bluuebunny/crossref_metadata_2025 huggingface dataset:
Risk Factors for Serious Injury During Falls by Older Persons in the Community
Authors: Tinetti Mary E. , Doucette John , Claus Elizabeth , Marottoli Richard
Published: April 2015

BACKGROUND: Serious fall injury represents a little studied, yet common and potentially preventable, cause of morbidity and mortality among older persons. We determined the frequency of, and risk factors for, experiencing serious fall injury events among older persons in the community.

SUBJECTS: A representative sample of 1103 community‐living persons aged 72 years and older underwent comprehensive baseline and 1‐year evaluations.

MAIN OUTCOME MEASURES: During a median 31 months of follow‐up, fall data were obtained using fall calendars. Injury data were obtained from telephone interviews and from surveillance of emergency room and hospital records.

RESULTS: At least one fall was experienced by 546 (49%) participants. A total of 123 participants, representing 23% of fallers and 12% of the cohort, experienced 183 serious fall injury events. The factors independently associated with experiencing a serious injury during a fall included cognitive impairment (adjusted odds ratios 2.2; 95% confidence interval 1.5,3.2); presence of at least two chronic conditions (2.0; 1.4,2.9); balance and gait impairment (1.8; 1.3,2.7); and low body mass index (1.8; 1.2,2.5). In a separate analysis, including only subjects who fell, female gender (1.8; 1.1, 2.9) as well as most of the above factors were associated with experiencing a fall injury.

CONCLUSIONS: Several readily identifiable factors appeared to distinguish the subgroup of older fallers at risk for suffering a serious fall injury. These factors should help guide who and what to target in prevention efforts.
Can Physically Restrained Nursing‐Home Residents Be Untied Safely? Intervention and Evaluation Design
Authors: Neufeld Richard R. , Libow Leslie S. , Foley William , White Harry
Published: April 2015

OBJECTIVE: To develop an intervention that will enable nursing home personnel to remove physical restraints from nursing‐home residents safely and cost effectively.

DESIGN: A multicenter prospective pre‐post study.

SETTING: Sixteen high‐restraint‐use nursing homes, four each from California, Michigan, New York, and North Carolina. The 16 facilities has 2075 beds.

INTERVENTION: A 2‐year educational demonstration study, including a 2‐day workshop, specially prepared written and video materials, and telephone and on‐site clinical consultations. Each nursing home designated a nurse to be the clinical coordinator and to lead a multidisciplinary team in conducting a restraint assessment and devising interventions for removal.

OUTCOME MEASURES: We compared pre‐ and post‐study aggregate and individual facility rates of restraint use, incidents and accidents, family attitudes, financial impact, serious injuries, and staff attitudes and work patterns.

CONCLUSION: Preliminary data suggest that this intervention was well received and appears to be effective in achieving restraint‐free care.
Functional Improvement with Vitamin D Replenishment in a Cohort of Frail, Vitamin D‐Deficient Older People
Authors: Gloth F. Michael , Smith Charles E. , Hollis Bruce W. , Tobin Jordan D.
Published: April 2015

OBJECTIVE: To evaluate functional improvement in a population of frail, homebound older persons with low vitamin D status as vitamin D stores improve.

DESIGN: Randomized, controlled intervention study.

SETTING: Subjects' homes and a nursing facility in Baltimore, Maryland.

PARTICIPANTS: The first 32 subjects (community‐dwelling, homebound older subjects from the Johns Hopkins Elder Housecall Program and nursing home residents from the Johns Hopkins Geriatrics Center) entered in a longitudinal study of vitamin D replacement.

MEASUREMENTS: Baseline 25‐hydroxyvitamin D levels were measured and repeated at least 1 month after therapy with either placebo or vitamin D (ergocalciferol). Subjects were also administered the Frail Elderly Functional Assessment (FEFA) questionnaire, an instrument demonstrated to be reliable, valid, and sensitive to small increments of functional change in this population.

MAIN RESULTS: All subjects started with 25‐hydroxyvitamin D levels less than 15 ng/mL. Those subjects whose levels improved by at least 3 ng/mL (> assay coefficient of variation) also demonstrated improvement in FEFA score. Regression analysis between change in FEFA score compared with change in 25‐hydroxyvitamin D was significant (r = .4; P = .02).

CONCLUSIONS: In this cohort of homebound older people, improvement in vitamin D status was associated with functional improvement as measured by the FEFA questionnaire.
Exitatory Amino Acids in Health and Disease
Authors: Thomas Robert Joseph
Published: April 2015

PURPOSE: To review the role of excitatory neurotransmitters in normal mammalian brain function, the concept of excitotoxic neuronal death as an important final common path in a variety of diseases, and modification of excitatory synaptic transmission as an important new pharmacological principle. These principles are discussed, with special emphasis on diseases of importance to older adults.

DATA SOURCES: A MEDLINE search from 1966 to May 1995 was undertaken, as well as a manual search of current issues of clinical and basic neuroscience journals, for articles that addressed glutamate N‐methyl‐D aspartate and/or excitotoxicity.

STUDY SELECTION: A total of 5398 original and 68 review articles were identified that addressed animal and human experimentation relevant to excitotoxic neuronal death. There were 364 articles with potential significance for clinical application identified; 132 of the most recent references are provided.

DATA EXTRACTION: All articles were classified into three categories: general receptor, biology pathogenesis of disease, and pharmacotherapy.

RESULTS: Glutamic and aspartic acids are the physiological mediators of most excitatory synaptic transmission. This is critical to several normal nervous system functions, including memory and long‐term modification of synaptic transmission and nociception. Activation of the inotropic NMDA and non‐NMDA receptors increases transmembrane calcium and sodium fluxes, and the metabotropic glutamate receptor activation results in generation of inositol triphosphate and inhibition of adenylate cyclase. Numerous modulatory sites exist, especially on the NMDA receptor. Nitric oxide, arachidonic acid, superoxide, and intracellular calcium overload are the ultimate mediators of neuronal death. Glutamate re‐uptake transporters belong to a unique family of amino acid transport systems, the malfunction of which is intricately involved in disease pathogenesis. Ischemic stroke, hypoglycemia, Parkinson's disease, alcohol intoxication and withdrawal, Alzheimer's disease, epilepsy, and chronic pain syndromes are only some of the important clinical neurological disorders with a major pathogenic role for the excitatory amino acids.

CONCLUSIONS: Pharmacological manipulation of the excitatory amino acid receptors is likely to be of benefit in important and common diseases of the nervous system. Only a few of the currently available drugs that modify excitatory neurotransmission, such as remacemide, lamotrigine, and tizanidine, have an acceptable therapeutic index. The identification of numerous receptor subtypes, topographic variabilities of distribution, and multiple modulatory sites will provide a true challenge to the neuropharmacologist.
Use of Post‐Hospital Care by Medicare Patients
Authors: Kane Robert L. , Finch Michael , Blewett Lynn , Chen Qing , Burns Risa , Moskowitz Mark
Published: April 2015

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has shortened hospital stays and, as a consequence, has increased the use of post‐hospital care. Medicare coverage provides for various types of post‐hospital care. This paper examines the characteristics of patients, cities, and hospitals associated with discharge to these different types of post‐hospital care.

METHODS: A total of 2248 consecutive Medicare patients having one of five diagnosis related groups (DRGs), who were about to be discharged from 52 hospitals in three cities in 1988–1989, were enrolled in the study. These DRGs comprised approximately one‐eighth of all Medicare hospital discharges and 40% of all Medicare‐paid post‐hospital care. Patients were interviewed in person before discharge and again 6 weeks after discharge. Clinical severity measures were developed from information abstracted from each patient's medical record. For each DRG, multinomial logit regression equations were developed to identify factors associated with the choice of one of four possible discharge locations: home with no formal care, home health care, nursing home care, or rehabilitation.

RESULTS: Discharge location could be predicted correctly in 52 to 71% of cases, depending on the DRG. This level of predictive accuracy was significantly greater than relying on the modal discharge location, which accounted for 33 to 62% of cases. Most of the predictive power came from information gathered at the discharge interview. The variables associated significantly with the discharge location varied with the DRG and location examined. Living alone and functional dependency at discharge were the significant predictors found most often.

CONCLUSIONS: Rather than assuming that everyone is discharged to the modal location, patient discharge location can be predicted. Much of the the explanation can be traced to a few variables such as functional status and living situation. The lack of greater accuracy suggests that factors other than those identified as important by clinical panels are involved in discharge planning for Medicare patients. J Am Geriatr Soc 44:242–250, 1996.
Function and Medical Comorbidity in South Texas Nursing Home Residents: Variations by Ethnic Group
Authors: Mulrow Cynthia D , Chiodo Laura K. , Gerety Meghan B , Lee Shuko , Basu Srabashi , Nelson Deanna
Published: April 2015

OBJECTIVE: To evaluate differences in functional status and burdens of medical conditions in Mexican American and non‐Hispanic white nursing home residents.

DESIGN AND SETTING: Cross‐sectional survey of 17 nursing homes in south Texas.

PARTICIPANTS: A total of 617 older nursing home residents, of whom 366 were Mexican American and 251 were non‐Hispanic white.

MEASURES: Activities of Daily Living (ADL) status abstracted from standard nurses notes and Burden of Disease abstracted from medical records.

RESULTS: Mexican American residents had greater numbers of ADL dependencies and poorer overall ADL scores than non‐Hispanic white residents. This poor functioning was not explained by age, gender, or marital or educational status. The average number of medical conditions was greater, and specific conditions, such as cerebrovascular disease, recent acute infections, diabetes, hypertension, and anemia, were more common in Mexican American residents compared with non‐Hispanic white residents. In models relating function with medical conditions and ethnic group, ADL scores and dependencies were significantly related to bowel and bladder incontinence, cerebrovascular disease, dementia, recent infections, and skin decubiti, but not to ethnic group.

CONCLUSION: Mexican American nursing home residents are more functionally dependent than non‐Hispanic white residents. The difference in function is explained by a greater burden of medical conditions in the Mexican American residents. J Am Geriatr Soc 44:279–284, 1996.
Does Treatment of Asymptomatic Bacteriuria in Older Ambulatory Women Reduce Subsequent Symptoms of Urinary Tract Infection?
Authors: Abrutyn Elias , Berlin Jesse , Mossey Jana , Pitsakis Peter , Levison Matthew , Kaye Donald
Published: April 2015

OBJECTIVE: To determine whether treatment of asymptomatic bacteriuria in older ambulatory women affects the subsequent development of symptoms of urinary tract infection.

DESIGN: A controlled clinical trial.

PARTICIPANTS: Older women not having urinary catheters.

MEASUREMENTS: Urine cultures every 6 months (the same organism at 105 colony‐forming units or more per mL on two midstream urine specimens defined asymptomatic bacteriuria) and questionnaire surveys for the new development of symptoms of urinary tract infection (dysuria, frequency, urgency, low back pain with fever) 1, 3, and 6 months after the initial survey.

RESULTS: Of the 23 initally culture‐positive participants receiving antibiotic treatment for asymptomatic bacteriuria, nine were culture positive at 6 months, which contrasts with 18 of 27 who received no treatment or placebo, P = .05. However, symptoms of urinary tract infection were more common in the antibiotic‐treated group.

CONCLUSION: Antibiotic therapy effectively reduced the subsequent occurrence of positive urine cultures, but symptoms were not reduced. Based on this study of morbidity, previous studies failing to show any relation to mortality, and the cost and complications of antibiotic therapy in the older population, treatment of asymptomatic bacteriuria in older women is contraindicated. J Am Geriatr Soc 44:293–295, 1996.
Minimum Data Set Plus (MDS+) Scores Compared with Scores from Five Rating Scales
Authors: Frederiksen Kirsten , Tariot Pierre , De Jonghe Erik
Published: April 2015

OBJECTIVE: To compare mandated Minimum Data Set Plus (MDS+) ratings of behavior, function, mood, communication, and cognition to ratings of these domains using analogous research instruments.

DESIGN: Cross‐sectional correlational study of criterion‐related validity.

SETTING: Three nursing homes in Rochester, New York.

PARTICIPANTS: Fifty‐two nursing home residents.

MEASUREMENTS: Nursing home staff completed the MDS+ for each subject. Research scales were completed by trained research clinicians, independently of and blinded to the MDS+ results, using the Mini‐Mental State Exam (MMSE), Brief Psychiatric Rating Scale (BPRS), Dementia Mood Assessment Scale (DMAS), Psychogeriatric Dependency Rating Scale (PGDRS), and Physical Signs and Symptoms Scale (PSMS).

RESULTS: MDS+ measures of functional status, cognitive impairment, and communication were highly correlated with comparable research rating scale scores. Pearson correlation between MDS‐functional status and PSMS scores was 0.89, between MDS‐dementia and BPRS Factor 3 (representing cognitive dysfunction) and MMSE scores was 0.85 and 0.77, respectively, and between MDS‐communication and MMSE and PGDRS Item 6 (assessing communication) scores was 0.74 and 0.62, respectively. Behavior and mood scores did not correlate nearly as well with comparable research scale scores. Pearson correlation between MDS‐behavior and PGDRS and BPRS total scores was 0.54 and 0.51, respectively, and between MDS‐mood and BPRS Factor 1 (depression) and DMAS 1–17 subtotal (mood disturbance) scores was 0.20 and 0.20, respectively.

CONCLUSION: This preliminary study in a small sample shows marked agreement between three of the five MDS+ components analyzed and comparable research rating scales and confirms that behavior and mood are difficult to assess with simple instruments. J Am Geriatr Soc 44:305–309, 1996.
Sequential Outbreak of Influenza A and B in a Nursing Home: Efficacy of Vaccine and Amantadine
Authors: Libow Leslie S. , Neufeld Richard R. , Olson Ellen , Breuer Brenda , Starer Perry
Published: April 2015

OBJECTIVE: To describe the sequential occurrence of influenza A and B in a nursing home, and to determine the efficacy of influenza vaccine and/or amantadine treatment with respect to incidence and sequelae.

SETTING: The Jewish Home and Hospital for Aged, a skilled‐care nursing facility.

PARTICIPANTS: Of 499 frail older nursing home residents, 139 contracted influenza during the study period (mean age 87.5 years; SD = 6.7). The residents were followed from February through April 1988.

INTERVENTION: Influenza vaccine and/or amantadine.

MEASUREMENTS: Episodes of influenza and their sequelae, i.e., pneumonia, hospitalization, and death.

RESULTS: The vaccine had no effect on the incidence of influenza‐like illness, length of illness, or the associated death rate. It reduced the rate of pneumonia secondary to influenza A and B (relative risk = .57; 95% CI: .37 to .89; P = .023). Amantadine did not affect the attack rate of influenza nor the rate of pneumonia secondary to influenza. It was associated with decreased mortality (relative risk = 0; P = .001), and shorter length of influenza A illness (PWilcoxon = .082). Although the combination of amantadine and vaccine did not affect length of influenza (A or B) illness, it was associated with a significantly lower rate of sequelae (relative risk = .58; 95% CI: .36 to .95; P = .024).

CONCLUSION: In this epidemic, the combination of amantadine and vaccine was most effective in reducing the rate of influenza‐associated sequelae. The possibility of a “biphasic” epidemic prompts consideration of vaccinating nonimmunized nursing home residents, even though it may be late in the influenza season.
Prognostic Value of Noninvasive Risk Stratification in Younger and Older Patients Referred for Evaluation of Suspected Coronary Artery Disease
Authors: Shaw Leslee J. , Miller D. Douglas , Romeis James C. , Younis Liwa T. , Gillespie Kathleen N. , Kimmey James R. , Chaitman Bernard R.
Published: April 2015

OBJECTIVES: The purpose of this investigation is to explore the relationship of patient gender and age on coronary artery disease diagnostic evaluation and to assess the impact of noninvasive testing results on coronary revascularization rates and cardiac event‐free survival.

STUDY DESIGN: Retrospective observational cohort.

PARTICIPANTS: From a series of 5322 consecutively tested patients from a Midwestern university tertiary medical center, a hospital cohort of 1345 patients with clinically suspected coronary artery disease was enrolled from 1988 through 1989.

MEASUREMENTS AND RESULTS: Cardiac risk factor and symptom profiles were worse in women, whereas rates of positive test results were similar in both sexes. Multivariable‐adjusted risk for follow‐up diagnostic testing was 1.8 and 1.9 times greater, respectively, for men ≤ and > 65 years of age than for women (P < .01). Younger women were 4.9 times (P = .001) more likely to experience a cardiac event than younger men, with no differences between younger and older women (relative risk = 1.1; P > .20). Overall cardiac event rates were 2.3, 7.4, 16.7, and 20.2% for young men, young women, older women, and older men, respectively. Initial screening was delayed 2 to 7 times longer for older and younger women compared with men (P < .001); the greatest delays were observed for younger women. Diagnostic follow‐up and subsequent cost of total care from initial evaluation through 2 years of follow‐up were higher for men than for women (P < .0001), with older women having the lowest rate of subsequent diagnostic and interventional follow‐up. In the highest risk patients, subsequent utilization rates were 40 and 20% higher for younger and older men than for similarly aged women. In particular, diabetics were less likely to undergo follow‐up diagnostic testing and revascularization (67% younger women).

CONCLUSIONS: Age appears to significantly and differently influence decisions regarding noninvasive and invasive medical service utilization in men and women and may partially account for variable outcomes in this and previous gender‐based comparisons.
Patient Factors Associated with Breast Cancer Screening Among Older Women
Authors: Marwill Sandra L. , Freund Karen M. , Barry Patricia P.
Published: April 2015

OBJECTIVES: To identify patient factors that influence physicians' decisions to recommend screening mammograms for older women.

DESIGN: A cross‐sectional survey including clinical case vignettes.

PARTICIPANTS: Random sample of Massachusetts internists, obstetrician/gynecologists, family/general practice physicians, and geriatricians.

OUTCOME MEASURE: Proportion of screening mammograms recommended for women in different versions of each case vignette.

RESULTS: A total of 482 (65%) of the eligible participants responded to a mailed survey of questions about breast cancer screening practices, attitudes toward ACS guidelines, and four clinical vignettes. Vignettes tested the impact of patient's age, cognitive function, nursing home residence, functional limitations, and comorbidity on the physician's decision to recommend a mammogram.

Ninety‐four percent of physicians reported often performing periodic clinical breast exams and mammograms for women aged 65 to 74. For women aged 75 to 84, 89% of physicians reported often performing periodic clinical breast exams, and 79% recommend mammograms. Only 48% strongly agreed with ACS guidelines for annual mammography for women over 65.

Age, dementia, and nursing home residence were patient factors associated with decreased mammogram use, but limited mobility and chronic medical problems were not. Physicians were more likely to recommend a mammogram for a woman aged 65 to 74 than for a woman 75 to 84. (P = .002) Physicians were more likely to recommend a mammogram for a woman without dementia than for a woman with mild dementia (P < .05) and for a woman living with her daughter than a for a woman living in a nursing home (P < .001).

CONCLUSIONS: Age older than 75, mild dementia, and nursing home residence are factors that negatively influence physicians' decisions to recommend mammography. Presence of chronic medical problems and functional limitations do not. Physicians appear to be using implicit judgments about quality of life and age rather than life expectancy based on comorbidity to determine breast cancer screening practices.
Tube Feeding the Demented Nursing Home Resident
Authors: Sheiman Sara L.
Published: April 2015

Despite the many complications and minimal benefits associated with long‐term enteral nutrition in patients with advanced dementia, it is, nevertheless, a widespread practice in nursing homes throughout the United States. This paper presents a review of the literature on dementia, geriatric nutrition, and enteral feeding. There appears to be limited research to support the long‐term benefits and safety of enteral nutrition in advanced dementia. Additionally, it is not yet clear that long‐term enteral nutrition in advanced dementia results in an improved quality of life.
Relationship Between Baseline Insulin‐Like Growth Factor‐I (IGF‐I) and Femoral Bone Density in Women Aged Over 70 Years: Potential Implications for the Prevention of Age‐Related Bone Loss
Authors: Boonen Steven , Lesaffre Emmanuel , Dequeker Jan , Aerssens Jeroen , Nijs Jos , Pelemans Walter , Bouillon Roger
Published: April 2015

OBJECTIVE: To test the hypothesis that the decline in femoral bone mass associated with healthy aging is partially accounted for by deficiency of the growth hormone‐insulinlike growth factor‐I (IGF‐I) axis.

DESIGN: Cross‐sectional study.

STUDY PARTICIPANTS: A sample of 245 community‐dwelling healthy women aged 70 and older. Exclusion criteria were diseases or medications known to affect the musculoskeletal system or the somatotrophic axis.

MEASUREMENTS: Serum levels of IGF‐I, calcitriol, and osteocalcin were determined by radioimmunoassay; serum calcidiol was measured by competitive binding assay, and serum parathyroid hormone (PTH) was assessed immuno‐chemically. Urinary pyridinium crosslinks were measured by fluorescent detection after high‐pressure liquid chromatography. Isometric and isokinetic quadriceps strength was evaluated using an isokinetic dynamometer. Bone density (BMD) was assessed by dual‐energy X‐ray absorptiometry at the proximal femur. Multiple regression was used to adjust for potential confounders.

RESULTS: At the proximal femur, BMD declined by 0.59–0.84% per year. In addition to body mass index and muscle strength, serum IGF‐I was found to be an independent predictor of BMD at all femoral sites.

CONCLUSION: The data support the hypothesis that circulating IGF‐I not only reflects the integrated growth hormone secretion but also has a direct role in the endocrine regulation of bone remodeling. The present findings support the need for further studies to assess the potential of IGF‐I in attenuating age‐related femoral bone loss. J Am Geriatr Soc 44:1301–1306, 1996.
Estrogen Replacement Therapy In Older Women: A Neuropsychological And Brain MRI Study
Authors: Schmidt R. , Fazekas F. , Reinhart B. , Kapeller P. , Fazekas G. , Offenbacher H. , Eber B. , Schumacher M. , Freidl W.
Published: April 2015

OBJECTIVE: To determine if postmenopausal women receiving estrogen perform better on demanding cognitive tests than women without estrogen replacement and if this beneficial effect on cognition is caused by estrogen‐related prevention of silent ischemic brain damage.

DESIGN: Cross‐sectional study comparing postmenopausal estrogen users and non‐users.

SETTING: Austrian Stroke Prevention Study

PARTICIPANTS: A total of 70 women currently using estrogen and 140 women who have never used estrogen from a subset of 222 postmenopausal women without neuropsychiatric or general disease undergoing extensive diagnostic work‐up in a large‐scale stroke prevention study among randomly selected community members.

MEASUREMENTS: Neuropsychological test scores and focal brain abnormalities as well as size of ventricles and cortical sulci as assessed by 1.5 Tesla MRI.

RESULTS: Estrogen users performed better than non‐users on almost all neuropsychological tests administered. When ANCOVA was used to correct for slight differences between groups in age, length of education, mean arterial blood pressure and self‐reported activation, values of P < .05 were noted on tasks assessing conceptualization, attention, and visuopractical skills. After adjustment for multiple comparisons, the differences in conceptualization and visuopractical skills remained significant. MRI showed a lower rate and extent of white matter hyperintensities and a significantly smaller total white matter hyperintensity area in women treated with estrogen (P = .043). The total white matter hyperintensity area was inversely related to the duration of estrogen replacement therapy (P = .040). However, there was no difference in neuropsychological performance between estrogen users with and without white matter abnormalities, and this was also supported by the lack of an association between cognitive test results and the extent of white matter disease.

CONCLUSIONS: Our study demonstrated an association between estrogen replacement therapy and better cognitive functioning and a lower rate of clinically unsuspected ischemic brain damage in postmenopausal women. J Am Geriatr Soc 44:1307–1313, 1996.
Medical Care in Old Age: What Do Nurses in Long‐term Care Consider Appropriate?
Authors: Gillick Muriel R. , Mendes Marc L.
Published: April 2015

OBJECTIVES: To determine whether nurses working in a long‐term care institution, who are knowledgeable about the full range of conditions common among older people, favor limitations of treatment in old age; and to study whether the level of intensity of care they regard as appropriate varies with the overall health status of the older individual.

DESIGN: Participants were asked to complete an intervention‐specific advance directive for themselves, with scenarios representing terminal illness, dementia plus chronic illness, chronic illness in a nursing home resident, chronic illness in a community‐dwelling older person, and a robust, community‐dwelling older person.

SETTING: A 725‐bed long‐term care institution, with residents having a mean age of 88 years and a wide range of physical and cognitive deficits.

PARTICIPANTS: Full‐time nurses at the long‐term care facility were eligible and were given survey instruments; 102 of the 145 eligible nurses completed the questionnaire.

MEASUREMENTS: The unit of analysis is the refusal rate, defined as the mean number of refusals of interventions for each respondent.

MAIN RESULTS: The overall refusal rate for all five scenarios taken together was 72.1%. The refusal rate in the case of terminal illness was 90.9%, in the case of dementia plus chronic illness 81.8%, in the case of dementia in a nursing home 69.1%, for a homebound older person with chronic illness 70.9%, and for a previously healthy 85‐year‐old person living in the community, 50.0% (P < .001).

CONCLUSIONS: Nurses working in a long‐term care institution have strong preferences about limiting a variety of interventions in old age. The greater the degree of physical and cognitive impairment, the more limitations they favor. This suggests the necessity of expanding advance planning to include a discussion of what constitutes appropriate treatment in a broad range of circumstances. J Am Geriatr Soc 44:1322–1325, 1996.
Rehabilitation of the Older Lower Limb Amputee: A Brief Review
Authors: Cutson Toni M. , Bongiorni Dennis R.
Published: April 2015

OBJECTIVE: To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation.

DESIGN: Literature review of articles and reports about lower limb amputation, using key words elderly amputee, rehabilitation, and lower limb amputation, through a computerized Medline Search.

CONCLUSIONS: Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait.

Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (trans‐femoral) amputations has increased, overall postsurgical mortality (10–30%), long term survival (40–50% @ 2 years, 30–40% @ 5 years), and risk of loss of the contralateral leg (15–20% @ 2 years) has not changed significantly since the 1960s.

Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years.

The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person.

Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed.

In addition, comparison of the various rehabilitation protocols and the impact of cardiac testing before rehabilitation are needed. J Am Geriatr Soc 44:1388–1393, 1996.
The Prevention for Elderly Persons (PEP) Program: A Model of Municipal and Academic Partnership to Meet the Needs of Older Persons for Preventive Services
Authors: Reuben David B. , Hirsch Susan H. , Frank Janet C. , Maly Rose C. , Schlesinger Michael S. , Weintraub Nancy , Yancey Sharon
Published: April 2015

OBJECTIVE: To create a program to identify preventive needs for community‐dwelling older persons and incorporate intervention strategies to improve implementation of these services.

DESIGN: Program development and case‐series.

SETTING: Community‐based meal sites, academically administered program.

PARTICIPANTS: Persons 60 years of age or older attending meal sites and their primary care physicians.

MEASUREMENTS: Demographic characteristics, self‐reported preventive health behaviors and services, blood pressure measurement.

RESULTS: During the first 2 years of the program, 927 persons 60 years of age or older were screened. The most common physician‐initiated preventive recommendations were: tetanus booster (72%), aspirin prophylaxis (68%), pneumonia vaccination (61%), and colorectal cancer screening (51%). The most common self‐care recommendations have been: calcium supplementation (54% of women) and breast self examinations (51% of women). As part of the adherence intervention, we were able to complete health educator calls for 600 (65%) subjects. In addition, the physicians of 599 (65%) subjects were contacted either by telephone (n = 496) or by letter only (n = 97).

CONCLUSION: A community‐based preventive services program can identify large numbers of unmet preventive services needs, and a dual intervention strategy aimed at meeting these needs can be delivered successfully to the majority of participants. Implementation rates of specific recommendations and impacts on health outcomes remain to be determined. J Am Geriatr Soc 44:1394–1398, 1996.
Balance and Strength Training in Older Adults: Intervention Gains and Tai Chi Maintenance
Authors: Wolfson Leslie , Whipple Robert , Derby Carol , Judge James , King Mary , Amerman Paula , Schmidt Julia , Smyers Donna
Published: April 2015

OBJECTIVE: To determine the effect on balance and strength of 3 months of intensive balance and/or weight training followed by 6 months of low intensity Tai Chi training for maintenance of gains.

DESIGN: Randomized control intervention. Four groups in 2 × 2 design: Control, Balance, Strength, Balance + Strength, using blinded testers.

SETTING: Exercise and balance laboratory at University of Connecticut Health Center.

PARTICIPANTS: Subjects were 110 healthy community dwellers (mean age 80) who were free of dementia, neurological disease, and serious cardiovascular or musculoskeletal conditions.

INTERVENTIONS: Short‐term training (3 months) occurred 3 times/week (45 minutes Balance and Strength, 90 minutes Balance + Strength). Balance training included equilibrium control exercises on firm and foam surfaces and center‐of‐pressure biofeedback. Strengthening consisted of lower extremity weight‐lifting. All subjects then received long‐term group Tai Chi instruction (6 months, 1 hour, 1 time/week).

MEASUREMENTS: Losses of balance during Sensory Organization Testing (LOB), single stance time (SST), voluntary limits of stability (FBOS), summed isokinetic torque of eight lower extremity movements (ISOK), and usual gait velocity (GVU).

RESULTS AND CONCLUSIONS: Balance training meaningfully improved all balance measures by restoring performance to a level analogous to an individual 3 to 10 years younger: LOB = −;2.0 ± 0.3 (adjusted paired differences, P < .005 ANOVA); SST = 7.0 ± 1.2 sec; and FBOS = 9.0 ± 2.0% of foot length (P < .05). Strengthening increased ISOK by 1.1 ± 0.1 Nm kg−1 (P < .005) There was no interaction between balance and strength training. Significant gains persisted after 6 months of Tai Chi, although there was some decrement.
Exercise with Physically Restrained Nursing Home Residents: Maximizing Benefits of Restraint Reduction
Authors: Schnelle John F. , MacRae Priscilla G. , Giacobassi Karen , MacRae Holden S. H. , Simmons Sandra F. , Ouslander Joseph G.
Published: April 2015

OBJECTIVE: To evaluate an exercise protocol designed to improve strength and mobility, and to decrease injury risk factors in physically restrained nursing home residents.

DESIGN: A randomized controlled trial.

PARTICIPANTS: Ninety‐seven residents were randomized into either exercise or control groups. Thirty‐five exercise and 37 control group residents completed all post‐assessments after a 9‐week trial.

INTERVENTION: Walking or wheelchair movement training was supplemented by rowing exercise three times per week. Practice in behaviors related to safe movement was provided incidental to the exercise.

MEASUREMENT: Endurance, speed, and injury risk measures relevant to walking, wheelchair propulsion, and standing were assessed by standardized protocols. Rowing endurance, rowing range of motion, and handgrip strength measures were collected to assess the effect of the rowing component of the exercise protocol.

RESULTS: Fifty‐four percent of the subjects who provided consent did not complete the protocol because of health status changes, lack of cooperation, or physical limitations that precluded exercise. The subjects who completed the exercise program showed significant improvement on injury risk and measures related to upper body strength (handgrip strength, rowing endurance, wheelchair endurance, and speed). Measures related to lower body strength did not significantly improve.

CONCLUSION: Physically restrained residents are very frail, and it is difficult to implement a long‐term exercise program with many residents because of this frailty. However, a substantial proportion of residents did cooperate well with the exercise program and showed improvement on measures correlated with decreased injury risk. The exercise program could be easily modified to include more lower body exercise, and the resultant protocol would be an important adjunct to restraint reduction programs.
The Change in Serum Protein Concentration in Response to the Stress of Total Joint Surgery: A Comparison of Older Versus Younger Patients
Authors: Puskarich‐May Cheryl L. , Sullivan Dennis H. , Nelson Carl L. , Stroope Henry F. , Walls Robert C.
Published: April 2015

OBJECTIVE: To investigate whether the physiological response to surgery‐induced stress, as measured by changes in serum secretory proteins, is more profound in older than in younger total joint arthroplasty patients.

DESIGN: Retrospective study.

SETTING: A 267‐bed teaching hospital.

PARTICIPANTS: A total of 220 ambulatory patients with normal admission serum albumin levels, of whom 106 were 65 years of age or older (mean age 73.3 ± 6.2 years) and 114 less than age 65 (mean age 48.8 ± 12.2 years).

METHODS: Serum albumin and transferrin levels obtained at admission and on the fifth and tenth postoperative days were compared in the two age groups.

RESULTS: In both age groups, admission serum albumins were significantly higher than on the corresponding postoperative Day 5 levels (40.4 ± 3.7 g/L vs 25.0 ± 3.3 g/L, P < .001 and 39.5 ± 2.5 g/L vs 23.9 ± 3.1 g/L, P < .001 in older and younger patients, respectively). The drop in the serum concentration of albumin by postoperative Day 5 in the older patients was not significantly different from that of the younger patients (a drop of 15.6 ± 3.3 g/L in the older vs 15.4 ± 4.4 g/L for the younger, P = .740). Among the 64 patients who remained in the hospital 10 days subsequent to surgery, the average postoperative Day 10 serum albumin concentration was significantly lower in the older patients when compared with the younger (26.2 vs 29.1 g/L P = .016). Similar results were obtained for serum transferrin.

CONCLUSIONS: Subsequent to elective arthroplasty, the magnitude of change in serum albumin and transferrin concentrations is similar in older compared with younger, patients, suggesting that this stress response to surgery is not age dependent. In contrast, the rate of recovery of the serum protein concentrations to preoperative levels may be slower in the older patients. However, this issue needs to be investigated further.
Patients' Willingness to Accept Life‐Sustaining Treatment When the Expected Outcome is a Diminished Mental Health State: An Exploratory Study
Authors: Mazur Dennis J. , Merz Jon F.
Published: April 2015

OBJECTIVE: To assess patients' willingness to accept life‐sustaining treatment when the expected outcome is a diminished mental health state.

DESIGN: Structured interviews with a consecutive series of patients.

SETTING: A university‐based Department of Veterans Affairs Medical Center.

PATIENTS: One hundred four male patients (mean age = 65.4 years; range 37–82) seen consecutively in a general medicine clinic.

MEASUREMENTS: We assessed the acceptability of temporary ventilatory support for a hypothetical case of severe pneumonia. Patients were asked to consider mental health states involving minor cognitive deficits that varied only in their expected frequency and duration.

RESULTS: All patients except one were willing to accept temporary life support in the management of severe pneumonia. Of these 103 patients, 76 patients specified the number of days they would allow themselves to be continued on intubation and ventilatory support. The length of time varied from 1 day to 2 years and was longer when patients reported having had a stroke or reported being in fair or poor health.

Fifty patients were willing to accept all diminished mental health states, including the most severe state (F). Patients who reported having been in a medical intensive care unit were more likely to accept intubation in the most severe state (F).

CONCLUSIONS: In the case of “severe pneumonia,” about half of our older male veterans reported a willingness to accept intubation and ventilatory support even if it resulted in persistent cognitive disability. These results suggest that experience in a medical intensive care unit with ventilators and experience with strokes may make patients more tolerant of treatments that may result in impaired cognitive function.
Effects of Exercise on Neurobehavioral Function in Community‐Dwelling Older People More Than 75 Years of Age
Authors: Okumiya Kiyohito , Matsubayashi Kozo , Wada Tomoko , Kimura Shigeaki , Doi Yoshinori , Ozawa Toshio
Published: April 2015

OBJECTIVE: We evaluated the effects of exercise on neurobehavioral function in healthy older people more than 75 years of age.

DESIGN: A randomized controlled trial with 6‐month follow‐up was conducted.

SETTING: The study was performed in the rural town of Kahoku, Japan, the population of which is considered representative of the older popuration of Japan.

PARTICIPANTS: We studied 42 healthy volunteers (18 men and 24 women; mean age, 79 years (range, 75 to 87 years)) who were randomly assigned to one of two groups, exercise or control.

INTERVENTION: Subjects assigned to the exercise group were instructed to exercise for 60 minutes twice a week for 6 months. Subjects in the control group were not instructed to engage in any specific exercise regimen.

MEASUREMENTS: The following measurements were recorded for both groups at baseline and at 6‐month follow‐up: (1)Neurobehavioral function as determined by the following tests: Mini‐Mental State Exam (MMSE), Hasegawa Dementia. Scale Revised (HDSR), Visuospatial Cognitive Performance Test (VCP‐test), Button score, Up & Go test, and Functional Reach; and (2)Body mass index and blood pressure.

RESULTS: The effects of exercise were shown in the Up & Go test and Functional Reach (ANOVA with repeated measures).

CONCLUSION: This study demonstrates the acceptability and effectiveness of exercise on neurobehavioral function, even in older people more than 75 years of age.
Low TSH Levels in Nursing Home Residents Not Taking Thyroid Hormone
Authors: Drinka Paul J. , Amberson John , Voeks Susan K. , Schomisch Jerry , Schirz Paul , Christensen Dean
Published: April 2015

BACKGROUND: Many practitioners perform a thyroid stimulating hormone (TSH) assay as a screening test in older patients. The introduction of sensitive TSH assays with lower normal limits has created a laboratory abnormality that is often of uncertain significance. Mechanisms include autonomous overproduction of thyroid hormone, nonthyroidal illness including medication effects, and hypothalamic/pituitary dysfunction.

OBJECTIVE: To characterize the clinical status and course of nursing home residents with low TSH and normal total T4 levels in the absence of treatment with thyroid hormone.

DESIGN: Retrospective chart review was performed to determine participants status at the time of the low TSH level, with additional recording of follow‐up thyroid hormone levels, cardiac rhythm, and mortality. Mortality was compared with that of a control group matched for age and sex.

SETTING: A nursing home for veterans and their spouses.

MAIN RESULTS: Forty subjects with low TSH and initially normal total T4 were identified. Only three subjects were subsequently diagnosed as hyperthyroid. TSH levels of 18 subjects subsequently normalized, and four additional subjects had low total T3 levels suggesting a nonthyroidal mechanism. Seven subjects died during the first 4 months of follow‐up compared with three in a control group (P < .001). Nine of the 40 subjects had a history of or current atrial fibrillation. No new atrial fibrillation was documented during 388 months of EKG follow‐up.

CONCLUSIONS: Low total T3 levels, TSH normalization, and excess mortality suggest that nonthyroidal illness plays a role in the pathogenesis of low TSH determinations in the nursing home. Autonomous production of thyroid hormone also plays a role. We believe that the term “subclinical hyperthyroidism” should be used only if the clinician believes that autonomous overproduction of thyroid hormone is the cause of a low TSH level. If subsequent research shows correctable adverse consequences associated with subclinical hyperthyroidism from autonomous overproduction of thyroid hormone, a more aggressive diagnostic approach will be needed to define the mechanism of a low TSH level at the time of its discovery.
Prevalence of Appropriate and Inappropriate Indications for Use of Digoxin in Older Patients at the Time of Admission to a Nursing Home
Authors: Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of digoxin use and appropriate and inappropriate indications for digoxin use in older patients at the time of admission to a nursing home.

DESIGN: In a prospective study of 500 consecutive patients aged 60 years of age or older admitted to a nursing home, 96 (19%) patients were receiving digoxin at the time of admission to the nursing home. Appropriate and inappropriate indications for digoxin use were investigated in these 96 patients.

SETTING: A large, long‐term health care facility where 500 consecutive older patients were studied.

PATIENTS: The 500 patients included 344 women and 156 men, mean age 81 ± 8 years (range 60–100).

MEASUREMENTS AND MAIN RESULTS: Ninety‐six of the 500 patients (19%) were receiving digoxin at the time of admission to the nursing home. Fifty‐one (53%) of the 96 patients receiving digoxin had an appropriate indication for digoxin use, and 45 (47%) had an inappropriate indication for digoxin use. Appropriate indications for digoxin use included atrial fibrillation with or without congestive heart failure (CHF) in 35 patients (36%) and CHF with sinus rhythm and abnormal left ventricular (LV) ejection fraction in 16 patients (17%). Inappropriate indications for digoxin use included CHF with sinus rhythm and normal LV ejection fraction in 18 patients (19%), misdiagnosis of edema or dyspnea as CHF in patients with sinus rhythm and normal LV ejection fraction in 17 patients (18%), history of possible (undocumented) paroxysmal atrial fibrillation in nine patients (9%), and sinus tachycardia in one patient (1%). Two of the 45 patients (5%) inappropriately treated with digoxin had evidence of digitalis toxicity on their admission electrocardiogram.

CONCLUSIONS: The prevalence of digoxin use was 19% in older patients at the time of admission to the nursing home. Almost half of patients (47%) receiving digoxin at the time of admission had an inappropriate indication for digoxin use at that time.