospital, Krankenhaus Bethanien, which is affiliated with the University Clinic, Heidelberg.

Patients

A consecutive convenience sample of 18 independently living elderly patients (median age 76 years) completed the study. The patients were on maintenance therapy with cardiac glycosides and/or potassium‐sparing diuretics prescribed to be taken once daily.

Intervention

The monitoring method provides information about patients' real timing of drug use by continuously recording date and time of openings and closings of the medication containers (monitors). In addition to a standard measure, the percentage of prescribed doses taken, information about regularity of drug use is obtained.

Results

Compliance, percentage of prescribed doses taken, was remarkably variable; it ranged from 24% to 100%, 95% CI: 62%‐84%. Mean compliance declined from the first to the third week after discharge, 85% vs 69%, 95% CI: 74%‐95% and 56%‐81%, respectively (P < 0.05). Omissions of doses, the predominant pattern of non‐compliance, were observed in 17 of 18 patients. Regularity of dose timing, as defined by the number of interdose intervals within 24 h ± 15%, varied from 10% to 100%, 95% CI: 46%‐76%. Conclusions: Continuous electronic monitoring revealed highly variable compliance in patients prescribed maintenance therapy. Even with a once‐daily regimen, persistent and high compliance cannot be assumed. The monitoring technique may be of great value to research and, possibly, to practical therapeutic management.
BOOK REVIEWS
Authors: Elon Rebecca D.
Published: April 2015

Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 2nd Ed. Edited by John C. Beck, William B. Applegate, Richard W. Besdine, Dan G. Blazer, George T. Grossberg, David B. Reuben, Gregg A. Warshaw, and Mark E. Williams; Managing editor, Barbara R. Popecki. New York, American Geriatrics Society, 1991. 512 pages plus answer and bibliography booklets. $160.00.
BOOK REVIEWS
Authors: Bradley Edward B.
Published: April 2015

Medical Care in the Nursing Home By Joseph G. Ouslander, Dan Osterweil and John Morley. New York, McGraw‐Hill, Inc., 1991. 451 pages. $49.95.
Major Surgery in Nursing Home Patients: Procedures, Morbidity, and Mortality in the Frailest of the Frail Elderly
Authors: Keating Herbert J.
Published: April 2015

Objective

To determine the surgical procedures being done on long‐term care (level 2) nursing home residents and the resultant in‐hospital morbidity and mortality.

Design

A retrospective chart review of inpatient medical records from two hospitals, identified by computerized search of medical records and/or referral by directors of nursing of area nursing homes.

Setting

Patients originated in skilled‐care nursing homes in New Castle County, Delaware, USA. Surgery was performed in the area's two major hospitals, one a 1000‐bed regional referral and teaching hospital, and the other a 300‐bed community hospital.

Patients

Residents of skilled‐care nursing homes (level 2) who underwent major surgery between January 1979 and December 1989.

Measurements and Main Results

Eighty procedures were performed in 74 patients. Many different types of procedures were done. After primary repair of hip fracture the most common procedures were non‐orthopedic extremity and abdominal surgeries. Three deaths occurred (mortality 3.8%), and all were in patients undergoing emergency surgery who were classified above American Society of Anesthesiology Class 3. Serious complications occurred in 43% of the procedures and were most commonly cardiopulmonary and psychiatric, including profound depression in four. Antibiotic‐associated colitis occurred in three patients and required a second surgical procedure in one. Fewer adverse outcomes were seen in patients undergoing elective surgical procedures with spinal or local anesthesia than in patients receiving general anesthesia.

Conclusions

Although retrospective and limited to inpatient data, in‐hospital surgical mortality in this very frail population was low, comparable to series in unselected geriatric populations. However, major complications were very common. Primary hip surgery repair may have been too frequently done. A multi‐institution, prospective trial would be useful to assess functional outcome of surgery in this population.
Longitudinal Prescribing Patterns in a Nursing Home Population
Authors: Wayne Sharon J , Rhyne Robert L , Stratton Mark
Published: April 2015

Objective

This study documents the patient characteristics associated with prescribed medications on entry to a nursing home and the change in prescribing patterns after 3 months.

Design

One‐year admission cohort.

Setting

Three university‐affiliated community nursing homes in Albuquerque, NM.

Patients

All new admissions (n = 81) to a University geriatrics team, covering intermediate and skilled levels of care during 1 year (July 1, 1988–July 1, 1989).

Methods

Outcome measures were scheduled and as‐needed (PRN) medications prescribed at entry and 3 months. Data collected at entry included patient demographics, activities of daily living index, mental status score, and medical diagnoses.

Results

Older persons were prescribed fewer scheduled medications than younger ones, and women fewer than men. There was a positive association between the number of diagnoses and the number of scheduled medications (r = 0.25, P = 0.02). No associations were found between medications prescribed and mental status or functional level. There were no associations between as‐needed (PRN) medications and any of the variables studied. Overall, there was a significant increase in the average total number of medications prescribed between admission (4.7) and 3 months (6.2). This was due to an increase in the number of PRN medications from 1.3 at admission to 3.0 at 3 months (P < 0.001).

Conclusions

Measuring medications at consistent points in a person's nursing home stay may be more informative than using cross‐sectional sampling. Future studies on medications in nursing home populations should distinguish between PRN and scheduled medications because medication prescribing patterns may be different in these categories.
A Prospective Study of Pressure Sore Risk among Institutionalized Elderly
Authors: Bergstrom Nancy , Braden Barbara
Published: April 2015

Objective

To determine if dietary intake, nutritional status, and other physical markers are risk factors for the development of pressure sores in the elderly.

Design

Cohort study.

Setting

250‐bed skilled nursing facility with 90 extended care beds in which the average length of stay is 28 days.

Patients

Two hundred newly admitted residents (70% female, 95% Caucasian) who were over age 65, estimated to stay > 10 days, at risk for pressure sore development (Braden Scale score ≤17) but free of existing pressure sores were studied for 12 weeks or until discharge.

Measures

Skin assessment, Braden Scale score, blood pressure, body temperature, anthropometrics, and dietary intake were studied weekly. CBC, serum albumin, serum total protein, serum iron, iron binding capacity, serum zinc and copper, and serum vitamin C were studied weekly for 4 weeks and biweekly for 8 weeks.

Main Outcome Measures

Presence/absence and stage of pressure sores.

Main Results

Stage I pressure sores developed in 70 (35%) and Stage 2 or worse in 77 (38.5%) residents. Subjects who developed pressure sores were older (P < 0.001) and had lower systolic and diastolic blood pressure (P < 0.001) and higher body temperature (P < 0.001) than those without pressure sores. Dietary intake of all nutrients was lower among subjects who developed pressure sores. Using logistic regression, the best predictors or pressure sore development were the Braden Scale score, diastolic blood pressure, temperature, dietary protein intake, and age.

Conclusions

Risk assessment is recommended upon admission to a nursing home and weekly for the first month. Risk status can be effectively predicted by using the Braden Scale in combination with knowledge of age, blood pressure, temperature, and dietary protein intake.
Post‐Operative Delirium: Predictors and Prognosis in Elderly Orthopedic Patients
Authors: Williams‐Russo Pamela , Urquhart Barbara L. , Sharrock Nigel E. , Charlson Mary E.
Published: April 2015

Objective

To compare the effect of post‐operative analgesia using epidural versus intravenous infusions on the incidence of delirium after bilateral knee replacement surgery in elderly patients. Additional risk factors and impact on post‐operative recovery were also assessed.

Design

Prospective randomized controlled trial.

Setting

Urban referral hospital specializing in elective orthopedic surgery.

Patients

60 consecutive patients undergoing bilateral knee replacement surgery with epidural anesthesia were approached; 51 patients were eligible and consented. The mean age was 68, 55% were women, and there was a high prevalence of comorbid medical disease. No patient was demented pre‐operatively.

Intervention

Random allocation to either continuous epidural infusion of bupivicaine and fentanyl or continuous intravenous infusion of fentanyl. Infusions were initiated at the first complaint of pain and continued through the 36‐ to 48‐hour stay in the recovery room.

Main Outcome Measure

Acute post‐operative delirium defined using an algorithm based on DSM III criteria.

Results

The overall incidence of acute delirium was 41%, with no difference between types of post‐operative analgesia. Predictors of delirium were age, gender, and pre‐operative alcohol use. All cases resolved within 1 week, and length of stay and achievement of physical therapy goals were the same for delirious and non‐delirious patients.

Conclusions

There is a high incidence of post‐operative delirium in elderly non‐demented patients following bilateral knee replacement, regardless of whether post‐operative analgesia is administered by the epidural or intravenous route.
Napping and 24‐Hour Sleep/Wake Patterns in Healthy Elderly and Young Adults
Authors: Buysse Daniel J. , Browman Kaitlin E. , Monk Timothy H. , Reynolds Charles F. , Fasiczka Amy L. , Kupfer David J.
Published: April 2015

Objective

To examine differences between healthy elderly and young adults in daytime napping, nocturnal sleep, and 24‐hour sleep/wake patterns. A second objective was to determine whether elderly subjects with more and less frequent naps differed in their clinical features or nocturnal sleep.

Design

Survey by sleep/wake logs and polysomnography. Comparison by age.

Setting

Sleep/wake logs were completed in the subjects' homes. Polysomnographic studies were conducted on an outpatient basis in a sleep and chronobiology research laboratory.

Subjects

Convenience samples of forty‐five healthy subjects over 78 years of age (21M, 24F) and 33 healthy adults between 20 and 30 years of age (20M, 13F).

Main Outcome Measures

Using self‐reports, we estimated the frequency and timing of daytime naps; timing, duration, and quality of nocturnal sleep; and 24‐hour patterns of sleep and wakefulness. Also Polysomnographic sleep measures.

Results

Compared to young adults, elderly subjects reported a greater mean number of daytime naps (P = .004), shorter nocturnal sleep with more wakefulness and earlier sleep hours (P < .003 for each), and a trend for a shorter 24‐hour sleep fraction. Among the elderly, more‐frequent and less‐frequent nappers did not differ in clinical ratings, self‐report sleep measures, or polysomnographic measures. There was a trend for more sleep‐disordered breathing and periodic limb movements in more frequent nappers.

Conclusions

These findings are consistent with an age‐related decrease in amplitude of the circadian sleep propensity rhythm, or with the expression of a semi‐circadian (12‐hour) sleepiness rhythm. However, we cannot exclude the additional possibility that napping results from lifestyle factors and nocturnal sleep pathologies in a subset of the elderly.
The Dynamics of Disability and Functional Change in an Elderly Cohort: Results from the Alameda County Study
Authors: Strawbridge William J. , Kaplan George A. , Camacho Terry , Cohen Richard D.
Published: April 2015

Objective

To examine changes in functional status over time by age, gender, and ethnicity in a representative sample of older persons.

Design

Six‐year prospective cohort study.

Setting

Alameda County, California.

Participants

508 persons 65 years old and older at baseline in 1984.

Main Outcome Measures

Activities of daily living (ADL) dependence, mobility impairment, and functioning on an 18‐item scale.

Results

The prevalence of ADL dependence and mobility impairment at baseline increased with age, while function decreased. Particularly striking differences occurred for those 80 and older. Changes in function over the 6‐year follow‐up showed a similar pattern. While death rates for males were higher, females had poorer initial functioning, and surviving females declined more than surviving males. The incidence of ADL dependence and mobility impairment during follow‐up was similar for males and females, although females survived longer with incident disability than did males. Blacks had poorer baseline functioning, more ADL dependence and mobility impairment, and declined more than non‐Blacks during follow‐up. Some of the baseline difference in function between Blacks and non‐Blacks was due to higher rates of chronic illness and co‐morbidity. In spite of the general downward trend in functioning over the 6 years, 13% of the males and 20% of the females improved.

Conclusion

Age‐related changes in function for older persons are complex and result in much heterogeneity. Clarifying the reasons for such heterogeneity is an important and challenging area of research.
Hearing Loss Prevalence and Management in Nursing Home Residents
Authors: Garahan Margaret Bunce , Waller Julian A. , Houghton Martha , Tisdale William A. , Runge Carl F.
Published: April 2015

Objectives

To determine the prevalence and management of hearing loss and hearing handicap among non‐demented nursing home residents.

Design

Descriptive study of total population of two nursing homes.

Participants

All 121 eligible residents.

Settings

Two nursing homes.

Mini Outcome Measures

Audiometry, questionnaires of nurses and subjects regarding perceived hearing handicap, and documentation in medical records of hearing loss.

Results

77% had at least a mild (≥26 dB Hearing Level) hearing loss in the better ear, and 51% had a moderate to severe loss (≥41 dB HL). Self‐assessments of hearing handicap by residents, together with audiometric findings and expressed interest in a hearing aid, were more useful guides for aural rehabilitation needs than were nurses' assessments of residents' handicaps. Medical records failed to identify 48% of residents with moderate to severe hearing losses. Fifty‐eight percent of residents with severe hearing loss currently had hearing aids, and 38% more would like to have an aid.

Conclusion

Residents should have hearing evaluations with documentation of results on admission and periodically under the direction of a nurse trained as a hearing specialist. Environmental modifications of the NH plus use of hearing aids can improve hearing.
The Impact of Pacemaker Implantation on Cognitive Functioning in Elderly Patients
Authors: Rockwood Kenneth , Dobbs Allen R. , Rule Brendan G. , Howlett Susan E. , Black William R.
Published: April 2015

Objective

To describe and quantify the impact of pacemaker implantation on cognitive functioning in the elderly.

Design

Prospective case‐control, non‐randomized trial. Data were collected from clinical and family interviews and from a psychological test battery.

Setting

Pacemaker clinic in a tertiary care hospital.

Participants

Nineteen elderly (65+ years) patients undergoing new or replacement pacemaker implantation for dysrhythmias and volunteer controls matched for age, sex, and short Mental Status Questionnaire test results, without dysrhythmia or intervention.

Main Outcome Measures

Subjective and clinical impressions based on family interviews; results of psychological test battery before and 6–12 months after pacemaker implantation.

Results

Prior to pacemaker implantation, three patients met DSM‐III criteria for dementia and two for delirium. Paced patients demonstrated deficiency in immediate memory, language, memory for less structured information, and learning of abstract materials. These deficits were due primarily to the poor performance of patients with complete heart block. Despite clinical and subjective impressions of improvement, there was no change in psychologic test performance subsequent to pacemaker implantation.

Conclusions

Impaired cognitive functioning is not always clinically apparent but appears common in patients with cardiac dysrhythmias; it is not altered 6–12 months after pacemaker implantation.
Reduced Infectivity of Cold‐Adapted Influenza A H1N1 Viruses in the Elderly: Correlation with Serum and Local Antibodies
Authors: Powers Douglas C. , Murphy Brian R. , Fries Louis F. , Adler William H. , Clements Mary Lou
Published: April 2015

Objective

To compare young and elderly adults in terms of their immune responses and rates of infection following intranasal vaccination with a live attenuated influenza virus.

Design

Time series, comparing outcomes in young and elderly convenience sample.

Method

Retrospective laboratory analysis of serum and nasal wash specimens collected during prior studies in which young or elderly volunteers had been inoculated with cold‐adapted influenza A/Kawasaki/86 (H1N1) reassortant virus.

Setting

Johns Hopkins Center for Immunization Research.

Participants

Healthy young and elderly adults with prevaccination serum hemagglutination inhibition (HAI) antibody titers ≤1:8.

Outcome Measurements

Antibody responses in serum and nasal washes.

Main Results

The proportion of vaccinees who developed any serum or local antibody response was higher in young compared with elderly subjects (20/20 vs 5/14, P < 0.0005). Resistance to infection with cold‐adapted virus correlated with pre‐vaccination levels of serum immunoglobulin G (IgG), serum IgA, and nasal wash IgA antibody to whole virus antigen. Age was highly correlated with a lack of response to vaccine by simple regression, but not when data were adjusted for pre‐existing antibody levels.

Conclusions

Cold‐adapted reassortant influenza A H1N1 viruses achieve lower rates of infection in elderly than young adults, primarily due to age‐related differences in preexisting levels of immunity which may not be reflected by HAI titer.
Time Dependency of Cognitive Recovery with Cobalamin Replacement: Report or a Pilot Study
Authors: Martin David C. , Francis Joseph , Protetch Jack , Huff F. Jacob
Published: April 2015

Objective

To examine the effects of cobalamin repletion on cognition in elderly subjects with low serum cobalamin and evidence of cognitive dysfunction.

Design

Time series data collected in an open trial of parenteral cobalamin therapy.

Settings

Outpatient geriatric assessment centers, inpatient geropsychiatry unit, and tertiary care university hospital.

Participants

Twenty‐two subjects with low serum cobalamin (<150 pmol/L) and evidence of cognitive dysfunction were entered consecutively over an 8‐month period of time. Eighteen subjects completed the study.

Interventions

Subjects received 1000 micrograms of cyanocobalamin intramuscularly daily for 1 week, then weekly for 1 month, then monthly thereafter for a minimum of six months.

Outpatient measure

The Maths Dementia Rating Scale (DRS) was administered both before and at least 6 months after full cobalamin replacement therapy. The hypothesis that cognitive improvement was dependent on the duration of cognitive symptoms was formulated a posteriori.

Results

After a minimum of 6 months of cobalamin therapy, 11 of 18 patients showed cognitive improvement. There was a striking correlation between duration of cognitive symptoms and response to therapy. Patients symptomatic for <12 months gained an average of twenty points on the DRS (paired f test P = 0.0076), whereas patients symptomatic >12 months lost an average of three points (paired t test P = .34). Two patients symptomatic for only 3 months normalized their DRS scores, gaining 31 and 28 points, respectively.

Conclusion

There may be a time‐limited window of opportunity for effective intervention in patients with cognitive dysfunction and low serum cobalamin.
Light to Moderate Alcohol Consumption and Mortality in the Elderly
Authors: Scherr Paul A. , LaCroix Andrea Z. , Wallace Robert B. , Berkman Lisa , Curb J. David , Cornoni‐Huntley Joan , Evans Denis A. , Hennekens Charles H.
Published: April 2015

Objective

To determine whether there is a relationship of low to moderate alcohol consumption with cardiovascular mortality in the elderly.

Design

Prospective cohort studies with 5‐year mortality follow‐up.

Setting

Three populations of community‐dwelling elders.

Participants

Population‐based cohorts of men and women, aged 65 or older, in three populations. Subjects with prior myocardial infarction, stroke, or cancer, as well as those lacking alcohol consumption data, were excluded from statistical analyses leaving 2,694 subjects in East Boston, Massachusetts, 2,293 subjects in Iowa, and 1,904 subjects in New Haven, Connecticut.

Main Outcome Measurements

Alcohol consumption, total mortality, cardiovascular mortality, and cancer mortality.

Results

Low to moderate alcohol consumption was associated with statistically significant lowered total as well as cardiovascular mortality in East Boston and New Haven. The relative risks of total mortality for low to moderate consumers of alcohol compared to those consuming no alcohol in the previous year were 0.7 (95% CI 0.6–0.8) in East Boston and 0.6 (95% CI 0.5–0.8) in New Haven. For cardiovascular mortality, the RRs were 0.6 in East Boston and 0.5 in New Haven (95% CI's exclude null). These results persisted after control for potential confounding variables. In Iowa, there were no significant differences in total or cardiovascular mortality according to alcohol consumption patterns. For cancer mortality, there were no significant associations with alcohol consumption in any of the three populations.

Conclusions

These data suggest that the relationship of low to moderate alcohol consumption with reduced total and cardiovascular mortality, which are well documented in middle age, also occur in older populations.
BOOK REVIEWS
Authors: Bancati Frederick L.
Published: April 2015

Learning Clinical Reasoning. By Kassirer JP and Kopelman RI. Baltimore, Williams & Wilkins, 1991. 332 pages. $32.00.
Fluoxetine in Elderly Patients: Is There Cause for Concern?
Authors: Brymer Chris , Winograd Carol Hutner
Published: April 2015

Objective

To assess whether fluoxetine use is associated with significant weight loss or other side effects in depressed elderly patients with concomitant medical illness.

Design

A retrospective chart review.

Setting

A tertiary care VA hospital.

Patients

Five groups of outpatients were studied: (1) patients greater than 75 years old receiving fluoxetine (n = 15); (2) patients 60 to 71 years old receiving fluoxetine (n = 20); (3) patients greater than 75 years old receiving nortryptiline or desipramine (n = 20); (4) patients greater than 75 years old with a history of depression but on no antidepressant medication (n = 20); and (5) patients greater than 75 years old with no history of depression (n = 28).

Measurements

Mortality, change in weight, reports of anorexia or nausea, and serum sodium and glucose measurements.

Main Results

Patients greater than 75 years of age taking fluoxetine experienced significantly greater weight loss (average 4.6 kilograms, P = 0.0062) than the other groups. Both groups of patients taking fluoxetine were significantly more likely to report nausea (P = 0.0095) and anorexia (P = 0.0009). No significant differences were noted in mortality or the frequency of hypoglycemia or hyponatremia between groups.

Conclusion

The frequency and degree of weight loss noted here in medically ill elderly receiving fluoxetine warrants further investigation.
Factors Attenuating the Validity of the Geriatric Depression Scale in a Dementia Population
Authors: Feher Edward P. , Larrabee Glenn J. , Crook Thomas H.
Published: April 2015

Objective

The validity of the Geriatric Depression Scale (GDS) in cognitively impaired patients has been questioned. We investigated possible factors (memory loss, dementia severity, unawareness of illness) attenuating the validity of the GDS in patients with dementia.

Patients

Eighty‐three patients who met research diagnostic criteria for “probable Alzheimer's disease.” Subjects with major depressive disorder were excluded. Dementia severity ranged from mild to moderate.

Setting

Outpatient clinics, including institutional settings and private research settings.

Measurements

Depression—GDS; Hamilton Depression Scale. Memory—Wechsler Memory Scale; Benton Visual Retention Test. Dementia severity—Mini‐Mental State Examination. Self‐awareness of cognitive deficits—Difference score between a self‐report memory questionnaire and an informant‐rated memory questionnaire.

Results

Multiple regression analysis revealed that Hamilton scores were the major predictor of GDS scores. Memory scores and self‐awareness scores were also significant predictors. Dementia severity scores were not a significant predictor.

Conclusions

The GDS is a valid measure of mild‐to‐moderate depressive symptoms in Alzheimer patients with mild‐to‐moderate dementia. However, Alzheimer patients who disavow cognitive deficits also tend to disavow depressive symptoms, and the GDS should be used with caution in such patients. Finally, the argument that memory impairment precludes accurate self‐report of recent mood is negated by our finding that many patients accurately reported depressive symptoms and that worse memory was associated with more self‐reported depressive symptoms.
Geriatric Education Part I: Efficacy of a Mandatory Clinical Rotation for Fourth Year Medical Students
Authors: Fields Suzanne D. , Jutagir Rajendra , Adelman Ronald D. , Tideiksarr Rein , Olson Ellen
Published: April 2015

Objectives

To describe the curriculum of a mandatory, fourth‐year geriatrics clerkship and assess its impact on medical students' knowledge of geriatric medicine and attitudes toward the elderly.

Design

One group, before/after trial.

Setting

Mount Sinai School of Medicine of the City University of New York.

Participants

Entire fourth year class of medical students (n = 127).

Intervention

Four‐week‐long clinical geriatrics clerkship.

Measurements

Pre‐ and post‐rotation: test of knowledge; Aging Semantic Differential (ASD) attitude scale; Modified Maxwell‐Sullivan attitude scale; questionnaire.

Main Results

Seventy percent of students found the rotation to be educationally valuable; however, only one‐third of students would have taken the clerkship had it not been required. Mean geriatric knowledge score increased by 18.7% (P < 0.001). Mean ASD attitude score did not change significantly (130.5 ± 19.2 pre‐rotation versus 126.6 ± 18.8 post‐rotation, P = 0.15), but students started the rotation with a neutral attitude. Over 90% of students agreed they would welcome elderly into their future practice.

Conclusion

If a national curricular goal is to improve medical students' knowledge of geriatric medicine, required rather than elective rotations may be in order.
The Test for Severe Impairment: An Instrument for the Assessment of Patients with Severe Cognitive Dysfunction
Authors: Albert Marilyn , Cohen Carolyn
Published: April 2015

Objective

To develop a reliable and valid test of cognitive function suitable for patients with severe cognitive impairment.

Design

Administration of a test; test‐retest reliability; comparison to traditional test.

Setting

Chronic long‐term‐care facility.

Patients or Other Participants

The participants were 40 elderly residents with severe cognitive impairment.

Main Outcome Measures

Results of the Test for Severe Impairment (TSI) and its subsections (language, memory, executive function, and motor performance); correlation of test and retest scores; correlation of TSI with Mini‐Mental State Exam.

Results

The TSI was significantly correlated with the Mini‐Mental State Exam (r = 0.83, P ≤ 0.0001). Test‐retest reliability was high (r = 0.96, P < 0.0001). The internal reliability of the test was also good (alpha = 0.90). Preliminary result of a factor analysis suggests that factor scores may be derived that relate to memory, language production, and knowledge of body parts.

Conclusions

The TSI is a valid and reliable test of cognitive function in patients with severe cognitive impairment. It is appropriate to use it as a unified scale.
Measurement of Activities of Daily Living in Hospitalized Elderly: A Comparison of Self‐Report and Performance‐Based Methods
Authors: Sager Mark A. , Dunham Nancy Cross , Schwantes Amy , Mecum Laurie , Halverson Kaia , Harlowe Diane
Published: April 2015

Objective

To determine the accuracy of self‐reports of physical functioning by hospitalized elderly.

Design

Comparison of two measures.

Patients and Setting

Two‐hundred forty‐seven medical inpatients (mean age 78.7 years) hospitalized at St. Marys Hospital Medical Center, Madison, WI.

Main Outcome Measures

Measures of five activities of daily living by self‐report and by performance.

Results

The rate of agreement between self‐report and performance ADL measures was the lowest in the areas of bathing and dressing where the agreement was 63% and 64%, respectively. When patients reported needing no help in these two tasks, they were measured lower 32% of the time for dressing and 42% for bathing. When patients reported needing help in an activity the agreement rate between patient and occupational therapist varied widely, from only 42% for toileting to 78% for bathing. The two factors which were statistically associated with poor agreement between the two ADL measurements were cognitive impairment (P < 0.001) and a decline from the pre‐hospital level of ADL functioning which had occurred during hospitalization (P < 0.001).

Conclusions

These data suggest that there may be significant differences between patient assessments and performance‐based measurements of ADL functioning in hospitalized elderly at time of discharge. These differences may have implications for the collection of functional measurements for discharge planning or for geriatric research in the hospital environment.
The Caretaker Obstreperous‐Behavior Rating Assessment (COBRA) Scale
Authors: Drachman David A. , Swearer Joan M. , O'Donnell Brian F. , Mitchell Ann L. , Maloon Alan
Published: April 2015

Objective

To evaluate the usefulness and reliability of the Caretaker Obstreperous‐Behavior Rating Assessment (COBRA), a new test instrument for caretaker assessment of types and severity of “obstreperous behaviors” (OBs) in demented patients.

Design

COBRA was completed by caretakers of 31 outpatients and 36 nursing home inpatients with dementia. Test‐retest reliability was determined when 25 of the outpatient caretakers re‐evaluated their demented relative 1 week later; inter‐rater reliability was determined on nursing home inpatients by comparing the reports of two nurse's aids with equivalent knowledge of seven of the patients.

Setting

(1) University medical center Alzheimer's Disease and Related Disorders Clinic; (2) community nursing home.

Patients

Thirty‐one sequentially‐seen outpatients with dementia; 36 nursing home patients with dementia.

Intervention

Following instruction in the use of the COBRA Scale, caretakers provided scores for their demented patient. The instrument has three unique features: (1) it divides OBs into four categories for ease of comprehension: Aggressive/Assaultive; Mechanical/Motor; Ideational/Personality; and Vegetative; (2) a companion videotape shown to caretakers in advance illustrates each behavior to improve reliability of reporting; (3) the significance of each OB is estimated with severity and frequency measures.

Main Outcome Measurements

Frequency and severity of OBs are epitomized in 12 summary scores. Test‐retest correlations (for outpatients) and inter‐rater correlations (for inpatients) were analyzed with Pearson Product Moment and Spearman Rank Order correlations.

Results

Prevalence of OBs and severity was reported for the experimental groups. Summary scores revealed test‐retest correlations of .95 to .73 for 11 of 12 scores (outpatients), and inter‐rater correlations of .99 to .73 for 8 of 12 scores (inpatients). Age, gender, and disease etiology were not significantly related to OBs; clinical severity correlated with type and severity of OBs.

Conclusions

The COBRA scale provides a convenient, comprehensive, and reliable means for caretakers to identify the types and measure the severity of OBs in demented outpatients and nursing home inpatients. If additional studies confirm these observations, COBRA will be a useful instrument for assessing the effects of interventions on OBs in patients with dementia.
Milacemide: A Placebo‐Controlled Study in Senile Dementia of the Alzheimer Type
Authors: Dysken Maurice W. , Mendels Joseph , LeWitt Peter , Reisberg Barry , Pomara Nunzio , Wood James , Skare Stacy , Fakouhi J. Daniel , Herting Robert L.
Published: April 2015

Objective

Milacemide, a MAO‐B inhibitor that is also a prodrug for glycine, was tested as a treatment for senile dementia of the Alzheimer type (SDAT) because of its potential for enhancing cognition in animal models of impaired learning and memory.

Design

Double‐blind, placebo‐controlled, randomized clinical trial.

Setting

Sixteen study sites, both university‐affiliated and private.

Patients

A total of 228 outpatients (116 men and 112 women) with SDAT, ranging in age from 49–93 years. Intervention: 1200 mg/day milacemide treatment for 1 month (113 patients received milacemide, and 115 patients received placebo).

Main Outcome Measures

Alzheimer's Disease Assessment Scale and the Mini‐Mental State Examination.

Results

Milacemide‐treated SDAT patients did not show significant improvement in any of the outcome measures used. Significant elevations in liver enzymes in four subjects were of sufficient magnitude to necessitate withdrawal from the study.

Conclusions

Milacemide does not appear to be an effective treatment in enhanci g cognition in SDAT patients.
A Comparison of a Two‐Wheeled Walker and a Three‐Wheeled Walker in a Geriatric Population
Authors: Mahoney Jane , Euhardy Reenie , Carnes Molly
Published: April 2015

Objective

There are few data on the effect of walkers on gait and mobility or on comparisons of different walker types. We compared a commonly used 4‐legged, 2‐wheeled walker and a newer 3‐legged, 3‐wheeled walker in measures of gait, mobility, and patient satisfaction.

Design

Cross‐over controlled trial.

Setting

In the Physical Therapy Department of a Veterans Affairs hospital.

Participants

Subjects were 15 male and female frail elderly veterans (mean age, 82 years), both inpatients and outpatients, consecutively enrolled from a sample of 35 patients referred to the Physical Therapy Department for mobility problems. Subjects met the following criteria: age 65 or over, ambulatory, no prior use of a wheeled walker, stable medical condition, and informed consent.

Intervention

Subjects were evaluated without either walker and with each of the two walkers on a 15‐foot walkway and a 60‐foot obstacle course. Subjects were asked which walker they preferred.

Outcome Measure

Outcome measures were stride length on the walkway, time on an obstacle course, and walker preference.

Results

Stride length was 1.4 inches (3.6 cm) greater with the 3‐wheeled walker than with the 2‐wheeled walker (P = 0.016 by Wilcoxon signed‐rank test). Time on the obstacle course was 16.0 seconds less with the 3‐wheeled walker than the 2‐wheeled walker (P = 0.002). The 3‐wheeled walker was subjectively preferred.

Conclusions

The 3‐wheeled walker appears to have a greater positive impact on gait and mobility than the 2‐wheeled walker.
Prevalence of Hepatitis B Surface Antigen, Hepatitis C Antibody, and HIV‐1 Antibody among Residents of a Long‐Term‐Care Facility
Authors: Simor A. E. , Gordon M. , Bishai F. R.
Published: April 2015

Objective

To determine the prevalence of hepatitis B antigen (HBsAg), antibody to hepatitis C virus (anti‐HCV), and antibody to human immunodeficiency virus (anti‐HIV) among residents of a long‐term care facility.

Design

Anonymous unlinked serosurvey.

Setting

Accredited university‐affiliated long‐term‐care facility in Toronto with 300 chronic‐care hospital patients, 350 nursing home residents, and 200 residents of a senior citizens' apartment complex.

Interventions

Sera from left‐over blood samples obtained from residents in November 1990 were tested for HBsAg, anti‐HCV, and anti‐HIV using standard methods.

Results

A total of 508 sera were tested. The number (%) positive for HBsAg, anti‐HCV, and anti‐HIV, respectively were: 3(0.6%), 7(1.4%), and 0(0%).

Conclusions

This is the first report defining rates of infection with bloodborne infective agents among residents of a long‐term care facility. These results support the use of hepatitis B vaccine for medical and nursing staff and the implementation of universal precautions in long‐term care facilities.
State Regulations Governing Infection Control Issues in Long‐Term Care
Authors: Crossley Kent , Nelson Lara , Irvine Patrick
Published: April 2015

Objective

To examine states' regulations governing infections and infection control in long‐term‐care institutions.

Design

Collection and examination of relevant documents from all of the states, the District of Columbia, the Joint Commission on Accreditation of Health Care Organizations, and Medicare/Medicaid.

Main Outcome Measures

Rules governing (1) admissions of patients with infections, (2) tuberculin testing of residents, (3) employee health, (4) use of immunizations, (5) human immunodeficiency virus (HIV)‐infected patients, and (6) infection control were compared.

Results

There were wide variations in states' policies in each of these areas and many were inconsistent with current scientific knowledge.

Conclusion

Uniform federal standards for long‐term care would probably provide a better and more economical way to ensure quality of care in these institutions.
Protein‐Energy Malnutrition in Elderly Medical Patients
Authors: Constans T. , Bacq Y. , Bréchot J.‐F. , Guilmot J.‐L. , Choutet P. , Lamisse F.
Published: April 2015

Study Objective

To evaluate (1) the prevalence of protein‐energy malnutrition in elderly patients; (2) the changes in nutritional status during the hospital stay; and (3) (main objective) the relationship between simple nutritional parameters and short‐term in‐hospital mortality.

Design

Prospective time series at admission and on the 15th day of hospitalization.

Setting

Medical care unit in a teaching hospital.

Participants

Consecutive sample of 324 hospitalized patients ≥70 years (86.4% of eligible patients). Norms of measurements were obtained from a referred sample of healthy control subjects (26 males and 36 females).

Main Outcome Measures

Mid‐arm circumference, triceps skinfold thickness, serum albumin, prealbumin, and retinol‐binding protein levels were measured in patients at admission and on the 15th day.

Results

(1) Prevalence of PEM was 30% in male and 41% in female patients. (2) Both mid‐arm circumference and serum albumin level decreased over the first 15 days of hospital stay (53 patients, paired t test, P < 0.05). Triceps skinfold thickness did not change. (3) A step‐wise discriminant‐function analysis determined the utility of the parameters at admission as predictors of in‐hospital mortality before the 15th day. Mid‐arm circumference, triceps skinfold thickness, albumin, and prealbumin levels, as well as age, are predictors of in‐hospital mortality, with 73% sensitivity, 69% specificity, and 70% of correctly classified patients of both sexes.

Conclusions

Parameters used are predictors for short‐term in‐hospital mortality of elderly patients hospitalized in an acute medical unit. The lean body mass is preferentially mobilized for energy during hospitalization.
Empowerment of the Older Patient? A Randomized, Controlled Trial To Increase Discussion and Use of Advance Directives
Authors: Sachs Greg A. , Stocking Carol B. , Miles Steven H.
Published: April 2015

Objective

To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives.

Design

Randomized, controlled trial of an educational intervention versus usual care.

Setting

Outpatient geriatrics clinic of a university hospital.

Patients

One hundred and thirty‐one non‐demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty‐eight patients were in the trial arm and 83 in the control.

Main Outcome Measures

All patients had their charts re‐examined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re‐interviewed to examine their reasons for not executing an advance directive.

Main Results

Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P > 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier.

Conclusions

Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.
The Effect of Age on Driving Skills
Authors: Carr David , Jackson Thomas Wayne , Madden David J. , Cohen Harvey Jay
Published: April 2015

Objective

To assess the effect of age on driving skills independent of the limitations related to disease or dementia.

Design

Prospective comparison of driving skills across three age groups.

Setting

A university‐based research study of student and university‐affiliated volunteers.

Participants

Healthy elderly (age 65+), teen‐age (age 18–19), and young adult drivers (age 25–35). Twenty subjects in each age group were recruited after meeting entry criteria for the study.

Main Outcome Measures

Total error count and score on the Miller Road Test, a standardized road test developed by the Division of Bus and Traffic Safety in North Carolina.

Results

The elderly were found to have fewer errors than either of the two younger groups of drivers (P= 0.0013). Specific driving skills were judged to be either superior or unchanged in the elderly subjects in comparison to their younger counterparts.

Conclusions

Road test skills appear to be well preserved in the healthy elderly population. More road test studies are needed on elderly individuals with mental and physical impairments to determine if road tests can play a role in identifying the driver at high risk for a crash.
The Clock Test: A Sensitive Measure To Differentiate Normal Elderly from Those with Alzheimer Disease
Authors: Tuokko H. , Hadjistavropoulos T. , Miller J. A. , Beattie B. L.
Published: April 2015

Objective

To examine the clinical utility of the Clock Test for identifying dementia.

Design

Group comparisons.

Setting

A hospital‐based out‐patient diagnostic clinic.

Patients

Volunteer sample of elderly individuals (normal elderly, NE, n = 62) and a referred sample of probable Alzheimer Disease (AD, n = 58) patients meeting NINCDS‐ADRDA criteria.

Main Outcome Measure

The Clock Test is composed of three components: Clock Drawing, Clock Setting, and Clock Reading. A detailed scoring system for qualitative as well as quantitative evaluation of Clock Drawing errors was used. Five time settings, varying in level of complexity, were used to evaluate Clock Setting and Clock Reading.

Results

The groups differed significantly on Clock Drawing, Clock Setting, and Clock Reading (P < 0.001). On Clock Drawing, the AD group made significantly more errors of omission and misplacement of numbers than the NE group (P < 0.001). Using cut‐off scores derived to maximize separation between the groups to define deficits in performance, the sensitivity and specificity for the diagnosis of AD of Clock Drawing, Clock Setting, and Clock Reading were 92% and 86%, 87% and 97%, 92% and 85%, respectively. Using a criterion of deficits on two or more of the three components, sensitivity and specificity increased to 94% and 93%, respectively.

Conclusions

Deficits on clock drawing in AD may be reflective of a generalized disturbance in the conceptualization of time rather than constructional apraxia, per se. The functionally relevant components of Clock Setting and Clock Reading combined with Clock Drawing make the Clock Test particularly useful as a screening and research tool for AD.
Comparing Proxy and Patients' Perceptions of Patients' Functional Status: Results from an Outpatient Geriatric Clinic
Authors: Weinberger Morris , Samsa Gregory P. , Schmader Kenneth , Greenberg Stanley M. , Carr David B. , Wildman Diane S.
Published: April 2015

Objective

To compare ratings of patients referred for geriatric evaluation and their proxies with respect to patients' ability to perform activities of daily living.

Design

Retrospective chart audit.

Setting

University‐based Outpatient Geriatric Clinic.

Patients

Elderly medicine patients referred to a university‐based outpatient geriatrics clinic for the first time.

Main Outcome Measures

Modified Katz Physical Activities of Daily Living (PADL) and Instrumental Activities of Daily Living (IADL).

Results

With regard to PADLs, patients were generally rated as independent by both patients (91%) and proxies (87%); for IADLs, ratings of independence by both patients (68%) and proxies (51%) were significantly lower. Concordance between patient and proxy ratings was significantly (P<0.001) greater for PADLs (92%) than for IADLs (82%). When disagreement occurred, patients consistently rated themselves as more independent than their proxies, especially for IADLs. Moreover, concordance between patients and proxies regarding IADLs was significantly (P<0.001) worse for patients who had scores below 24 on the Folstein Mini‐Mental State Examination (72%) compared with those scoring 24 or higher (95%).

Conclusions

Patient and proxy ratings were concordant when rating patients' ability to perform PADLs. Moreover, concordance was extremely high on IADLs when patients' Folstein scores were 24 or higher. Concordance with respect to IADLs was relatively poor only among patients with Folstein scores below 24. In that case, patients had a more optimistic view of their independence, compared with their proxies.