bluuebunny/crossref_metadata_2025 huggingface dataset:
Barriers to Effective Communication in Skilled Nursing Facilities: Differences in Perception between Nurses and Physicians
Authors: Cadogan Mary P. , Franzi Cheryl , Osterweil Dan , Hill Terry
Published: April 2015

BACKGROUND: Effective communication between nurses and physicians is central to the clinical care of nursing home residents. Anecdotal evidence suggests that communication between the groups is unsatisfactory, but no empirical data exist with which to validate assumptions. The purpose of this pilot study was to compare perceptions of potential communication barriers among nurses and physicians in four California nursing homes.

METHODS: Registered nurses (n = 59), and physicians (n = 47) involved in the direct clinical care of nursing home residents completed a 12‐item questionnaire designed to elicit perceptions about potential communication barriers. Five specific categories of barriers were identified. These included nurse competence, time burden of calls, necessity of calls, professional respect, and language comprehension. Responses were compared using t test analysis.

RESULTS: Significant differences in perceived communication barriers were identified. Physicians, but not nurses, perceive nursing competence to be a significant barrier. Nurses perceive physicians to be unpleasant. Both physicians and nurses perceive that physicians do not value nurses' opinions. Neither group perceived language expression, language comprehension, or time burden of phone calls to be barriers to communication.

CONCLUSIONS: Issues related to the perceived competency of nurses by physicians is consistent with existing data from other clinical settings. Differences in awareness about scope of practice and regulatory requirements between the groups may offer a partial explanation for the discordant perceptions. Perceptions by nurses (but not physicians) of unpleasantness and/or disrespect during telephone encounters may reflect the broader ongoing differences in professional culture, social status, and gender inequality between the two groups. Further clarification of the causes of barriers to effective communication is essential in order to plan appropriate interventions.
What is the Quality of the Reporting of Research Ethics in Publications of Nursing Home Research?
Authors: Karlawish Jason H.T. , Hougham Gavin W. , Stocking Carol B. , Sachs Greg A.
Published: April 2015

OBJECTIVE: To assess the quality of reporting of research ethics in published clinical research that involves a particularly vulnerable population: nursing home residents.

DESIGN: A structured review of publications researched from 1992 to 1996 that involve nursing home residents. The review instrument assessed each publication's compliance with four common standards for research that involves nursing home residents or the cognitively impaired: justification of the use of nursing home residents, Institutional Review Board (IRB) review, nursing home committee review, and informed consent. For each publication, these results were summed into a quality score. The research ethics requirements contained in the journals' instructions for authors that corresponded with each publication were categorized in order to compare whether an association exists between the average quality score for each category and the detail of its research ethics instructions.

RESULTS: Forty‐five publications were identified. The four quality measures of research ethics showed that (1) all 45 publications reported justification of use of nursing home residents, (2) 36 publications reported that informed consent was obtained or waived, (3) 18 publications reported IRB review, and (4) six publications reported nursing home committee review. Of the 35 publications reporting informed consent was obtained, 16 reported assessing subjects' decisional capacity, and 24 reported whether cognitively impaired subjects were included (19) or excluded (5). The research ethics requirements of each publication's instructions for authors ranked it in one of four categories: (A) None (9); (B) Less than “Uniform Requirements (UR) for Manuscripts Submitted to Biomedical Journals” (7); (C) UR (24); (D) UR plus Additional Instructions (5). A positive association exists between the detail of a research ethics instructions category and the average research ethics quality score for each category (Kruskal‐Wallis χ2 = 11.2, P = .01). That is, the more detailed the instructions, the greater the quality score.

CONCLUSION: In publications of research that involves nursing home residents, basic standards of research ethics are not typically reported. However, the positive association between research ethics instructions category and research ethics quality score suggests that a journal's instructions for authors or other features of peer review and editing can affect the quality of reporting research ethics.
Life‐Sustaining Treatment Decisions for Nursing Home Residents: Who Discusses, Who Decides and What Is Decided?
Authors: Levin Jennifer R. , Wenger Neil S. , Ouslander Joseph G. , Zellman Gail , Schnelle John F. , Buchanan Joan L. , Hirsch Susan H. , Reuben David B.
Published: April 2015

OBJECTIVE: To evaluate whether nursing home residents and their families reported discussions about life‐sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician‐patient communication about life‐sustaining treatment.

DESIGN: Cross‐sectional interviews and retrospective chart abstraction.

SETTING: Three regions: West Coast, New England, Western.

SAMPLE: A total of 413 nursing home residents, 363 family/ surrogate interviews, and 192 resident interviews.

MAIN OUTCOME MEASURES: Measured were (1) physician‐resident communication about life‐sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart.

RESULTS: Seventy‐four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life‐sustaining treatment. Of residents with DNR orders who could have participated in discussions about life‐sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician‐family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician‐resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician‐resident discussion about life‐sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses.

CONCLUSIONS: Chart orders to limit therapy are common, but physician‐resident discussions about life‐sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.
The Renal Effects of Nonsteroidal Anti‐inflammatory Drugs in Older People: Findings from the Established Populations for Epidemiologic Studies of the Elderly
Authors: Field Terry S. , Gurwitz Jerry H. , Glynn Robert J. , Salive Marcel E. , Gaziano J. Michael , Taylor James O. , Hennekens Charles H.
Published: April 2015

OBJECTIVE: To determine whether older people who use nonsteroidal anti‐inflammatory agents (NSAIDs) have increased levels of blood urea nitrogen (BUN), serum creatinine, and BUN:serum creatinine ratio.

DESIGN: Cross‐sectional, secondary data analysis.

SETTING: Older people living in the communities of East Boston, MA, New Haven, CT, and Washington and Iowa Counties, Iowa.

PARTICIPANTS: A total of 4099 people aged 70 years or older who were participants in the National Institute on Aging's Established Populations for Epidemiologic Studies of the Elderly project, had survived to the 6‐year follow‐up interview and had consented to the blood drawing.

MEASUREMENTS: We assessed use of the NSAIDs at the 3‐and 6‐year interviews through a drug inventory and visual review of medication containers. Markers of renal function assessed through analysis of blood samples drawn at the time of the interview included BUN and creatinine.

RESULTS: Fifteen percent of the cohort reported use of NSAIDs during the 2 weeks preceding the 6‐year interview. Controlling for age, sex, and a range of potential confounding variables, NSAID users had significant prevalence odds ratios of 1.9 (95% confidence interval (CI), 1.5‐2.3) for being in the highest quartile of BUN (>23), 1.3 (CI 1.1‐1.7) for the highest quartile of serum creatinine (≥1.4), and 1.7 (CI 1.4‐2.1) for the highest quartile of the BUN:creatinine ratio (≥19.4). Chronic NSAID users (those who reported NSAID use at both the 3‐year and 6‐year interviews) accounted for the increased risk of high serum creatinine levels.

CONCLUSION: Community‐dwelling older people who use NSAIDs tend to have higher levels of common laboratory markers of renal dysfunction. This hypothesis requires further testing in prospective cohort studies designed a priori to evaluate these issues. J Am Geriatr Soc 47:507–511, 1999.
The Relationship Between Clinical Assessments of Nutritional Status and Adverse Outcomes in Older Hospitalized Medical Patients
Authors: Covinsky Kenneth E. , Martin Gay E. , Beyth Rebecca J. , Justice Amy C. , Sehgal Ashwini R. , Landefeld C. Seth
Published: April 2015

BACKGROUND: Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status.

OBJECTIVE: To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use.

DESIGN: Prospective cohort study SETTING: A tertiary care hospital

PATIENTS: A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service

MEASUREMENTS: Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review.

RESULTS: 219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47‐5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06–7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05–9.87).

CONCLUSION: Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission. J Am Geriatr Soc 47:532–538, 1999.
Cross‐Sectional Versus Longitudinal Estimates of Cognitive Change in Nondemented Older People: A CERAD Study
Authors: Unger Joseph M. , van Belle Gerald , Heyman Albert
Published: April 2015

OBJECTIVES: To investigate the effect of increasing age on cognition in nondemented older people.

DESIGN: A cross‐sectional and longitudinal analysis.

PARTICIPANTS: A total of 454 control subjects for Alzheimer's cases from the cohort assembled by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD).

MEASUREMENT: The Mini‐Mental State Examination (MMSE) to assess cognitive function.

RESULTS: Cross‐sectional estimates were derived by generalized linear models and longitudinal estimates by generalized estimating equations. The cross‐sectional model indicated a small but significant decline in MMSE of ‐.4 points per 10 years. The longitudinal model indicated a small but significant increase in MMSE of about +.6 points per 10 years. Evidence of an early learning effect and nonrandom dropout exists.

CONCLUSIONS: The question of “normal” aging can be approached by considering cross‐sectional information and, usually separately, longitudinal information. This study does both using recently developed statistical methods. We conclude that there is a small but significant decline in scores on the MMSE with increasing population age. The effect can be masked in longitudinal cohorts by a learning effect (especially early in follow‐up) and other factors associated with repeated testing. J Am Geriatr Soc 47:559–563, 1999.
The Influence of Physician Race, Age, and Gender on Physician Attitudes Toward Advance Care Directives and Preferences for End‐Of‐Life Decision‐Making
Authors: Mebane Eric W. , Oman Roy F. , Kroonen Leo T. , Goldstein Mary K.
Published: April 2015

OBJECTIVE: To determine whether physicians' preferences for end‐of‐life decision‐making differ between blacks and whites in the same pattern as patient preferences, with blacks being more likely than whites to prefer life‐prolonging treatments.

DESIGN: A mailed survey.

SETTING AND PARTICIPANTS: American Medical Association (AMA) and National Medical Association (NMA) databases. To enrich the sample of black physicians, we targeted physicians in the AMA database practicing in high minority area zip codes and graduates of the traditionally black medical schools.

MAIN OUTCOME MEASURES: Self‐reported physician attitudes toward end‐of‐life decision‐making and preference of treatment for themselves in persistent vegetative state or organic brain disease compared by race, controlling for age and gender.

RESULTS: The 502 physicians (28%) who returned the questionnaire included 280 white and 157 black physicians. With regard to attitudes toward patient care, 58% of white physicians agreed that tube‐feeding in terminally ill patients is “heroic,” but only 28% of black physicians agreed with the statement (P < .001). White physicians were more likely than black physicians to find physician‐assisted suicide an acceptable treatment alternative (36.6% vs 26.5% of black physicians) (P < .05).

With regard to the physicians preferences for future treatment of themselves for the persistent vegetative state scenario, black physicians were more than six times more likely than white physicians to request aggressive treatments (cardiopulmonary resuscitation, mechanical ventilation, or artificial feeding) for themselves (15.4% vs 2.5%) (P < .001). White physicians were almost three times as likely to want physician‐assisted suicide (29.3% vs 11.8%) (P < .001) in this scenario. For a state of brain damage with no terminal illness, the majority of all physicians did not want aggressive treatment, but black physicians were nearly five times more likely than white physicians (23.0% vs 5.0%) (P < .001) to request these treatments. White physicians, on the other hand, were more than twice as likely to request physician‐assisted suicide (22.5% vs 9.9%), P < .001 in this scenario.

CONCLUSIONS: Physicians preferences for end‐of‐life treatment follow the same pattern by race as patient preferences, making it unlikely that low socioeconomic status or lack of familiarity with treatments account for the difference. Self‐denoted race may be a surrogate marker for other, as yet undefined, factors. The full spectrum of treatment preferences should be considered in development of guidelines for end‐of‐life treatment in our diverse society. J Am Geriatr Soc 47:579–591, 1999.
A Randomized Clinical Trial of Outpatient Comprehensive Geriatric Assessment Coupled with an Intervention to Increase Adherence to Recommendations
Authors: Reuben David B. , Frank Janet C. , Hirsch Susan H. , McGuigan Kimberly A. , Maly Rose C.
Published: April 2015

BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain.

OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15‐month health outcomes.

DESIGN: A randomized controlled trial.

SETTING: Community‐based sites.

PATIENTS: 363 community‐dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment)

INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations.

MEASUREMENTS: Medical Outcomes Study Short Form‐36 (MOS SF‐36), restricted activity and bed days, Physical Perfomance Test, NIA lower‐extremity battery.

RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow‐up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF‐36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF‐36 emotional/well being, pain, and mental health summary scales were also demonstrated.

CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health‐related quality‐of‐life decline among community‐dwelling older persons who have specific geriatric conditions.
The Effects of Aerobic Exercise and T'ai Chi on Blood Pressure in Older People: Results of a Randomized Trial
Authors: Young Deborah Rohm , Appel Lawrence J. , Jee SunHa , Miller Edgar R.
Published: April 2015

OBJECTIVE: To compare the effects on blood pressure of a 12‐week moderate‐intensity aerobic exercise program and a T'ai Chi program of light activity.

DESIGN: A randomized clinical trial.

SETTING: A suburban clinic in the Baltimore, MD, area.

PARTICIPANTS: Sixty‐two sedentary older adults (45% black, 79% women, aged > 60 years) with systolic blood pressure 130–159 mm Hg and diastolic blood pressure < 95 mm Hg (not on antihypertensive medication).

INTERVENTION: Participants were randomized to a 12‐week aerobic exercise program or a light intensity T'ai Chi program. The goal of each condition was to exercise 4 days per week, 30 minutes per day.

MEASUREMENTS: Blood pressure was measured during three screening visits and every 2 weeks during the intervention. Estimated maximal oxygen uptake and measures of physical activity level were determined at baseline and at the end of the intervention period.

RESULTS: Mean (SD) baseline systolic and diastolic blood pressures were 139.9 (9.3) mm Hg and 76.0 (7.3) mm Hg, respectively. For systolic blood pressure, adjusted mean (SE) changes during the 12‐week intervention period were −8.4 (1.6) mm Hg and −7.0 (1.6) mm Hg in the aerobic exercise and T'ai Chi groups, respectively (each within‐group P < .001; between‐group P = .56). For diastolic blood pressure, corresponding changes were −3.2 (1.0) mm Hg in the aerobic exercise group and −2.4 (1.0) mm Hg in the T'ai Chi group (each within‐group P < .001; between‐group P = .54). Body weight did not change in either group. Estimated maximal aerobic capacity tended to increase in aerobic exercise (P = .06) but not in T'ai Chi (P = .24).

CONCLUSIONS: Programs of moderate intensity aerobic exercise and light exercise may have similar effects on blood pressure in previously sedentary older individuals. If additional trials confirm these results, promoting light intensity activity could have substantial public health benefits as a means to reduce blood pressure in older aged persons.
Angiotensin‐Converting Enzyme Inhibitor Use in Older Patients with Heart Failure and Renal Dysfunction
Authors: Philbin Edward F. , Santella Robert N. , Rocco Thomas A.
Published: April 2015

OBJECTIVE: To examine the relationship between angiotensin‐converting enzyme (ACE) inhibitor use and clinical outcomes among recently hospitalized patients with congestive heart failure (CHF) and coexisting renal insufficiency.

DESIGN: A prospective cohort study.

SETTING: Ten community hospitals in upstate New York.

PARTICIPANTS: A total of 1076 hospital survivors identified from a consecutive series of CHF inpatients.

MEASUREMENTS: Patients were followed prospectively for 6 months after hospital discharge to track mortality, hospital readmission, and quality of life. Clinical outcomes were stratified by ACE inhibitor use among those with renal dysfunction, defined as serum creatinine > 2.0 mg/dL, and among the remaining patients, whose serum creatinine was > 1.9.

RESULTS: ACE inhibitor use was lower among 187 patients with renal dysfunction than among 889 patients with preserved function (41 vs 69%, P < .001). Age and sex were among the significant determinants of drug use in both groups. After adjustment for covariables, ACE inhibitor use among those with abnormal renal function was not associated with a lower risk for death or readmission, or better quality of life. By comparison, ACE inhibition conferred meaningful clinical benefit among those whose creatinine was < 1.9 mg/dL.

CONCLUSION: Convincing evidence of clinical benefit from ACE inhibitor use is not readily detectable among a sample of 187 unselected older patients with CHF and moderate or severe renal insufficiency. Further studies to identify subsets of this group who might benefit are warranted.
Effectiveness of Behavioral Therapy to Treat Incontinence in Homebound Older Adults
Authors: McDowell B. Joan , Engberg Sandra , Sereika Susan , Donovan Nancy , Jubeck Mary Ellen , Weber Elizabeth , Engberg Richard
Published: April 2015

OBJECTIVES: To examine the (1) short‐term effectiveness of behavioral therapies in homebound older adults and (2) characteristics of responders and nonresponders to the therapies.

DESIGN: Prospective, controlled clinical trial with crossover design.

SETTING: Adults aged 60 and older with urinary incontinence and who met Health Care Financing Administration criteria for being homebound were referred to the study by homecare nurses from two large Medicare‐approved home health agencies in a large metropolitan county in southwestern Pennsylvania.

MEASURES: Structured continence and medical history, OARS Physical and Instrumental Activities of Daily Living scales, Folstein Mini‐Mental State Examination Score, Clock Drawing Test, Geriatric Depression Scale, Performance‐Based Toileting Assessment, bladder diaries, and physical examination.

RESULTS: One hundred five subjects were randomized to biofeedback‐assisted pelvic floor muscle training (53 to the treatment group and 52 to the control groups). Control subjects with complete pre‐ and post‐control data (n = 45) experienced a median 6.4% reduction in urinary accidents in contrast to a median 75.0% reduction in subjects with complete pre‐ and post‐treatment data (n = 48, P < .001). Following the control phase, subjects crossed over to the treatment protocol. Eighty‐five subjects completed treatment, achieving a median 73.9% reduction in UI. Exercise adherence was the most consistent predictor of responsiveness to the behavioral therapy.

CONCLUSIONS: Clinically significant reductions in urinary incontinence are achievable with behavioral therapies in many cognitively intact homebound older adults despite high levels of co‐morbidity and functional impairment.
Age‐related Brain Changes Associated with Motor Function in Healthy Older People
Authors: Camicioli Richard , Moore M.M. , Sexton G. , Howieson D.B. , Kaye Jeffrey A.
Published: April 2015

OBJECTIVE: To identify the MRI imaging findings associated with motor changes in healthy older people.

DESIGN: A cross‐sectional study.

SETTING: A study of neurologic function in very healthy older people, the Oregon Brain Aging Study.

PARTICIPANTS: Clinical and MRI data were examined in 50 very healthy older subjects (mean age = 85.1, SD = 7.2 years).

MEASUREMENTS: Clinical measures (finger tapping, hand opening and closing, steps and time to walk 30 feet and timed standing on one foot) were dependent variables in multiple regression analyses using age and the following MRI measures as independent variables: total brain volume (TBV)/intracranial volume; ventricular volume/TBV; periventricular high signal/TBV; deep high signal/TBV.

RESULTS: The number of steps and the time to walk 30 feet were each associated with periventricular high signal (steps: r = .58, P < .001; time: r = .60, P < .001) and ventricular volume (steps: r = .54, P < .001; time: r = .58, P < .001). These associations remained significant after adjusting for age. None of the other clinical variables was associated with the MRI volumes.

CONCLUSIONS: Gait measures were associated significantly with periventricular high signal and ventricular volume. These CNS changes contribute to the cause of these important markers of aging.
Risk Factors for Lack of Recovery of ADL Independence After Hospital Discharge
Authors: Hansen Kurt , Mahoney Jane , Palta Mari
Published: April 2015

OBJECTIVE: To determine risk factors for lack of recovery of independent functioning after hospitalization for acute medical illness.

DESIGN: Secondary analysis of cohort study of patients receiving home nursing after discharge.

SETTING: Evaluations performed in the home after discharge and 1 month later.

PARTICIPANTS: A total of 73 adults aged 65 years and older who were independent in activities of daily living (ADLs) before hospitalization and dependent at discharge.

MEASUREMENTS: Self‐report and objective measures of function, mobility, and cognition.

OUTCOME: Return to independence in ADLs 1 month after discharge.

RESULTS: Fifty‐nine percent of patients did not return to previous ADL independence by 1 month postdischarge. The likelihood for not recovering was 87% (95% CI, 70–100%) if a patient had a Mini‐Mental State Examination score (MMSE) < 24 at discharge (P = .015). Among patients with good cognition, 85% (95% CI, 66–100%) of those who used an assistive device indoors before hospitalization did not recover (P = .007). Among patients with good cognition and no previous assistive device use, 73% (95% CI, 47–99%) of those with a Timed “Up and Go” of > 40 seconds did not recover (P = .012). The likelihood of recovery was high (76%, 95% CI 56–96%) if a patient had no assistive device prehospital, a good MMSE, and a Timed “Up and Go” of < 20 seconds.

CONCLUSION: We hypothesize that a classification strategy using cognition, prehospital mobility, and discharge physical performance will predict patients who are less likely to recover functional independence after hospitalization. If this is validated in future study, it may help clinicians identify patients who are more likely to benefit from additional intervention.
Incidence of New Thromboembolic Stroke in Persons 62 Years and Older with Chronic Atrial Fibrillation Treated with Warfarin Versus Aspirin
Authors: Aronow Wilbert S. , Ahn Chul , Kronzon Itzhak , Gutstein Hal
Published: April 2015

OBJECTIVE: To investigate the incidence of new thromboembolic (TE) stroke in older persons with chronic atrial fibrillation treated with oral warfarin versus aspirin.

DESIGN: In an observational study of 312 older persons with chronic atrial fibrillation, long‐term aspirin 325 mg daily was administered to 187 persons, and oral warfarin, in a dose adjusted to maintain the international normalized ratio (INR) between 2.0 and 3.0, was administered to 115 persons. The incidence of new TE stroke was analyzed in persons treated with warfarin versus aspirin at 36 ± 17 months (1 to 99 months) follow‐up.

SETTING: A large, long‐term healthcare facility.

PATIENTS: The patients included 208 women and 104 men, mean age 84 ± 7 years (range 62 to 101 years).

MEASUREMENTS AND MAIN RESULTS: Four of 125 persons (3%) on warfarin stopped taking warfarin compared with four of 187 persons (2%) on aspirin who stopped taking aspirin because of adverse effects (P not significant). In persons with prior stroke, the incidence of new TE stroke was 40% (27 of 67) in persons treated with warfarin versus 81% (56 of 69) in persons treated with aspirin (P < .001). In persons with no prior stroke, the incidence of new TE stroke was 22% (13 of 58) in persons treated with warfarin versus 56% (66 of 118) in persons treated with aspirin (P < .001). The incidence of new TE stroke in all subjects was 32% (40 of 125) in persons treated with warfarin versus 65% (122 of 187) in persons treated with aspirin (P < .001). Cox regression analysis showed that persons taking warfarin had a 76% less chance of developing a new TE stroke than those taking aspirin after controlling the confounding effects of other risk factors.

CONCLUSION: In an observational study of older persons with chronic atrial fibrillation, persons treated with oral warfarin to maintain an INR between 2.0 and 3.0 had a significantly lower incidence of new TE stroke than persons treated with oral aspirin 325 mg daily.
Chronic Care Clinics: A Randomized Controlled Trial of a New Model of Primary Care for Frail Older Adults
Authors: Coleman E. A. , Grothaus L. C. , Sandhu N. , Wagner E. H.
Published: April 2015

OBJECTIVE: To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults.

DESIGN: Randomized controlled trial with 24 months of follow‐up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care.

SETTING: Nine primary care physician practices that comprise an ambulatory clinic in a large staff‐model HMO in western Washington State.

PARTICIPANTS: Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline.

INTERVENTION: Intervention practices (5 physicians, 96 patients) held half‐day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high‐risk medications; and a patient self‐management/support group. Control practices (4 physicians, 73 patients) received usual care.

MEASUREMENTS: Changes in self‐reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention‐ to‐treat analysis adjusted for baseline differences, covariates, and practice‐level variation. Prescriptions for high‐risk medications and cost/utilization data obtained from administrative data were similarly analyzed.

RESULTS: After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P =. 10).

CONCLUSIONS: Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system‐wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.
Relationship of Age and Simulated Flight Performance
Authors: Yesavage Jerome A. , Taylor Joy L. , Mumenthaler Martin S. , Noda Art , O'Hara Ruth
Published: April 2015

OBJECTIVE: To determine the relationship between age and aviator performance on a flight simulator.

DESIGN: A cross‐sectional observational study.

PARTICIPANTS: The sample consisted of 100 aviators aged 50 to 69 (mean = 58)

MAIN OUTCOME MEASURES: Pilots were tested on a Frasca 141 flight simulator (Urbana, IL), linked to a UNIXbased IRIS 4D computer (Silicon Graphics, Mountain View, CA), which both generated graphics of the environment in which the pilots flew and collected data concerning the aircraft's flight conditions.

RESULTS: We found that increased age was significantly associated with decreased aviator performance on a flight simulator.

CONCLUSIONS: Although there was a significant relationship between increased age and decreased aviator performance, age explained 22% or less of the variance of performance on different flight tasks; hence, other factors are also important in explaining the performance of older pilots.
Treatment for the Secondary Prevention of Stroke in Older Patients: The Influence of Dementia Status
Authors: Moroney Joan T. , Tseng Chin‐Lin , Paik Myunghee C. , Mohr J. P. , Desmond David W.
Published: April 2015

OBJECTIVE: To investigate the influence of dementia status on treatment for the secondary prevention of stroke in older patients.

DESIGN: Based on patient examinations and medical record review, we investigated the frequency of aspirin and/or warfarin use at hospital discharge for the prevention of recurrent stroke in older patients hospitalized with acute ischemic stroke.

SETTING: A large academic medical center. PARTICIPANTS: A cohort of 272 patients, mean age 72.1 ± 8.5 years.

MEASUREMENTS: We performed neurologic examinations and reviewed medical records to investigate the effects of a clinical diagnosis of dementia and other potentially relevant factors on treatment with aspirin or warfarin at hospital discharge.

RESULTS: Thirty‐one patients (11.4%) were not prescribed aspirin or warfarin at hospital discharge. Logistic regression determined that dementia (odds ratio (OR) = 2.57, 95% confidence interval (CI), 1.04–6.30) was a significant independent determinant of nontreatment with aspirin or warfarin, adjusting for abnormal gait (OR = 2.01, CI,. 88–4.59); discharge to a nursing home or other institutional residence (OR = 2.55, CI,. 83–7.81); cardiac disease (OR =. 39, CI,. 16−.95); cortical infarct location (OR =. 45, CI,. 18–1.10); male sex (OR =. 47, CI,. 20–1.15); age 80+ (OR = 1.14, CI,. 46–2.82) and age 70–79 (OR =. 96, CI,. 32–2.88) versus age 60–69.

CONCLUSIONS: Our results suggest that dementia is a significant independent determinant of nontreatment with aspirin or warfarin when otherwise indicated for the prevention of recurrent stroke. The underutilization of aspirin and warfarin in older stroke patients with dementia may be a modifiable basis for their increased risk of recurrence and death.
Reporting of Dementia on Death Certificates: A Community Study
Authors: Ganguli Mary , Rodriguez Eric G.
Published: April 2015

OBJECTIVE: To determine the extent to which conditions suggesting dementia are reported on death certificates of older adults and to identify the factors associated with reporting of dementia.

DESIGN: A prospective epidemiological study in which community‐dwelling subjects with and without dementia were identified and followed until death, after which their death certificates were examined.

POPULATION: A total of 527 individuals who died during 8 years of follow‐up of a population‐based cohort of 1422 persons aged 65 and older at study entry. MEASUREMENTS: Demographic; study diagnoses, including Clinical Dementia Rating (CDR) Scale stages and diagnoses of Probable and Possible Alzheimer's disease (AD) by NINCDS‐ADRDA criteria; disorders listed on death certificates as immediate, underlying, or contributory causes of death.

RESULTS: Of 172 deceased subjects with study diagnoses of dementia, 30.2% had CDR =. 5 and 69.8% had CDR ≥ 1. Of 168 subjects in which dementia subtype could be diagnosed, Probable AD was diagnosed in 31.0% and Possible AD in 38.7%. On their death certificates, conditions indicating or suggesting dementia were reported in 23.8% of dementias overall; in 1.9% of those with CDR =. 5 and 33.3% of those with CDR ≥ 1; in 36.5% of those with Probable AD and 21.5% of those with Possible AD. In a multiple logistic regression model, variables associated independently with the reporting of dementia in demented individuals were: higher CDR stage of dementia (odds ratio (OR) 22.6; 95% confidence interval (CI), 2.9–174.7); likely etiology of dementia, Probable AD (OR = 3.5; CI, 1.1–10.6); and place of death, long‐term care institution (OR = 3.8; 95% CI, 1.6‐ 9.0).

CONCLUSIONS: Although Alzheimer's disease is widely regarded as a leading cause of death, dementias are reported on the death certificates of only a quarter of demented individuals in the population at large. Reporting is more likely in those with more advanced dementia, with Probable Alzheimer's disease, and those who die in long‐term care institutions.
Comparison Based on Age of Baseline Electrocardiographic Abnormalities in Non‐Q‐Wave Myocardial Infarction
Authors: Stratmann Henry G. , Kleiger Robert E. , Ferry David R. , Zoble Robert G. , Chow Bruce K. , Lavori Philip W. , Boden William E. ,   The VANQWISH Trial Research Investigators
Published: April 2015

OBJECTIVE: To compare the incidence of electrocardiographic abnormalities between older (age > 70 years) and younger patients presenting with acute non‐Q‐wave myocardial infarction.

DESIGN: Retrospective review of qualifying electrocardiograms in 918 patients enrolled in the multicenter Veterans Affairs Non‐Q‐Wave Infarction Strategies In‐ Hospital (VANQWISH) study.

SETTING: Seventeen Department of Veterans Affairs medical centers.

PARTICIPANTS: A total of 918 patients (224 > 70 years old) with acute non‐Q‐wave myocardial infarction. MEASUREMENTS: Comparison of electrocardiograms in patients aged > 70 years and younger patients for presence of left ventriculary hypertrophy, widened QRS complex, ST and T wave abnormalities, rhythm other than sinus, heart rate > 80 beats/minute, and location of acute non‐Q‐wave myocardial infarction.

RESULTS: Left ventricular hypertrophy and ST depression > 1 mm were significantly more frequent in older than in younger patients.

CONCLUSIONS: Older patients presenting with non‐Q‐wave myocardial infarction have a greater incidence of left ventricular hypertrophy and ST depression on their electrocardiograms than younger patients. Both of these electrocardiographic findings have previously been associated with increased risk of death and recurrent myocardial infarction and may help account for the worse prognosis of non‐Q‐wave myocardial infarction in older patients.
Factors Influencing the Proportion of Food Consumed by Nursing Home Residents with Dementia
Authors: Amelia Elaine J.
Published: April 2015

BACKGROUND: Assessment of and interventions for promoting eating in persons with late‐stage dementia have primarily focused on facilitation of safe feeding and methods to promote ingestion of nutrients via several routes. Using Social Exchange Theory, this study examined how the quality of the interaction between care giver and care receiver influenced the proportion of food consumed by persons with late‐stage dementia.

METHODS: Fifty‐three dyads composed of nursing home residents with late‐stage dementia and Certified Nursing Assistants (CNAs) were observed during the breakfast meal. The proportion of food consumed by the residents was measured by weight. The study included measures of the quality of interaction between the resident and the CNA (Interaction Behavior Measure‐Modified (IBM‐M) and the IBM), CNA empathy (Interpersonal Reactivity Index), and CNA power (Control subscale of the FIRO‐B).

RESULTS: Specific resident behaviors and the CNA's ability to allow another person to control a relationship were most predictive of the variance in the proportion of food consumed (R2 =. 41; F3,49 = 12.54; P <. 001). The quality of the resident‐CNA interaction accounted for 32% of the variance in the proportion of food consumed. One aspect of power was correlated significantly to the proportion of food consumed whereas CNA empathy was not.

CONCLUSIONS: Because eating is the most social of all ADLs and is culturally bound, clinicians need to examine the interactional components of meals within the caregiving dyad when a person with late‐stage dementia fails to ingest adequate nutrients.
Calorie Restriction in Primates: Will It Work and How Will We Know?
Authors: Roth George S. , Ingram Donald K. , Lane Mark A.
Published: April 2015

Dietary caloric restriction is the most robust and reproducible means of slowing aging and extending lifespan and healthspan in short‐lived mammals and lower organisms. Numerous aspects of this paradigm have been investigated in laboratories around the world since its inception more than 60 years ago. However, two questions about calorie restriction remain unanswered to this day: (1) By what mechanism does it work? and (2) Will it work in humans? This review will focus on the latter with particular emphasis on evaluation criteria, current studies in primate models, available data, and plans for actual human caloric restriction interventions.
Incorporating Education on Palliative Care into the Long‐Term Care Setting
Authors: Steel Knight , Ribbe Miel , Ahronheim Judith , Hedrick Hannah , Selwyn Peter A. , Forman Walter , Keay Timothy
Published: April 2015

Approximately one‐third of all Americans will pass through a long‐term care facility before they die, and many who require palliative care will reside there during the final weeks and months of their lives. In order to address this need, the unique characteristics of long‐term care facilities are outlined, and the incentives for all levels of academic institutions to offer education in that setting are presented.
Primary Care of Long‐Stay Nursing Home Residents: Approaches of Three Health Maintenance Organizations
Authors: Reuben David B. , Schnelle John F. , Buchanan Joan L. , Kington Raynard S. , Zellman Gail L. , Farley Donna O. , Hirsch Susan H. , Ouslander Joseph G.
Published: April 2015

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long‐stay nursing home (NH) residents and to compare this care with that of fee‐for‐service (FFS) residents at the same NHs.

DESIGN: Cross‐sectional interviews and case‐studies, including retrospective chart reviews for 1 year.

SETTING: The programs were based in 20 community‐based nursing homes in three regions (East, West, Far West).

PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization.

RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization.

CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems. J Am Geriatr Soc 47:131–138, 1999.
Use of Primary Care Teams by HMOS for Care of Long‐Stay Nursing Home Residents
Authors: Farley Donna O. , Zellman Gail , Ouslander Joseph G. , Reuben David B.
Published: April 2015

OBJECTIVE: To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long‐stay residents of nursing homes.

DESIGN: Using mail survey techniques, 34 Medicare risk‐contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long‐stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs.

PARTICIPANTS: HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes.

MEASUREMENTS: Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs.

RESULTS: Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non‐program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders.

CONCLUSIONS: Survey findings point to the potential importance of formal HMO primary care programs for long‐term nursing home residents, which may expand with growth in the older population and Medicare‐managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible. J Am Geriatr Soc 47:139–144, 1999.