bluuebunny/crossref_metadata_2025 huggingface dataset:
Acute Stroke in Very Old People: Clinical Features and Predictors of In‐Hospital Mortality
Authors: Arboix Adrià. , García‐Eroles L. , Massons J. , Oliveres M. , Targa C.
Published: April 2015

OBJECTIVES: To examine demographic characteristics, clinical features, neuroimaging data, and outcome of all acute stroke events occurring in individuals aged 85 years or older.

DESIGN: Collection of data from a prospective hospital‐based stroke registry.

SETTING: Between January 1986 and December 1995, the data was collected of 2,000 stroke patients admitted consecutively to the department of neurology (having 25 beds and an acute stroke unit) of Sagrat Cor‐L'Alianza Hospital of Barcelona (an acute care, 350‐bed teaching hospital serving a population of approximately 250,000).

PARTICIPANTS AND MEASUREMENTS: For the purpose of this study, very old patients (aged 85 years or older) were selected (n = 262). The data of very old stroke patients were compared with the data of patients younger than 85 years of age (n = 1738). Predictors of in‐hospital mortality based on clinical and neuroimaging variables were recorded within 48 hours of stroke onset, and outcome variables (medical complications that developed during hospitalization) were assessed by multiple regression analysis.

RESULTS: The very old patients showed a significantly greater frequency of atherothrombotic (27.5% vs 21.9%, P < .05) and cardioembolic infarctions (24.4% vs 26.3%, P < .001) and a lesser frequency of stroke of unusual cause. Acute stroke in the very old patients was more severe than in patients younger than 85 years of age, with greater rates of in‐hospital mortality (27% vs 13.5%, P < .001), longer duration of hospital stay (22.03 ± 29.6 vs 17.5 ± 21.5 days, P < .001), and lesser frequency of absence of neurologic deficit at the time of hospital discharge (21.4% vs 33.1%, P < .001). Altered consciousness, limb weakness, sensory symptoms, involvement of the parietal lobe and temporal lobe, involvement of the internal capsule (with a protective effect), intraventricular hemorrhage, cardiac events, and respiratory events were selected as independent predictors of in‐hospital mortality in the multivariate analysis.

CONCLUSIONS: Very old patients with acute stroke showed a differential clinical profile, different frequency of stroke subtypes, and a poorer outcome compared with stroke patients who were younger than 85 years of age. Clinical and neuroimaging factors that are indicative of the severity of stroke and that were available at the time of the initial diagnosis and at the time of the development of cardiac and respiratory complications showed a predominant influence on in‐hospital mortality and may help clinicians to establish prognosis more accurately. J Am Geriatr Soc 48: 36–41, 2000.
Comparison of Rectal and Infrared Ear Temperatures in Older Hospital Inpatients
Authors: Smitz Simon , Giagoultsis Theodora , Dewé Walthère , Albert Adelin
Published: April 2015

OBJECTIVES: To assess the agreement between infrared emission detection (IRED) ear and rectal temperatures and to determine the validity of IRED ear thermometry in detecting rectal fever.

DESIGN: Prospective, convenience sample, unblinded study.

SETTING: An acute geriatric unit (teaching hospital) and a multidisciplinary intensive care unit.

PARTICIPANTS: The study included 45 inpatients (26 women and 19 men), aged 78.3 ± 6.9 years, admitted over a 4‐month period. Twelve of the patients were definitely infected.

MEASUREMENTS: Sequential rectal (RT) and ear temperature (ET) measurements were performed using mercury‐in‐glass and IRED ear thermometers, respectively. IRED ear temperatures were measured at both ears (unadjusted mode), with the highest of six ear temperatures considered the true value.

RESULTS: Mean RT (37.39°C ± 0.52°C) was significantly (P < .001) higher than mean ET (36.89°C ± 0.59°C). A highly significant positive correlation was found between RT and ET (slope = 0.69; 95% CI, 0.52–0.86; P < .001; r = 0.78). The mean bias (mean of the differences) between RT and ET was 0.50°C ± 0.37°C (95% CI, 0.41°C‐0.59°C), and the 95% limits of agreement −0.22°C and 1.23°C (95% CI, −0.38°C to 1.39°C). According to the standard criterion (RT ≥ 37.6°C), 14 patients were febrile. Using an optimum IRED ear fever threshold (37.2°C), the sensitivity and specificity of IRED ear thermometry for predicting rectal fever were 86% and 89%, respectively (positive predictive value, 80%; negative predictive value, 93%).

CONCLUSIONS: The degree of agreement between rectal temperature and the highest of six IRED ear temperatures was acceptable. Using an optimal IRED ear fever threshold of 37.2°C (99°F), IRED ear thermometry had acceptable sensitivity and specificity for predicting rectal fever. J Am Geriatr Soc 48: 63–66, 2000.
In the Steps of Giants: The Early Geriatrics Texts
Authors: Chase Peter , Mitchell Kathleen , Morley John E.
Published: April 2015

This article briefly reviews some of the major early geriatric textbooks of the last two centuries. Among the more important are books by George Day, Charcot, Nascher, Worcester, and Cowdry. Lord Amulree's book Adding Life to Years has become a watchword of modern geriatrics. It is of interest that during this time period the basic plea for high touch care of older patients and the lament that physicians have little knowledge of the needs of older patients has remained remarkably constant. J Am Geriatr Soc 48: 89–94, 2000.
Dying with End Stage Liver Disease with Cirrhosis: Insights from SUPPORT
Authors: JD Katalin Roth , MD Joanne Lynn , PhD Zhenshao Zhong , MD Marie Borum , Dawson Neal V.
Published: April 2015

OBJECTIVES: To understand patterns of care and end‐of‐life preferences for patients dying with end stage liver disease with cirrhosis (ESLDC).

METHODS: Data were collected during the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), a prospective cohort study of seriously ill hospitalized adults at five teaching hospitals in the United States, and included all patients enrolled in SUPPORT with ESLDC.

RESULTS: Of 575 patients with ESLDC, 166 died during index hospitalization, and 168 died in the following year. The majority were male (65%) and white (80%); the median age was 52 years. Most rated their quality of life as poor or fair, and multiple comorbidities were common. Most spent their last few days completely disabled. Families often reported loss of most income and the need to leave work or other activities in order to care for patients. Pain was at least moderately severe most of the time in one‐third of patients. End‐of‐life preferences were not associated with survival. Most patients (66.8%) preferred CPR, but DNR orders and orders against ventilator use increased near death.

CONCLUSIONS: Patients with liver disease were young, likely to be male, and often had low incomes. The high burden of pain was comparable to that reported for patients with lung and colon cancer. Persons dying with liver disease may benefit from increased attention to relief of symptoms, improved home care, and advanced care planning.
Dying with Lung Cancer or Chronic Obstructive Pulmonary Disease: Insights from SUPPORT
Authors: Claessens Michael T. , Lynn Joanne , Zhong Zhenshao , Desbiens Norman A. , Phillips Russell S. , Wu Albert W. , Harrell Frank E. , Conno Alfred F.rs
Published: April 2015

CONTEXT: Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient.

OBJECTIVE: To compare the course of illness and patterns of care for patients with non‐small cell lung cancer and severe COPD.

DESIGN: Prospective cohort study of seriously ill, hospitalized adults.

SETTING: Five teaching hospitals in the United States.

PATIENTS: Patients with Stage III or IV non‐small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008).

MAIN OUTCOME MEASURES: Patients' preferences for pattern of care and for ventilator use; symptoms; life‐sustaining interventions; and survival prognoses.

RESULTS: Sixty percent in each group wanted comfort‐focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28% of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2‐month and 6‐month survival prognoses, even days before death.

CONCLUSIONS: Hospitalized patients with lung cancer or COPD preferred comfort‐focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life‐sustaining interventions, and short‐term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life‐sustaining interventions.
Description of the SUPPORT Intervention
Authors: Murphy Patricia , Kreling Barbara , Kathryn Erica , Stevens Marguerite , Lynn Joanne , Dulac Jennie
Published: April 2015

BACKGROUND: The purpose of Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was to improve outcomes for seriously ill hospitalized adults by improving information and decisionmaking. The SUPPORT intervention has been characterized only briefly in previous publications.

OBJECTIVE: To characterize the intervention in SUPPORT and its implementation.

DESIGN: Reports derived from training and administrative materials, quantitative descriptions of implementation activities, and qualitative analysis of narrative reports and focus group participation by the intervention nurses.

SETTING AND PATIENTS: SUPPORT enrolled 2652 patients in the intervention arm and 2152 in the control arm of a block‐randomized trial of enhanced information, counseling, and support. The patients were hospitalized with one of nine serious illnesses in one of five US teaching hospitals between 1992 and 1994.

MEASUREMENTS: (1) Reports on training and supervisory materials; (2) Rates of intervention component completion from contact logs and reports completed by the intervention nurses; and (3) grounded theory analysis of patient narratives, overview questionnaires, and focus group transcripts from the intervention nurses.

RESULTS: Prognostic reports were delivered on time to the caregiving team in 83% of cases on Day 3. Reports of surrogate interviews of patient preferences and understanding were delivered on time to the caregiving team in 72% of first week cases. Patients' own reports of preferences were unavailable for 56% of cases in the first week. Overall, 39% of the rest of the patients had their interview information delivered on time to the caregiving team. The SUPPORT intervention nurses averaged 8.5 contacts with patients, 7.6 with surrogates, 3.5 with physicians, and 11.7 with other staff. The intervention nurses felt that they were fully involved in 81% of cases and had a limited role in another 14%. The major issues for patients were: understanding their situation, communication and decision‐making, advance planning, do not resuscitate orders, and general support, including support for loss and grieving. The narrative sources showed that the nurses were enthusiastic, dedicated, and strong in their support of the study objectives. They identified various barriers to effectiveness and voiced doubt that the analytic targets would show an effect from the intervention.

CONCLUSIONS: The SUPPORT intervention was implemented vigorously and completely.
Prediction of Survival for Older Hospitalized Patients: The HELP Survival Model
Authors: Teno Joan M , Harrell Frank E. , Knaus William , Phillips Russell S. , Wu Albert W. , Connors Alfred , Wenger Neil S. , Wagner Douglas , Galanos Anthony , Desbiens Norman A. , Lynn Joanne
Published: April 2015

OBJECTIVE:To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older.

DESIGN:A prospective cohort study with mortality follow‐up using the National Death Index.

SETTING:Four teaching hospitals in the US.

PARTICIPANTS:Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery.

MEASUREMENTS:A log‐normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care.

RESULTS:A total of 1266 patients were enrolled over a 10‐month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow‐up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver‐operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log‐normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time.

A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly.

CONCLUSIONS:Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.
Length of Stay and Therapeutic Intervention Allow Estimation of In‐Hospital Resource Use Independent of Site and Inflation
Authors: Alzola Carlos , Lynn Joanne , Wagner Douglas , Wu Albert W.
Published: April 2015

OBJECTIVES:To develop and evaluate a model to estimate inpatient resource utilization for seriously ill patients using periodic medical record abstraction and hospital length of stay.

DESIGN:A prospective cohort study of prognoses and preferences and outcomes of seriously ill hospitalized adults. The predictive model was based on the Therapeutic Intervention Scoring System (TISS), length of stay (LOS), and hospital site, and was developed on Phase I data and validated on Phase II data.

SETTING:Five teaching hospitals in the United States

PARTICIPANTS:The derivation sample included 4301 patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). The validation sample included 4804 patients.

MEASUREMENTS:Hospital charges were correlated with the product of hospital length of stay and average score from the TISS. Model fit assessment usedR2for total hospital charges.

RESULTS:The correlation between hospital charges and the final model, after adjusting for site differences, was 0.86. The correlation was similar when validating the model in an independent data set.

CONCLUSIONS:We present a method to estimate hospital resource utilization that is independent of site and inflation and can estimate actual costs in multiyear, multisite research endeavors.
Communication and Decision‐Making in Seriously Ill Patients: Findings of the SUPPORT Project
Authors: Covinsky Kenneth E. , Fuller Jon D. , Yaffe Kristine , Johnston C. Bree , Hamel Mary Beth , Lynn Joanne , Teno Joan M. , Phillips Russell S.
Published: April 2015

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most comprehensive efforts to describe patient preferences in seriously ill patients, and to evaluate how effectively patient preferences are communicated. Our objective was to review findings from SUPPORT describing the communication of seriously ill patients' preferences for end‐of‐life care.

METHODS: We identified published reports from SUPPORT describing patient preferences and the communication of those preferences. We abstracted findings that addressed each of the following questions: What patient characteristics predict patient preferences for end of life care? How well do physicians, nurses, and surrogates understand their patients' preferences, and what variables are correlated with this understanding? Does increasing the documentation of existing advance directives result in care more consistent with patients' preferences?

RESULTS: Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in ADL function are less likely to want CPR. However, there is considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patient's preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient's age, the physician's specialty, and the geographic site of care were strong determinants of whether DNR orders were written. In SUPPORT patients, there was no evidence that increasing the rates of documentation of advance directives results in care that is more consistent with patients' preferences.

CONCLUSIONS: SUPPORT documents that physicians and surrogates are often unaware of seriously ill patients' preferences. The care provided to patients is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end‐of‐life care may require systematic change rather than simple interventions.
The Effects of Patient Race on Outcomes in Seriously Ill Patients in SUPPORT: An Overview of Economic Impact, Medical Intervention, and End‐Of‐Life Decisions
Authors: Borum Marie L. , Lynn Joanne , Zhong Zhenshao
Published: April 2015

BACKGROUND: Black Americans have significantly lower life expectancy than white Americans. Racial differences in medical access, management, and DNR orders have been documented.

OBJECTIVE: To review the effects of patient race on intervention and end‐of‐life decisions in seriously ill patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN: Review of published analyses from SUPPORT.

SETTING: Five teaching hospitals

PARTICIPANTS: A total of 9105 patients aged 18 years or older (15% black race) meeting diagnostic and illness severity criteria.

MEASUREMENT: Analysis of data collected by chart abstraction and interviews.

RESULTS: Blacks reported significant loss in savings, although adjusting for diagnosis and disease severity did not demonstrate significant racial differences. Economic hardship was associated with a preference for comfort care, except in black patients (OR 0.71; CI 95%, 0.57‐0.88). Blacks received less intervention with no significant difference in survival. Pain level and control were not affected by race. Blacks were more likely to want CPR, although adjustment for self‐pay or Medicaid eliminated racial differences. Blacks were more likely to continue to prefer CPR 2 months after hospitalization (28% vs 17%) and were more likely to change a DNR order to preferring CPR (40 vs 27%). Blacks also more frequently wished to discuss CPR preferences with their physicians but were less likely to have this type of communication (OR 1.53; CI 95%, 1.11‐2.11).

CONCLUSIONS: Patient race may impact on medical intervention and preferences in seriously ill patients. However, in this population, the differences are of modest clinical importance.
Insights About Dying from the SUPPORT Project
Authors: Freeborne Nancy , Lynn Joanne , Desbiens Norman A.
Published: April 2015

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) project was a study of 9105 seriously ill patients, 4274 of whom died within 6 months. HELP, the Hospitalized Elderly Longitudinal Project, was an ancillary study, in four of the five SUPPORT hospitals, of 1286 persons aged 80 years and older, 321 of whom died within 6 months. This paper reviews the SUPPORT and HELP literature to bring together insights concerning the time near death of seriously ill patients.

METHODS: We reviewed published reports from SUPPORT and HELP, specifically, demographics of dying; characteristics of a prognostic model to estimate survival; patient symptoms near death; patient preferences and decision‐making near death; ineffectiveness of the SUPPORT intervention; costs of dying while seriously ill; and the impact of serious illness on the family. We also compared and contrasted the experience of patients with different conditions.

RESULTS: Patients in SUPPORT who died were typically younger than age 75. Most SUPPORT patients who died were male and most had an income of less than $11,000, although the older patients in HELP were even more likely to have had such low incomes. Patients with cirrhosis were much younger than most decedents, and patients with cancer were less often poor. Most had serious symptoms close to death. The place of death was more closely related to hospital bed supply than to decisions made by healthcare providers or individual patient preferences or characteristics. Prognosis near death was quite uncertain, especially in patients with heart and lung failure.

CONCLUSIONS: Although SUPPORT aimed to describe and compare decision‐making affecting seriously ill patients, it also illuminated many other aspects of their course near death.
Age Differences in Care Practices and Outcomes for Hospitalised Patients with Cancer
Authors: Rose Julia Hunnum , O'Toole Elizabeth E. , Dawson Neal V. , Thomas Charles , Connors Alfred F. , Wenger Neil S. , Phillips Russell S. , Hamel Mary Beth , Cohen Harvey J. , Lynn Joanne
Published: April 2015

OBJECTIVE:To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy.

DESIGN:Prospective cohort study (SUPPORT project).

SETTING:Five United States teaching hospitals; data was gathered between 1989 and 1994.

SUBJECTS:Nine hundred twenty five older (age ≥ 65 years), 983 middle aged (age = 45–64 years), and 274 younger (age = 18–44 years) hospitalized patients receiving care for non‐small cell lung cancer, colon cancer metastasized to the liver, or multi‐organ system failure associated with malignancy.

MEASUREMENTS:Care practices and patient outcomes were determined from hospital records. Length of survival was identified using the National Death Index. After adjusting for important variables, including severity of illness (i.e., SUPPORT model estimate for 2‐month survival, cancer condition), hospital site, selection to intervention and sociodemographic variables, age group differences in care practices and outcomes were identified using general linear models.

RESULTS:Older patients with cancer had lower resource utilization during hospitalization (P< .04) and were less likely to receive cancer‐related treatments (i.e., chemotherapy, platelet infusions, scheduled intravenous medications) than middle‐aged and young‐adult patients in the first week of hospitalization (P≤ .01). More care topics were discussed with older patients and their families then with younger patients and their families (P< .001). Length of stay and total hospital costs were lower for older and middle‐aged patients than for younger patients. Although more older patients had discussions about transfer to hospice (P< .001), older patients were no more likely to be discharged with supportive care (inpatient hospice or home with home/hospice care). Older patients died sooner than middle‐aged patients (P< .01).

CONCLUSIONS:Patient age influenced care decisions and outcomes. Older patients (age ≥ 65 years) received less aggressive care, had more discussions about care decisions, and died sooner than younger patients with cancer. Younger patients had longer stays, higher hospital costs, and greater probability of rehospitalization. Although well over half of patients died within 6 months of hospitalization, few patients in any age group were discharged with supportive care. Future studies should examine age differences in palliation, as well as acute care of cancer patients across inpatient and ambulatory care settings and should assess quality of care at the end of life.
Physician Understanding Of Patient Resuscitation Preferences: Insights and Clinical Implications
Authors: Wenger Neil S. , Phillips Russell S. , Teno Joan M. , Oye Robert K. , Dawson Neal V. , Liu Honghu , Califf Robert , Layde Peter , Hakim Rosemarie , Lynn Joanne
Published: April 2015

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in‐hospital CPR.

DESIGN: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician‐patient communication with physician understanding of patient CPR preferences. Among patients preferring to forgo CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician.

PATIENTS/SETTING: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments.

GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forgo CPR. Younger patient age, higher physician‐estimated quality of life, and higher physician prediction of 6‐month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forgo CPR. Physicians who spoke with patients about resuscitation and had longer physician‐patient relationships understood patients' preferences to forgo CPR more often. Patients whose physicians understood their preference to forgo CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation.

CONCLUSIONS: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forgo CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forgo CPR but whose wishes are not understood by their physician may receive unwanted treatment.
Living and Dying with Chronic Obstructive Pulmonary Disease
Authors: Lynn Joanne , Ely E. Wesley , Zhong Zhenshao , McNiff Kristin Landrum , Dawson Neal V. , Connors Al , Desbiens Norman A. , Claessens Michael , McCarthy Ellen P.
Published: April 2015

OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life.

STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

SETTING: Hospitalization for exacerbation of COPD at five US teaching hospitals.

PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled.

METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier.

OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families.

RESULTS: One‐year survival was 59%, 39% had ≥3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19‐ 0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated.

One‐quarter of patients had serious pain throughout, and two‐thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do‐Not‐Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%.

CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.
A Randomized Controlled Trial of Exercise to Improve Outcomes of Acute Hospitalization in Older Adults
Authors: Siebens Hilary , Aronow Harriet , Edwards Diane , Ghasemi Zahra
Published: April 2015

OBJECTIVE: Older adults hospitalized for nondisabling diagnoses can lose functional ability. Lack of exercise or physical activity during the acute illness and recovery may be contributory. This study evaluated whether increased exercise in hospital and afterward would shorten length of stay and improve physical function at 1 month.

DESIGN: A randomized controlled trial.

SETTING: A 700‐bed community‐based hospital with academic and teaching programs.

PARTICIPANTS: Three hundred patients (mean age 78.2 years ± 5.6) with nondisabling medical and surgical diagnoses who were admitted to an acute care hospital between December 1990 and April 1992. All patients had an expected length of stay 5 or more days, were ambulatory before admission, and were not expected to die within 12 months.

INTERVENTION: A hospital‐based general exercise program was administered to intervention patients along with encouragement to continue the program, self‐administered, at home.

MEASUREMENTS: The primary outcome was hospital length of stay. Secondary outcomes at 1 month post‐discharge included measures of physical function and other general health indicators.

RESULTS: There was no significant difference in length of stay between treatment and control groups controlling for baseline characteristics and diagnoses. The intervention was associated with better function in instrumental activities of daily living (β = .433 (95% CI, 0.044–0.842)) at 1 month but no change in perceived general health status and other measures of physical function.

CONCLUSIONS: An exercise program started during hospitalization and continued for 1 month did not shorten length of stay but did improve functional outcome at 1 month.
Comparison of Informal Caregiving by Black and White Older Adults in a Community Population
Authors: McCann Judith J. , Hebert Liesi E. , Beckett Laurel A. , Morris Martha Clare , Scherr Paul A. , Evans Denis A.
Published: April 2015

OBJECTIVES: To examine the prevalence of informal caregiving and demographic factors associated with caregiving time in older community residents and compare caregiving prevalence and time spent providing care by black and white residents.

DESIGN: A cross‐sectional, population‐based study.

SETTING: The study was conducted as part of the Chicago Health and Aging Project (CHAP) in a geographically defined community of black and white residents aged 65 and older.

PARTICIPANTS: Participants were 5924 community residents (61.4% black; 38.6% white) who answered questions about informal caregiving responsibilities during a structured interview about a broad range of health and social factors.

METHODS: Data were collected during an in‐home interview. Multiple logistic and linear regression models were used to examine the association between caregiving and race, gender, age, marital status, and education.

RESULTS: More than 16% of residents had provided care to others during the previous 12 months, and 10.3% were currently providing care. Compared with whites, blacks were 30% more likely to be caregivers, spent almost 13 more hours each week in caregiving activities, and were more likely to assist friends. The probability of caregiving increased significantly with age for married persons, decreased with age for unmarried persons, and was lower for men compared with women. The time spent providing care each week increased significantly with age for married persons and did not differ between men and women.

CONCLUSIONS: Although physicians and other healthcare providers typically view older people as the recipients of informal care, individuals older than age 65 provide a substantial amount of care to others with health problems and disability. Most research has focused on the needs of young and middle‐aged caregivers, and little is known about the needs of these older caregivers. Future research should use sampling strategies that provide adequate numbers of white and non‐white participants for meaningful comparisons. This will permit identification of racial and cultural differences in caregiving so that interventions can be tailored to specific groups.
Subsystems Contributing to the Decline in Ability to Walk: Bridging the Gap Between Epidemiology and Geriatric Practice in the InCHIANTI Study
Authors: Ferrucci Luigi , Bandinelli Stefania , Benvenuti Enrico , Di Iorio Angelo , Macchi Claudio , Harris Tamara B. , Guralnik Jack M
Published: April 2015

BACKGROUND: Older patients are often referred to geriatricians because of complaints of progressive difficulties in walking. The diagnostic and therapeutic approach to these patients is complex. Multiple physiologic subsystems may influence the ability to walk, and no standard criteria are currently available to establish whether these subsystems are functioning within the normal range. To address this lack of knowledge we conducted the InCHIANTI study.

OBJECTIVE: To identify measures that clinicians can use to understand the causes of walking difficulties in older persons.

DESIGN: A population‐based study of persons living in the Chianti geographic area (Tuscany, Italy).

PARTICIPANTS: 1453 persons (age‐range 20–102 years; 91.6% of the eligible) selected from city registry of Greve in Chianti and Bagno a Ripoli (Tuscany, Italy), using a multistage sampling method.

MEASUREMENTS: Factors that influence walking ability were classified into six main physiologic subsystems: central nervous system, perceptual system, peripheral nervous system, muscles, bone/joints, and energy production/delivery. Measures of the integrity and functioning of each of these proposed subsystems were identified and administered to all participants.

CONCLUSIONS: Data collected in InCHIANTI will be used to identify the main risk factors that influence loss of the ability to walk in older persons, to define physiologic subsystems that are critical for walking, to select the best measures of their integrity, and to establish critical ranges in these measures that are compatible with “normal” walking ability. The final goal is to translate epidemiological research into a geriatric clinical tool that makes possible more precise diagnosis and more effective treatment in patients with walking dysfunction.
Returning to the Bedside: Using the History and Physical Examination To Identify Rotator Cuff Tears
Authors: Litaker David , Pioro Mathilde , Bilbeisi Hazem El , Brems John
Published: April 2015

OBJECTIVES: To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT).

DESIGN: Retrospective chart review

SETTING: Orthopedic practice limited to disorders of the shoulder

PARTICIPANTS: 448 consecutive patients with suspected RCT referred for arthrography over a 4‐year period

MAIN OUTCOME MEASURE: Presence of partial or complete RCT on arthrogram

RESULTS: 301 patients (67.2%) had evidence of complete or partial RCT. Clinical findings in the univariate analysis most closely associated with rotator cuff tear included infra‐ and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), arc of pain (P = .004), and impingement sign (P = .01). Stepwise logistic regression based on a derivation dataset (n = 191) showed that weakness with external rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age ≥ 65 (AOR 4.05 (2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five‐point scoring system developed from this model was applied in the remaining patient sample (n = 216) to test validity. No significant differences in performance were noted using ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT to the diagnostic prediction of an expert clinician. This score had specificity equivalent to magnetic resonance imaging or ultrasonography in diagnosis of RCT.

CONCLUSIONS: The presence of three simple features in the history and physical examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromising sensitivity or specificity.
Misclassification of High‐Risk Older Subjects Using Waist Action Levels Established for Young and Middle‐Aged Adults—Results from the Rotterdam Study
Authors: Molarius Anu , Seidell Jacob C. , Visscher Tommy L.S. , Hofman Albert
Published: April 2015

OBJECTIVES: In the literature, cutoff points based on waist circumference (waist action levels) have been suggested to replace cutoff points based on body mass index (BMI) and waist‐hip ratio (WHR) in identifying subjects who are overweight or obese and/or with central fat distribution. These cutoff points have been based on analysis in mainly middle‐aged and younger adults. In this article, we examine the applicability of the suggested waist action levels in an older population.

PARTICIPANTS: A total of 6423 men and women aged 55 or over participating in the Rotterdam Study, a population‐based cohort study.

MEASUREMENTS: Sensitivities and specificities of the proposed waist action levels in relation to the cutoff points for BMI and WHR were calculated. Also, cardiovascular risk factor levels at baseline examination in the different categories defined by high/low waist circumference, BMI and WHR were investigated.

RESULTS: At waist action level 1 (waist circumference ≥94 cm in men, ≥80 cm in women), sensitivity was 71% in men and 86% in women for detecting those with high BMI (≥25 kg/m2) and/or WHR (≥0.95 in men, ≥0.80 in women). At waist action level 2 (waist circumference ≥102 cm in men, ≥88 cm in women in comparison with BMI ≥30 kg/m2 and/or WHR ≥0.95 in men, ≥0.80 in women), sensitivity was considerably lower: 35% in men and 59% in women. This was mainly due to a large proportion of subjects with low waist and BMI but high WHR. Specificity was high (>90%) at both action levels. Cardiovascular disease risk factors, except smoking, tended to increase with increasing waist circumference, WHR, and BMI.

CONCLUSIONS: The suggested cutoff points for waist circumference are only to a limited degree useful in identifying subjects with overweight and obesity and/or central fat distribution in an older population. This concerns especially the upper cutoff point (waist action level 2) and is mainly due to the increased central distribution of fat with advancing age.
The Use of Proxy Respondents in Studies of Older Adults: Lessons, Challenges, and Opportunities
Authors: Neumann Peter J. , Araki Sally S. , Gutterman Elane M.
Published: April 2015

OBJECTIVE:Proxies play a critical role as sources of health information for older persons with cognitive impairment and other chronic debilitating conditions. This paper reviews the validity of proxy responses for people older than age 60 in the following areas: functioning, physical and mental health, cognition, medical care utilization, and preferences for types of care and health states.

DESIGN:A Medline review identified 24 clinical studies from 1990 to 1999 that use proxy data as a source of information about older adults.

RESULTS:In general, studies report fairly good agreement between subjects and proxies in assessments of functioning, physical health, and cognitive status, and fair‐to‐poor agreement in assessments of psychological well‐being. Proxies tend to describe more impairment in functioning and emotional well‐being, relative to subjects, a pattern that is particularly marked among persons with cognitive impairment. In addition, proxies who report more caregiver responsibilities and subjective stress from caregiver duties provide more negative assessments of subjects' health and well‐being.

CONCLUSIONS:Findings tend to support the use of proxy ratings among older adults in many areas but not all when self‐reports are not feasible. There is a need for more evaluation of proxy data in relation to other measures, such as performance assessments, medical records, and claims data, which may be less subject to respondent biases.
The Relationship Between Cognitive/Neuropsychological Factors and Car Driving Performance in Older Adults
Authors: De Raedt Rudi , Ponjaert‐Kristoffersen Ingrid
Published: April 2015

OBJECTIVES: Because demographic changes produce a society with a growing number of older people, seniors constitute the fastest growing segment of car drivers. The objective of this research project was to identify cognitive factors related to driving problems in older adults. A top‐down approach has been used, testing theory‐driven hypotheses.

DESIGN: Correlational study.

SETTING: Fitness‐to‐Drive Assessment Centre of the Belgian Road Safety Institute.

PARTICIPANTS: The research sample consisted of 84 car drivers aged over 65 years, who were referred for a general fitness‐to‐drive evaluation.

MEASUREMENTS: The relations between seven specific neuropsychological tests and self‐reported accidents were investigated. Furthermore, the relations between these same tests and a road test, independently assessed using a detailed evaluation grid, were analyzed in depth. These analyses were followed by stepwise multiple regression analyses.

RESULTS: In a stepwise regression model, four neuropsychological tests could account for 64% of the variance of the score on the road test. Moreover, it could be demonstrated that specific cognitive subskills share common variance with specific real‐world situations. However, neuropsychological tests could explain only 19% of the variance of self‐reported at fault car accidents.

CONCLUSIONS: The initial results of this study indicate the relevance of a cognitive/neuropsychological approach to the driving ability of older people. However, the link with accident risk seems more complex. Consequently, neuropsychological screening procedures are in need of a broader perspective to prevent an overemphasis on unidimensional screening procedures focusing mainly on deficit and less on capacities for safe behavior.
The Geriatric Pain Measure: Validity, Reliability and Factor Analysis
Authors: Ferrell Bruce A. , Stein Wendy M. , Beck John C.
Published: April 2015

BACKGROUND: Pain is a multidimensional experience that should be evaluated beyond an estimate of intensity. A multidimensional pain measure has not been developed for older persons undergoing comprehensive geriatric assessment.

OBJECTIVE: To develop and evaluate validity and reliability of a multidimensional pain assessment instrument for older persons.

RESEARCH DESIGN: A series of steps in instrument development and evaluation.

SUBJECTS: A total of 176 subjects (mean age 84 ± 6.0 years) in ambulatory geriatric clinics; 64% were women, and 73% had a history of chronic pain.

MEASUREMENTS: Measurements included the Geriatric Pain Measure (GPM), the McGill Pain Questionnaire, Yesavage GDS, Katz ADLs, Lawton IADLs, Tinetti Gait and Balance, Folstein MMSE, and other demographic and clinical characteristics from interview and chart review.

RESULTS: The GPM demonstrated a standardized alpha = 0.9445, homogeneity ratio =0.457, and average inter‐item correlation =0.415. A subgroup of 50 subjects demonstrated concurrent validity of the GPM in comparison with the McGill Pain Questionnaire (Pearson's r correlation 0.6269 (P < .0000). Test‐retest reliability was demonstrated in another subgroup of 50 subjects who repeated the GPM within 48 to 72 hours (Pearson's r = 0.9018; P < .0000). Factor analysis revealed five clusters of components: Pain Intensity, Disengagement, Pain with Ambulation, Pain with Strenuous Activities, and Pain with Other Activities.

CONCLUSIONS: The GPM is a 24‐item questionnaire that is easy to administer and has significant validity and reliability in older persons with multiple medical problems. The GPM may be a useful addition to the multidimensional geriatric assessment process.
The Comorbidity Symptom Scale: A Combined Disease Inventory and Assessment of Symptom Severity
Authors: Crabtree H. L. , Gray C. S. , Hildreth A. J. , O'Connell J. E. , Brown J.
Published: April 2015

OBJECTIVES: To develop and evaluate a scale to quantify the presence and severity of symptoms arising from comorbid diseases in older people.

DESIGN: A validation cohort study of hospital inpatients and outpatients aged 65 years and older.

SETTING: A Hospital and community in Northeast England.

PARTICIPANTS: Development of the Comorbidity Symptom Scale ‐ Convenience sample of 50 hospital inpatients and outpatients aged 65 years and older. Evaluation of the Comorbidity Symptom Scale ‐ Convenience sample of 183 patients aged 65 years and older either awaiting cataract surgery or attending a geriatric day hospital.

MEASUREMENTS: For development of the Comorbidity Symptom Scale, 22 comorbid conditions were identified and incorporated into a questionnaire (the CmSS). Evaluation of the Comorbidity Symptom Scale ‐ Assessments included the CmSS, activities of daily living, perceived health status, and anxiety and depression.

RESULTS: A 23‐item scale was developed. Reliability of the CmSS was demonstrated by a test‐retest correlation coefficient for the total instrument score of r = 0. 87 (P < .001). The CmSS scores correlated with assessments of activities of daily living, perceived health status, and anxiety and depression.

CONCLUSIONS: The CmSS is a simple interviewer‐administered tool for use in older people and provides an objective measure of the presence of comorbid disease and the patient's perception of severity of associated symptoms.