bluuebunny/crossref_metadata_2025 huggingface dataset:
Characteristics of Diabetic Ketoacidosis in Older versus Younger Adults
Authors: Malone Michael L. , Gennis Virginia , Goodwin James S.
Published: April 2015

Objective

To describe how diabetic ketoacidosis in those aged 65 or over differs from that in younger adults.

Design

Retrospective chart review of all adult patients with a primary or secondary discharge diagnosis of diabetic ketoacidosis (n = 338).

Setting

Three urban teaching hospitals in Milwaukee, WI from January 1, 1987 to May 31, 1990.

Patients

Two hundred twenty cases in 150 patients met our criteria for severity of illness to be included in the study. Twenty‐seven cases were in patients ≥ age 65; 193 cases were in patients < age 65.

Results

The older patients were less likely to have been using insulin before hospitalization (55.6% vs 80.2%, P = 0.004) and less likely to have had a prior episode of diabetic ketoacidosis (8.0% vs 51.4%, P = 0.001). The presenting laboratory data were not significantly different between older and younger subjects. There was a trend toward a higher mean insulin dosage to bring the patient's blood glucose to ≤300 mg/dL for those age 65 or older; 69.1 units vs 44.9 units (P = 0.06). The time required to obtain a glucose <300 mg/dL was greater in older patients (10.5 vs 7.7 hours, P = 0.01). The average length of stay for those age 65 or older was 12.4 days vs 6.7 days (P = 0.001). Thirdly, of those age 65 or older, 7% vs 29% of younger subjects had a blood glucose or Accucheck ≤ 49 mg/dL at some time during their hospital course. The hypoglycemic episodes were more likely to be asymptomatic in older patients (P = 0.03). The mortality rate was 22% for those age 65 or older vs 2% for younger subjects (P = 0.001). The mortality rate for those in age groups 60–69 years, 70–79 years, and ≥ 80 years was 8%, 27%, and 33%, respectively. In patients ≥ 65, mortality was confined to those with coexisting renal disease or infection.

Conclusion

Older patients with diabetic ketoacidosis are less likely to have been using insulin before hospitalization. They tend to receive more insulin therapy during their acute management, have a longer average length of hospital stay, and have a higher mortality rate.
A Pilot Study of Anabolic Steroids in Elderly Patients With Hip Fractures
Authors: Sloan John P. , Wing Peter , Dian Larry , Meneilly Graydon S.
Published: April 2015

Objective

To determine the safety and efficacy of the anabolic steroid nandrolone in elderly patients with hip fractures. Design: A randomized double‐blind placebo‐controlled trial. Setting: The orthopedic ward of a university teaching hospital.

Participants

29 frail elderly females with hip fractures. Intervention: Subjects received nandrolone 2 mg/kg (n = 15) or placebo (n = 14) by weekly injection for 4 weeks or until discharge.

Measures

Baseline functional status was assessed by the Lawton‐Brody ADL and IADL. Hemoglobin, transferrin, thyroid‐binding prealbumin, albumin, liver function tests, creatinine, weight, MAMC, bioelectric impedance, standard anthropometrics and grip strength were measured at baseline and weekly intervals. Rehabilitation parameters and length of stay were recorded.

Results

The placebo and nandrolone groups were similar in age, although the control group had slightly higher baseline ADL scores. There was no difference between groups in biochemical parameters, anthropometrics, body composition, grip strength, rehabilitation end points or length of stay. One subject in the nandrolone group had a doubling of AST and was withdrawn from the study.

Conclusions

Nandrolone can be given safely to frail elderly subjects with hip fractures but is likely to be of minimal benefit at the doses we employed.
The Effect of Aging on Intact PTH and Bone Density in Women
Authors: Flicker L. , Lichtenstein M. , Colman P. , Buirski G. , Kaymakci B. , Hopper J. L. , Wark J. D.
Published: April 2015

Objective

To determine whether age‐related bone loss is negatively associated with serum intact parathyroid hormone (PTH).

Design

Survey.

Setting

University hospital outpatient department.

Participants

100 community‐dwelling women, age 18 to 80, recruited as a convenience sample.

Measurements

Dependent variables—bone density at the spine and femoral neck by dual‐energy X‐ray absorptiometry. Independent variables—age, menopausal status (binary) and intact serum PTH by Allegro immunometric assay.

Results

Post‐menopausal women had higher serum PTH and lower bone density of spine and femoral neck than pre‐menopausal women. Bone density at the spine decreased with age, but this effect was accounted for by menopausal state. Bone density at the femoral neck decreased with age even after adjusting for menopause. Log PTH was negatively associated with bone density at the femoral neck but not significantly at the spine. Multiple regression analysis adjusting for age and menopause showed no significant association between intact PTH and bone density at the spine or the femoral neck.

Conclusion

Although this study confirmed the rise in intact PTH with age, there is no evidence that this is the mediator of age‐related bone loss.
BOOK REVIEWS
Authors: Boettcher Iris F.
Published: April 2015

Principles of Geriatric Medicine and Gerontology, Second Ed. By William R. Hazzard, Reubin Andres, Edwin L. Bierman, and John P. Blass. New York, McGraw‐Hill Inc., 1990. 1280 pages. $110.00.
The Treatment of Urinary Incontinence with Electrical Stimulation in Nursing Home Patients: A Pilot Study
Authors: Lamhut Penny , Jackson Thomas W. , Wall L. Lewis
Published: April 2015

Objectives

To test the effectiveness of electrical stimulation in the treatment of urinary incontinence in female nursing home patients.

Setting

A community long term care facility.

Participants

Nine unselected female nursing home patients with urinary incontinence. All patients were moderately to severely cognitively impaired. By bedside cystometry, six patients had involuntary detrusor contractions while two had inconclusive results.

Intervention

Participants were treated with electrical stimulation for 8 weeks using the Microgyn II device. A current with a frequency of 20 hertz and a pulse width of 1 millisecond was delivered repeatedly for 2 seconds on, 4 seconds off for 15 minutes twice a week.

Measurements

The number of every‐2‐hour wet episodes during a 48‐hour period (Wet) was recorded by a blinded observer at baseline and after 4 and 8 weeks of treatment. We evaluated the overall effect of electrical stimulation by averaging the Wet at 4 and 8 weeks for each patient and comparing it to Wet at baseline.

Main Results

The mean ± standard deviation of intensity of electrical stimulation was 12 ± 5 milliamps. Mean Wet at baseline was 11.8 ± 4.2. For all patients mean Wet increased by 2.3 ± 3.2, P = 0.07. Analysis of patients with documented involuntary detrusor contractions showed a mean increase in Wet of 2.6 ± 3.6, P = 0.16. The volume of fluid at which an involuntary contraction occurred during cystometry showed a mean increase of 48.3 ± 52.6 mL, P = 0.07 after 8 weeks of treatment.

Conclusions

Electrical stimulation is well tolerated in elderly nursing home patients. However, it was ineffective in improving urinary incontinence. In fact, there was a tendency for the treatment to worsen the incontinence.
Endoscopic Biliary Endoprosthesis in Elderly Patients with Large Bile Duct Stones: Long‐Term Follow‐Up
Authors: Van Steenbergen Werner , Pelemans Walter , Fevery Johan
Published: April 2015

Objective

To assess the long‐term evolution of elderly patients with large or impacted bile duct stones, treated by an endoscopic biliary endoprosthesis.

Design

Case series.

Setting

Tertiary care center.

Patients

Twenty‐three patients with a mean (± SD) age of 86 ± 5 years (range, 77–97 years). On admission, 96% were highly symptomatic. These patients represent 8.4% of a group of 273 elderly patients (≧70 years old) with choledocholithiasis treated by endoscopic sphincterotomy between November 1984 and May 1989.

Intervention

Endoscopic insertion of a biliary endoprosthesis.

Results

Eighty‐seven percent (20/23) remained completely free of biliary symptoms and died of unrelated illness (48%) after a mean follow‐up of 23 months or are still alive (39%) with a mean follow‐up of 52 months. In four cases, this asymptomatic evolution now extends for more than 5 years.

Conclusion

Insertion of a biliary endoprosthesis offers an effective method for long‐term treatment of non‐extractable biliary stones in elderly patients.
Delusions and Behavioral Disturbances in Cognitively Impaired Elderly Persons
Authors: Lachs Mark S. , Becker Marion , Siegal Alan P. , Miller Ronald L. , Tinetti Mary E.
Published: April 2015

Objective

To compare cognitive function and the prevalence of selected behavioral problems in delusional and non‐delusional dementia patients.

Design

Retrospective medical record review.

Setting

An outpatient geriatric assessment center.

Participants

114 consecutive patients with dementia.

Main Outcome Measures

Delusions as recorded in a consultation report.

Results

Delusions were described in 25.5% of patients. A variety of behavioral disturbances were more common in delusional than non‐delusional patients, including agitation, angry or hostile outbursts, urinary incontinence, wandering or pacing, and insomnia. While cognitive function as measured by the MMSE was similar in delusional and non‐delusional patients (18.9 ± 3.8 and 19.2 ± 5.9, respectively), there was a statistically borderline tendency for delusions to occur more often in patients in the mid‐range of cognitive impairment (17 ≤ MMSE ≤ 23) compared with patients with greater or lesser degrees of cognitive impairment (32% vs 17% respectively).

Conclusion

Delusions in dementia are associated with a variety of behavioral problems. Further studies are needed to clarify the role of delusions in the development of disruptive behaviors in dementing illness.
Elderly Subjects Aged 70 Years and Above Have Different Risk Factors for Ischemic and Hemorrhagic Strokes Compared to Younger Subjects
Authors: Woo J , Lau E. , Kay R.
Published: April 2015

Objective

To compare risk factors for ischemic and hemorrhagic strokes in subjects aged 70 years and above with those in younger subjects.

Design

Case control study, with controls matched for age and sex in 5‐year age groups.

Setting

A general district hospital in Hong Kong with a catchment population of over 1 million.

Patients

All patients admitted consecutively over a 6‐month period. Classification of stroke was by neurological examination and CT scan, or autopsy if death occurred before CT scanning could be performed. Exclusion criteria: onset of ictus >48 hours before admission, those with previous stroke, subarachnoid hemorrhage, or embolic stroke from rheumatic heart disease, and those with liver, renal, biliary, or thyroid diseases. For ischemic strokes, 78 pairs <70 years and 121 pairs ≥70 years were recruited. For hemorrhagic strokes, the numbers were 40 and 39, respectively.

Results

For ischemic strokes, atrial fibrillation and the presence of ischemic heart disease were risk factors only for those aged 70 years and above, while smoking and left ventricular hypertrophy were risk factors only for those below 70 years. Hypertension and glucose intolerance were risk factors for both age groups, although the effect of glucose intolerance was less marked in the older group. No marked difference in serum lipids and lipoproteins as risk factors was observed between the two age groups. Hypertension was the only demonstrable risk factor for hemorrhagic stroke in the younger, but not in the older, group.

Conclusion

Risk factors for ischemic and hemorrhagic strokes are different in elderly compared with younger subjects, with the possibility that certain risk factors for ischemic strokes, in contrast to those for hemorrhagic strokes, may be modifiable even in subjects aged 70 years or above.
Screening for Drinking Disorders in the Elderly Using the CAGE Questionnaire
Authors: Buchsbaum David G. , Buchanan Robin G. , Welsh Josephine , Centor Robert M. , Schnoll Sidney H.
Published: April 2015

Objective

To assess the performance of the CAGE questionnaire in identifying elderly medicine outpatients with drinking problems.

Design

Cross‐sectional design, with the alcohol module of the Diagnostic Interview Schedule as the criterion standard.

Setting

The outpatient medical practice of an urban university teaching hospital.

Patients

Consecutive patients 18 years or older who signed a consent form approved by the university's institutional review board. For this study, 323 patients ≥60 years old.

Main Outcome Measures

Sensitivity, specificity, receiver operating characteristics (ROC) curve and positive predictive value for CAGE scores of 0–4 for patients 60 years or older.

Results

Thirty‐three percent of the sample group met study criteria for a history of drinking problems, including 63% of the male patients and 22% of the female patients. The sensitivity and specificity for a cut‐off score of one for all patients was 86% and 78%, respectively, and 70% and 91% for a cut‐off of two. The calculation of the area under the ROC curve was .86, and the positive predictive value of CAGE scores of 0–4 were 33%, 66%, 79%, 82%, and 94%, respectively. The predictive value for any score was higher in males than females, reflecting the higher prevalence of problems in the male population.

Conclusions

The CAGE can effectively discriminate elderly patients with a history of drinking problems from those without such a history. The chosen cut‐off score should consider the prevalence of drinking problems in the population being tested.
Prevention of Mental Disorder in the Elderly: Current Perspectives and Future Prospects
Authors: Rabins Peter V.
Published: April 2015

This article reviews primary, secondary, and tertiary preventive strategies in the mental health field. Primary prevention is currently restricted to some forms of dementia, but secondary and tertiary prevention can significantly diminish both short‐term and long‐term morbidity. Improved professional and lay education, better use of existing knowledge and resources, and improved communication among practitioners in the medical, psychosocial, and mental health fields can all lead to improved care at the present time.
Geriatricians' Attitudes toward Assisting Suicide of Dementia Patients
Authors: Watts David T. , Howell Timothy , Priefer Beverly A.
Published: April 2015

Objective

To identify geriatricians' attitudes toward assisting suicide of dementia patients, with particular reference to the case of Janet Adkins/Dr. Kevorkian.

Design

Mailed questionnaire survey.

Setting

Four distinct geographical regions of the US: Far West, Midwest, Southeast, and Northeast.

Participants

All 1,381 ABIM‐certified internist geriatricians in the four regions; 727 (52.6%) responded.

Main Outcome Measures

Positive, negative, or unsure responses to questionnaire items; comparison of responses between geographical regions.

Results

Sixty‐six percent of respondents felt that Dr. Kevorkian's assistance of Janet Adkins' suicide was not justifiable, while 14% stated it was morally justifiable. Twenty‐nine percent felt Janet Adkins' decision to commit suicide was morally wrong, while 49% stated it was not morally wrong. If the responding geriatricians themselves were diagnosed as having a dementing illness, 41% would consider suicide a possible option; 39% would not consider suicide. Twenty‐six percent favored easing restrictions on physician‐assisted suicide of competent dementia patients, while 57% opposed this. If current restrictions were eased, 21% would consider assisting suicide of competent dementia patients, and 66% would not. Respondents' attitudes showed some significant (P ≤ 0.05) variations by geographical region. Where regional differences were observed, respondents in the Midwest tended to show more conservative attitudes toward physician‐assisted suicide than those in the Far West and Northeast.

Conclusions

Most responding geriatricians would not consider assisting suicide of dementia patients, and most oppose easing restrictions on physician‐assisted suicide. Many, however, could accept the (unassisted) suicide of a competent dementia patient, and many would consider suicide themselves if stricken with dementia.
A Comparison of Caregivers for Elderly Stroke and Dementia Victims
Authors: Draper Brian M. , Poulos Christopher J. , Cole Andrew M. D. , Poulos Roslyn G. , Ehrlich Frederick
Published: April 2015

Objective

To compare elderly co‐resident caregivers of stroke and dementia patients on measures of burden and psychological morbidity.

Design

Cohort study.

Setting

Caregivers interviewed at home.

Subjects

Convenience sample, 99 co‐resident caregivers of dementia and stroke patients registered with a community rehabilitation and geriatric service and who were 60 years or over.

Main Outcome Measures

Caregiver burden as measured by self‐administered questionnaire and subsequent interview, using the Relatives Stress Scale (RSS) and psychological morbidity as measured on the General Health Questionnaire (GHQ).

Results

Forty‐six percent of caregivers had significant psychological morbidity (GHQ >4). Mean RSS score was 12.2 (SD 5.4). No significant differences were found between stroke and dementia caregivers on these measures. Caregiver burden was significantly correlated with psychological morbidity in both caregiver groups. Behavior and mood disturbance in the patient was significantly correlated with burden (dementia caregivers r = 0.66; stroke caregivers r = 0.49, P < 0.0001) and psychological morbidity (dementia caregivers r = 0.44, P < 0.01; stroke caregivers r = 0.30, P < 0.05). Caregiver's dissatisfaction with participation in life activities was correlated with burden (dementia caregivers r = 0.58; stroke caregivers r = 0.63, P < 0.0001) and psychological morbidity (dementia caregivers r = 0.67, stroke caregivers r = 0.56, P, 0.0001).

Conclusion

Elderly co‐resident caregivers for stroke and dementia patients experience similar degrees of burden and high levels of psychological morbidity. Psychiatric aspects of chronic disability, rather than physical aspects, were found to be more stressful to caregivers. All assessments of the disabled elderly should include measures of caregiver burden and psychological distress.
The Mini‐Mental State Examination: A Comprehensive Review
Authors: Tombaugh Tom N. , McIntyre Nancy J.
Published: April 2015

Objective

The purpose of this paper is to provide a comprehensive review of information accumulated over the past 26 years regarding the psychometric properties and utility of the Mini‐Mental State Examination (MMSE).

Participants

The reviewed studies assessed a wide variety of subjects, ranging from cognitively intact community residents to those with severe cognitive impairment associated with various types of dementing illnesses.

Main Outcome Measures

The validity of the MMSE was compared against a variety of gold standards, including DSM‐III‐R and NINCDS‐ADRDA criteria, clinical diagnoses, Activities of Daily Living measures, and other tests that putatively identify and measure cognitive impairment.

Results

Reliability and construct validity were judged to be satisfactory. Measures of criterion validity showed high levels of sensitivity for moderate‐to‐severe cognitive impairment and lower levels for mild degrees of impairment. Content analyses revealed the MMSE was highly verbal, and not all items were equally sensitive to cognitive impairment. Items measuring language were judged to be relatively easy and lacked utility for identifying mild language deficits. Overall, MMSE scores were affected by age, education, and cultural background, but not gender.

Conclusions

In general, the MMSE fulfilled its original goal of providing a brief screening test that quantitatively assesses the severity of cognitive impairment and documents cognitive changes occurring over time. The MMSE should not, by itself, be used as a diagnostic tool to identify dementia. Suggestions for the clinical use of the MMSE are made.
Pentoxifylline in Cerebrovascular Dementia
Authors: Black Ronald S. , Barclay Laurie L. , Nolan Karen A. , Thaler Howard T. , Hardiman Stephen T. , Blass John P.
Published: April 2015

Objective

To test the effect of pentoxifylline, a hemorheologic agent used to treat intermittent claudication, on the course of vascular dementia.

Design

Randomized, double‐blind, placebo‐controlled, parallel group trial.

Setting

Outpatient tertiary care center.

Patients

64 patients meeting DSM‐III criteria for multi‐infarct dementia with modified Hachinski ischemic scores ≥6, 38 of whom completed the trial.

Intervention

Pentoxifylline (Trental®) 400 milligram tablets three times daily vs placebo for 36 weeks.

Main Outcome Measure

Alzheimer's Disease Assessment Scale (ADAS).

Results

Baseline demographic values and psychometric variables were similar in the placebo and control groups; endpoint statistical analysis was used to allow the use of data from all patients in this clinically high‐risk group. For the total group, the slowing of deterioration did not reach statistical significance (by 2‐tailed t test), as measured by scores on the total ADAS (P = 0.058) or on the cognitive (ADAS items 1–11; P = 0.064) or non‐cognitive subscales (ADAS items 12–21; P = 0.234), although it was significant on the cognitive subscales excluding memory (ADAS items 2–6, 8–10; P = 0.036). For the subgroup of 40 patients who had CT and/or MRI evidence of stroke as well as meeting the other inclusion criteria, treatment with pentoxifylline was associated with significantly slower deterioration, as measured by the total ADAS (P = 0.023) and cognitive subscores (P = 0.020) but not non‐cognitive subscores (P = 0.118). For the subgroup of 37 patients who had at least one discrete clinical stroke, treatment with pentoxifylline was associated with significantly less deterioration on the total ADAS (P = 0.002) and both the cognitive (P = 0.001) and non‐cognitive (P = 0.017) subscores.

Conclusion

Treatment with pentoxifylline may slow the progression of dementia in patients who meet DSM‐III criteria for “multi‐infarct dementia” and who also have clinical and neuroradiological evidence of cerebrovascular disease.
Self‐Reported Functional Status Predicts Change in Level of Care in Independent Living Residents of a Continuing Care Retirement Community
Authors: Falconer Judith , Naughton Bruce J. , Hughes Susan L. , Chang Rowland W. , Singer Ruth H. , Sinacore James M.
Published: April 2015

Objective

To test the hypothesis that self‐reported functional status predicts change in level of care from independent to dependent in residents of a continuing care retirement community (CCRC).

Design

Two‐year longitudinal descriptive study of change in level of care and survival.

Subjects

One hundred fifty‐two residents in the independent‐living unit of a non‐profit CCRC. Mean age at initial evaluation was 82.3 years, SD 6.2.

Measurement

Predictor variables assessed at baseline were age, sex, physician estimate of functionally significant disease, self‐reported functional status, and performance‐based hand function. Criterion variables collected at 2‐year follow‐up were level of care (independent/dependent) and survival (alive/dead).

Main Results

Self‐reported functional status (P < 0.01) and age (P < 0.05) were significant predictors of change in level of care in a logistic regression analysis containing all predictor variables. No variable predicted survival.

Conclusions

Self‐reported functional status may help to predict dependency in older adults in good health who have few markers of dependency risk.
BOOK REVIEWS
Authors: Katz Paul R. , Buckwalter Kathleen C.
Published: April 2015

Specialized Dementia Care Units. By Coons DH (ed). Baltimore, The Johns Hopkins University Press, 1991. 280 pages. $42.50.
BOOK REVIEWS
Authors: Goldstein Marion Z.
Published: April 2015

Mental Health in the Nursing Home. By Brink TL. New York, Hawthorne Press, Inc, 1990. 215 pages. Hard cover $29.95, Soft cover $14.95.
The Use of Goal Attainment Scaling in a Geriatric Care Setting
Authors: Stolee Paul , Rockwood Kenneth , Fox Roy A. , Streiner David L.
Published: April 2015

Objective

Goal attainment scaling (GAS) is a measurement approach used extensively in mental health. It accommodates multiple individual patient goals, yet retains mathematical properties allowing comparisons between patients. This study was carried out to investigate the feasibility and measurement properties of GAS in a geriatric care setting.

Design

Prospective descriptive study.

Setting

The geriatric restorative care service and geriatric assessment unit at Camp Hill Hospital, a 350‐bed tertiary care facility in Halifax, Canada.

Patients

Fifteen patients aged 65 to 94 who were consecutively admitted to the two geriatric services (mean age 79 years, mean length of stay 37 days, 9 females).

Intervention

Goal Attainment follow‐up guides were developed independently for each patient by two geriatricians after a comprehensive assessment of the patient. These guides were later compared to assess level of agreement in goal setting and scale development. A single goal attainment follow‐up guide was then developed for each patient by consensus of the two geriatricians. At the end of the follow‐up, the guides were scored independently for each patient by one of the geriatricians and by the patient's primary care nurse.

Main Outcome Measures

GAS scores were determined on admission and discharge. Each patient also received admission and discharge ratings on the Barthel Index as well as a global rating of outcome (on a subjective 10‐point scale) by a geriatrician who was blinded to the Goal Attainment follow‐up score.

Results

GAS proved feasible, requiring 15–20 minutes to scale an average of six goals per patient. GAS also appears reliable. Of 87 goals, 71 (82%) were identified independently by two geriatricians, and the remainder were determined by consensus. This is also a measure of content validity. The physician‐nurse inter‐rater reliability was 0.87 (intraclass correlation). Concurrent validity was assessed by correlation with the Barthel Index (r = 0.86) and the global clinical outcome rating (r = 0.82). Content validity was also assessed by comparing our goal areas with those identified in recent consensus reports on geriatric assessment. Of these 13 assessment areas, 12 appeared to be reasonably well covered while one assessment area (sexual problems) was not identified for any of the 15 patients.

Conclusions

GAS appears to be a feasible method of goal setting and outcome evaluation in geriatric care settings, with promising reliability and validity.
The Equivalency of Infrared Tympanic Membrane Thermometry with Standard Thermometry in Nursing Home Residents
Authors: Castle Steven C. , Toledo Santiago D. , Daskal S. Lorraine , Norman Dean C.
Published: April 2015

Objective: To compare the equivalence of infrared tympanic membrane (TM) measure of body temperature with standard electronic oral (PO) and rectal (R) measures in a nursing home population.

Objective: Randomized repeated‐measurement design.

Methods: For the study, 82 randomly selected residents (mean age 79 ± 10 years) of the Nursing Home Care Unit of the VAMC West Los Angeles had PO, R, and TM temperatures measured before arising (6–8 am). An otoscopic exam and the age, sex, presence of neurologic disease, and compliance with thermometry was noted. Also, repeated measures of PO and TM temperatures were performed three times to assess variability. The Pearson's correlation coefficient was determined for PO versus R and for TM versus R temperatures. Stepwise regression analysis was performed with the dependent variable of R temperature and the independent variables of the mean TM temperature, age, sex, presence of neurologic disease, position of the resident, and extent of ear canal occlusion.

Results: The correlation of TM versus R (r = .39, P = .004) was better, though not significantly, than of PO versus R (r = .28, P = .04). TM had less variability than PO (pooled standard deviation .38 vs .45° F, respectively) and TM was implemented successfully more often than PO or R (96% vs 81% vs 81%).

Conclusion: Therefore, TM was at least equivalent or better than PO measures of temperature in this population. The efficacy of fever detection and the use and durability of long‐term use by nursing staff needs to be studied. J Am Geriatr Soc 1212–1216, 1992
The Effect of Geriatric Evaluation and Management on Medicare Reimbursement in a Large Public Hospital: A Randomized Clinical Trial
Authors: Rubin Craig D. , Sizemore Mark T. , Loftis Paula A. , Adams‐Huet Beverley , Anderson Ron J.
Published: April 2015

Objective: To study the effect of a geriatric evaluation and management program on health care charges and Medicare reimbursement.

Design: Prospective randomized controlled trial during a 1‐year study period.

Setting: Large medical school‐affiliated public hospital in an urban community.

Subjects: Patients at least 70 years old admitted to the medicine service were screened and randomized into two groups of 100 patients each.

Intervention: Patients randomized to the experimental group underwent initial comprehensive geriatric evaluation and once discharged from the hospital were enrolled in a geriatric care management and treatment program. The control group received usual care only. The major intervention of this study was in outpatient long‐term care.

Main Outcome Measure: Total charges for services billed to Medicare Part A and Part B and total Medicare reimbursement. The Medicare charge and reimbursement data were obtained by use of the Medicare Automated Data Retrieval System, a linked Medicare Part A and Part B utilization file.

Results: Total charges and reimbursement were greater for the control group but not significantly so. Subset analysis revealed significantly greater inpatient charges (P < 0.03) and Medicare reimbursement (P < 0.005) for the control patients and a greater likelihood of utilization of home health care services in the experimental group (P < 0.01).

Conclusion: A geriatric evaluation and management program appeared to shift utilization and Medicare expenditures from inpatient services to home health care services. There was no evidence that the experimental program resulted in increased expenditures for Medicare. In selected populations, geriatric evaluation and management programs may contribute to cost containment. J Am Geriatr Soc 40: 989–995, 1992
Screening for Depression in Hospitalized Elderly Medical Patients: Taking a Closer Look
Authors: Koenig Harold G. , Meador Keith G. , Cohen Harvey J. , Blazer Dan G.
Published: April 2015

Objective: To re‐examine the test characteristics of the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS) in elderly medical inpatients, simulating the procedure followed by clinicians when using screening instruments.

Design: Masked comparison of GDS and BCDRS with psychiatric interview.

Setting: Durham VA Medical Center.

Participants: 109 consecutively admitted persons aged 70 or over.

Measurements: Screening by a social worker using GDS and BCDRS on day one, followed the next day by an investigator's structured psychiatric interview to determine the presence of major depressive disorder (MDD).

Results: By this method, the sensitivity and specificity of the GDS (cutoff 11) were 82% and 76%, respectively; for the BCDRS (cutoff 6), they were 73% and 79%. Among those with a negative test, the likelihood of MDD dropped from an a priori probability of 10% to an a posteriori probability of 3% with the GDS and 4% with the BCDRS. Among those with a positive test, the likelihood of MDD was 27% for the GDS and 28% for the BCDRS. Excluding patients with cognitive impairment (MMSE ≤ 25) only slightly improved test characteristics.

Conclusion: These estimates are considerably below those reported in earlier studies where concordant screening, two‐stage screening, or other methods have been utilized and may impact the decision whether or not to screen for depression using these instruments. J Am Geriatr Soc 40:1013–1017, 1992
The Relationship between Low Vision and Performance of Activities of Daily Living in Nursing Home Residents
Authors: Marx Marcia S. , Werner Perla , Cohen‐Mansfield Jiska , Feldman Robert
Published: April 2015

Objective: To explore the link between low vision and Activities of Daily Living (ADL) performance in cognitively intact nursing home residents.

Design: Survey.

Setting: A non‐profit geriatric long‐term care facility.

Subjects: 21 males, 82 females, aged 66–98.

Measures: Survey of 103 nursing home residents. ADL functioning assessed via Maryland Appraisal of Patient Progress (MAPP); medical data collected through chart review; ophthalmological data obtained through dilated eye examination by an ophthalmologist.

Results: In comparison with residents having good vision (n = 52), a significantly greater proportion of residents with low vision (n = 51) were dependent on caregivers for performing ADLs (eg, toileting, transferring, washing). Residents with low vision had significantly more eye pathology (eg, cataracts, age‐related macular degeneration) than did residents with good vision. There were no significant differences between groups with regard to presence of musculoskeletal problems (eg, arthritis) or number of medical conditions (eg, cardiovascular disorder, cerebrovascular accident).

Conclusions: There is a strong link between low vision and ADL disability in nursing home residents. Moreover, ADL dependency is significantly related to the presence of eye disorders. J Am Geriatr Soc 40:1018–1020, 1992
Morbidity, Disability, and Health Status of Black American Elderly: A New Look at the Oldest‐Old
Authors: Miles T. P. , Bernard M. A.
Published: April 2015

There are over 2.5 million black Americans aged 65 and over living in the United States today, including some 258,000 persons aged 85 years and over. The post‐World War II baby boom within the US black population should ensure that the numbers of persons aged 65 and over will increase into the 21st Century. If present trends continue, it is projected that the current population of black elders will also age. This means that the numbers of black persons aged 85 and over will also increase. Data from both national surveys and population‐based community studies concerning the health and well‐being of black elders are now becoming available. This report presents information concerning self‐reported health status, chronic disease prevalence, disease‐risk‐factor prevalence, measures of physical functioning, and nursing home utilization rates for age groups within the black population aged 65 years and over. The availability of such data should lead to the development of targeted interventions designed to lessen impairment and prolong independent living. J Am Geriatr Soc 40:1047–1054, 1992
Geriatric Care Approaches in Health Maintenance Organizations
Authors: Kramer Andrew M. , Fox Peter D. , Morgenstern Nora
Published: April 2015

The objective of this project was to describe geriatric care provided under Medicare‐risk contracts in HMOs with established Medicare programs. These findings provided the basis for an invitational workshop, sponsored by the National Institute on Aging and the Robert Wood Johnson Foundation, to formulate a research agenda for geriatric care in HMOs. The case study method involved site visits to seven HMOs by a physician with expertise in geriatrics, a managed care specialist, and a program development specialist. Representatives from the HMOs included senior executive officials, physicians recognized for providing and promoting geriatric care, research and program development staff, and various clinical staff including pharmacists, geriatric nurse practitioners, nurses, and social workers. The most frequently encountered geriatric care programs were categorized by the following six objectives: (1) identifying high risk patients, (2) assessing multi‐problem patients, (3) treating multi‐problem patients, (4) rehabilitating patients following acute events, (5) reducing medication problems, and (6) providing long‐term care and home health care. Unique programs identified from these site visits included screening methods for new enrollees, approaches to comprehensive geriatric assessment, use of skilled nursing facilities for intensive rehabilitation and postacute care, and drug profiling and review. Utilization of geriatric nurse specialists and programs aimed at coordination with social services were pervasive in many of these HMOs. Workshop participants proposed several research and demonstration projects in all six areas. Overall consensus emerged that HMOs with Medicare‐risk contracts provide a valuable setting for experimentation in geriatric care. Given the current health policy emphasis on managed care and capitated payment methodologies, geriatric care research in HMOs should be a high priority. J Am Geriatr Soc 40:1055–1067, 1992
Mid‐Career Faculty Development Awards in Geriatrics: Does Retraining Work?
Authors: Robbins Laurence J.
Published: April 2015

Objective

To evaluate the success of a mid‐career physicians faculty retraining in geriatric medicine.

Design

Written survey of participants in the John Hartford Foundation's Mid‐Career Faculty Development Program (1984–1988).

Setting

Four well established geriatric fellowship training programs.

Participants

The 29 physicians who received John Hartford Foundation awards.

Results

Twenty‐one (87%) of 24 respondents felt that the fellowship year had either a “major” or “significant” impact on their careers, and 87% also spend a significant portion of their time training others in geriatrics.

Conclusion

This 4‐year experiment in mid‐career faculty retraining in geriatrics suggests that this approach is a viable alternative to traditional 2‐year fellowships for helping to reduce the shortage of faculty in geriatric medicine.
BOOK REVIEWS
Authors: Redford John B.
Published: April 2015

Disability in America: Toward a National Agenda for Prevention. Edited by Andrew M. Pope and Alvin Tarlov. Washington, DC, National Academy Press, 1991. 362 pages. $29.95.
Inpatient Community‐Based Geriatric Assessment Reduces Subsequent Mortality
Authors: Thomas David R. , Brahan Robert , Haywood Barry P.
Published: April 2015

Objective

To evaluate the effect of an Inpatient Geriatric Consultation Team on patient outcome.

Design

Randomized controlled clinical trial.

Setting

A non‐academic‐affiliated 503‐bed community hospital.

Patients

All inpatients over the age of 70 years. Sixty‐two patients received multidimensional geriatric assessment and 58 patients received no intervention.

Intervention

Team assessment, leading to formal recommendations to the attending physician.

Measurements

Data were collected on hospital length of stay, referrals to community service, discharge destination, hospital readmissions in 6 months, number of post‐discharge physician visits, and change in functional status. Mortality at 6 months and at 1 year was determined for each patient.

Main Results

At 6 months, 12/58 patients (21%) had died in the control group versus 3/62 (6%) patients in the experimental group (P = 0.01). During hospitalization, the length‐of‐stay was 10.1 days for the control group versus 9.0 days for the experimental group (P = 0.20). The control group had significantly more readmissions (0.6 per patient vs 0.3 per patient, P = 0.02). A higher number of experimental patients, 22% (13/59), showed improvement in ADL scores compared with 7% (4/46) of control patients, P = 0.07. At one year for all randomized patients, 7/68 (10%) of experimental patients and 13/64 (20%) of control patients had died.

Conclusions

Short‐term mortality can be reduced in community inpatient acute hospital settings by comprehensive geriatric consultation teams. Important differences in mortality remain at 1 year of followup. Trends towards improved functional status and fewer hospital readmissions favor the intervention group.
BOOK REVIEWS
Authors: Patterson W. Bradford
Published: April 2015

Geriatric Surgery. Comprehensive Care of the Elderly Patient. Edited by Mark R. Katlic. Baltimore, Urban and Schwarzenberg, 1990. 775 pages. $43.50.
Clinical Features Distinguishing Large Cohorts with Possible AD, Probable AD, and Mixed Dementia
Authors: Corey‐Bloom Jody , Galasko Douglas , Hofstetter C. Richard , Jackson J. Edward , Thal Leon J.
Published: April 2015

Objective: To determine whether clinical features and rate of cognitive and functional decline differed in cohorts of possible AD (poAD), probable AD (prAD), and mixed dementia (MIX) patients.

Design: Cohort study with 1‐year follow‐up examination, comparing three groups of subjects.

Setting: Outpatient evaluation at nine California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC).

Patients: There were 1701 elderly patients who presented for evaluation of memory complaints.

Measurements: Historical, physical, and neurological variables for cross‐sectional comparisons and 1‐year rate of change on the Mini‐Mental State Examination (MMSE), Blessed Information‐Memory‐Concentration test (BIMC), and Blessed Dementia Scale (BDS).

Results: Mean initial MMSE scores for poAD (n = 279), prAD (n = 928) and MIX (n = 430) were 17.9 (±7.4), 13.9 (±7.5), and 15.4 (±7.1). Delusions and psychosis occurred in about one‐third of each group, most often in those with moderate dementia (MMSE 11–20). PoAD were distinguished from prAD by significantly more alcohol abuse, physical health problems, and focal motor or sensory findings. MIX differed from AD alone by increased prevalence of cardiovascular disease, hypertension, stroke, TIA, and exposure to general anesthesia, and by a greater frequency on exam of depressed mood, focal motor or sensory findings, and gait disorder. All groups declined by about 2.8 points on the BIMC, 2.9 points on the MMSE, and 1.8 points on the BDS, a functional scale, over 1 year. Neither extrapyramidal signs nor psychosis predicted a more rapid rate of decline.

Conclusions: Various features help to distinguish poAD, prAD, and MIX in a large cohort of patients, but do not predict the rate of progression.
Validation of a Measure of Physical Illness Burden at Autopsy: The Cumulative Illness Rating Scale
Authors: Conwell Yeates , Forbes Nicholas T. , Cox Christopher , Caine Eric D.
Published: April 2015

Objective: To further validate an objective measure of physical illness burden, the Cumulative Illness Rating Scale (CIRS).

Design: Survey with correlation of CIRS ratings made from physician interviews and review of medical records with postmortem ratings made independently at tissue autopsy.

Subjects: Victims of completed suicide investigated by both psychological and tissue autopsy (n = 72).

Results: CIRS ratings made by examination of tissue at autopsy were highly predictive of analogous ratings based on historical data, accounting for 75% of the variance in CIRS scores. Taking autopsy findings as the gold standard of objective health assessment, historical ratings tend to underestimate physical illness at high levels of tissue pathology and to overestimate burden at lower levels.

Conclusions: The CIRS score, when derived from all available sources of medical information, is a valid objective measure of physical illness burden and has broad applicability to research in geriatrics.
Projecting the Need for Physicians to Care for Older Persons: Effects of Changes in Demography, Utilization Patterns, and Physician Productivity
Authors: Reuben David B. , Bradley Thomas B. , Zwanziger Jack , Beck John C.
Published: April 2015

Objective: To determine the influence of differing assumptions of population growth, visit rates, prevalence of functional impairment, physician productivity, and hospitalization rates on projected need for physicians to provide medical care for older persons.

Design: Sensitivity analysis of a manpower model.

Main Results: The factors that appear to have the most impact on projections of physician need are related to physician productivity, especially delegation to mid‐level providers, and case‐mix. Other factors, such as the variability of census projections and per capita visit rates, are likely to have less effect on overall physician supply needs.

Conclusions: Although case mix and delegation to mid‐level providers may both substantially affect the need for physician supply to care for older persons, only the latter can be directly affected by health policy decisions. Consideration should be given to increasing the supply of mid‐level providers and providing incentives for patients and physicians to receive and provide care in delivery systems that utilize mid‐level providers extensively.
HMO Medical Directors' Perceptions of Geriatric Practice in Medicare HMOs
Authors: Friedman Bruce , Kane Robert L.
Published: April 2015

Objective: To determine the extent to which health maintenance organizations (HMOs) with Medicare risk contracts utilize geriatricians and selected aspects of “organized” geriatric practice.

Design: A telephone interview survey.

Participants: Eighty‐two percent (64 of 78) of the HMOs with Medicare risk contracts as of June 1991.

Measurements: Questions to medical directors of the Medicare HMOs on (1) the presence of geriatricians, (2) the roles of geriatricians, and (3) “organized” geriatric practice.

Main Results: Fifty‐three percent of the Medicare HMOs have one or more geriatricians, but only 19% have attempted to recruit geriatricians. Geriatricians provide primary care in 76% of the HMOs with geriatricians and serve as specialist consultants in 61%. Geriatricians are reported to be used actively in 32% of the HMOs that have them. The proportion of HMOs utilizing “organized” geriatric activities ranges from a high of 58% for a general health information questionnaire to a low of 12% for a special form(s) for comprehensive geriatric assessment. While the percentage of HMOs using each of the “organized” strategies is higher for the HMOs with geriatricians than for those without, this is statistically significant for only one strategy—the use of special approaches or formal protocols for problems frequently found in the elderly (P = 0.04).

Conclusions: The perception of Medicare HMO medical directors is that about half of the HMOs utilize geriatricians and that there is evidence of “organized” geriatric practice. However, it appears that geriatricians and many of the elements of organized geriatric practice are used to a much lesser extent than experts recommend. Medicare HMOs must themselves test the various components of organized geriatric practice in order to determine their utility.
Sex Differences in the Psychiatric Manifestations of Alzheimer's Disease
Authors: Cohen Donna , Eisdorfer Carl , Gorelick Philip , Luchins Daniel , Freeh Sally , Semla Todd , Paveza Gregory , Shaw Helen , Ashford J. Wesson
Published: April 2015

Objective: To test the null hypothesis, ie, that there are no gender differences in psychiatric problems manifest in patients with Alzheimer's disease.

Design: Survey.

Setting: Patients living in the community and evaluated at Alzheimer's disease and geriatric outpatient programs.

Patients: Three hundred twenty‐eight women and 186 men clinically diagnosed with Alzheimer's disease using NINCDS/ADRDA or DSM‐III‐R criteria.

Measurements: Psychiatric signs and symptoms recorded following a psychiatric interview, including the Hamilton Depression Rating Scale.

Results: Approximately two‐thirds of both men and women had psychiatric problems, but women had significantly more multiple symptoms. When pairs of symptoms were analyzed for independence, agitation was only significantly associated with paranoia in men, whereas in women agitation was significantly associated with most other psychiatric problems.

Conclusion: The higher prevalence of multiple psychiatric problems in women may be due to many factors, including sociodemographic influences, physician bias, and/or other differences between men and women. The finding of a different pattern of association of symptoms with agitation in men and women deserves replication.