bluuebunny/crossref_metadata_2025 huggingface dataset:
Ineffectiveness of the SUPPORT Intervention: Review of Explanations
Authors: Lynn Joanne , DeVries Kier Olsen , Arkes Hal R. , Stevens Marguerite , Cohn Felicia , Murphy Pat , Covinsky Kenneth E. , Hamel Mary Beth , Dawson Neal V. , Tsevat Joel
Published: April 2015

BACKGROUND: The aim of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments — SUPPORT — was to improve the care of seriously ill patients by improving decision‐making for patients with life‐threatening illnesses. Several theories have been proposed to explain why the SUPPORT intervention was unsuccessful at improving outcomes.

OBJECTIVE: To review and discuss explanations offered by others regarding why the SUPPORT intervention failed to have a discernible impact on its prespecified outcome measures.

DESIGN: A descriptive review of published articles and book chapters, with synthesis of data‐based and conceptual insights.

METHODS: The Medline, Bioethicsline, and Ethx databases were searched for citations to SUPPORT articles between 1994 and the end of 1998. This search was supplemented by other published materials that had come to the authors' attention.

RESULTS: The critiques and explanations regarding the reasons the SUPPORT intervention did not improve outcomes were catalogued and organized into 11 major categories, the first 10 of which are explored in the present study: (1) the inception cohort was biased against an effect of the intervention, (2) the intervention was not implemented as designed, (3) the intervention failed because nurses were too readily ignored, (4) the intervention was too polite, (5) the intervention presented information ineffectively, (6) the intervention did not focus on primary care physicians, (7) the intervention falsely dichotomized do not resuscitate (DNR) decisions, (8) the intervention needed more years on site or an earlier start with each patient, (9) the intervention required more appropriate outcome measures, (10) the intervention was irrelevant because usual care is not seriously flawed, (11) the conceptual model behind SUPPORT was fundamentally flawed in aiming to improve individual, patient‐level decision‐making as the way to improve seriously ill, hospitalized patients' experiences.

CONCLUSIONS: Although some of the critiques were found to raise important concerns, we conclude in each case that the explanation offered is inadequate to explain the failure of the intervention. We urge further reflection on the fundamental assumptions that informed the design of that intervention and refer the reader to a more comprehensive treatment of that issue in the companion paper in this volume.
The Effect of Nutritional Supplementation on Survival in Seriously Ill Hospitalized Adults: An Evaluation of the SUPPORT Data
Authors: Borum Marie L. , Lynn Joanne , Zhong Zhenshao , Roth Katalin , Connors Alfred F. , Desbiens Norman A. , Phillips Russell S. , Dawson Neal V.
Published: April 2015

BACKGROUND: Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults.

OBJECTIVE: To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN: A prospective study of preferences, decision‐making, and outcomes.

SETTING: Five teaching hospitals

PARTICIPANTS: 6298 patients aged 18 or older meeting diagnostic and illness severity criteria.

MEASUREMENT: Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization.

RESULTS: A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42‐0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18‐2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27‐0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38‐0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4‐1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35‐3.42), and COPD (hazard: 1.37; 95%CI, 1.04‐1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12‐1.59).

CONCLUSIONS: Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.
Withholding Versus Withdrawing Life‐Sustaining Treatment: Patient Factors and Documentation Associated with Dialysis Decisions
Authors: Wenger Neil S. , Lynn Joanne , Oye Robert K. , Liu Honghu , Teno Joan M. , Phillips Russell S. , Desbiens Norman A. , Sehgal Ashwini , Kussin Peter , Taub Harry , Harrell Frank , Knaus William
Published: April 2015

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn.

DESIGN: Prospective cohort study

SETTING: Five teaching hospitals

PATIENTS: Five hundred sixty‐five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure.

MAIN OUTCOME MEASURES: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision‐making for dialysis withheld, withdrawn, and continued.

RESULTS: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2‐month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision‐making was lacking more often for patients with dialysis withheld than for dialysis withdrawn.

CONCLUSIONS: Measuring the equity of life‐sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.
Fulminant Chemical Hepatitis Possibly Associated with Donepezil and Sertraline Therapy
Authors: Verrico Margaret M. , Nace David A. , Towers Adele L.
Published: April 2015

OBJECTIVE: To describe a case of fulminant hepatitis possibly related to concomitant donepezil and seratriline therapy.

PATIENT AND SETTING: An 83‐year‐old woman treated in a dementia care facility and later in a tertiary medical center.

INTERVENTION AND MANAGEMENT: Discontinuation of donepezil and sertraline therapy with subsequent improvement evidenced by liver biopsy and liver function tests.

RESULTS: An older woman with Alzheimer's disease was admitted to a dementia care facility because of aggressive behavior. Treatment with sertraline was initiated in February 1998. Sertraline doses were increased gradually to 200 mg daily by May 1998, and some improvement in behavior was seen. Concomitant therapy with donepezil 5 mg qhs was initiated June 26, 1998. Ten days later, confusion and jaundice were noted. Total bilirubin was 5.6 mg/dL, GGTP was 1208 IU/L, and alkaline phosphatase was 369 IU/L. Computed tomography revealed cholelithiasis without ductal dilation. Liver, spleen, and pancreas seemed normal. Donepezil and sertraline were discontinued. The patient was admitted to our institution and treated for dehydration. A liver biopsy revealed scattered portal eosinophils and prominent cholestasis consistent with acute chemical hepatitis. The GGTP and total bilirubin of this patient peaked at 2235 IU/L and 22.6 mg/dL, respectively. The patient improved, and her liver function tests normalized over the next 2 months.
Celiac Disease In Older People
Authors: Tai Vicky , Crowe Morgan , O'Keeffe Shaun
Published: April 2015

In recent years, there has been increasing recognition that the classical textbook presentation of celiac disease with a malabsorption syndrome and a flat jejunal mucosa is only part of a broad spectrum of clinical and histological features associated with gluten sensitivity. Diagnosis of this treatable condition is often delayed or missed because of a failure to appreciate that celiac disease can present at any age and that symptoms are often subtle and not clearly related to gastrointestinal disease. Nonspecific symptoms and nutritional deficiencies are especially common in older patients and may not always be investigated thoroughly. Use of serological screening tests has improved ease of detection of celiac disease in patients without classical symptoms.
The Relationship Between Aerobic Exercise Capacity and Circulating IGF‐1 Levels In Healthy Men and Women
Authors: Haydar Ziad R. , Blackman Marc R. , Tobin Jordan D. , Wright Jeanette G. , Fleg Jerome L.
Published: April 2015

OBJECTIVES: To determine whether aerobic capacity is associated independently with insulin‐like growth factor‐I (IGF‐1) levels in healthy community‐dwelling men and women.

SETTING: The Baltimore Longitudinal Study on Aging (BLSA).

DESIGN: A cross‐sectional analysis of data from the population‐based cohort of the Baltimore Longitudinal Study of Aging (BLSA).

PARTICIPANTS: We studied 181 men and 92 women aged 20 to 93 years, volunteers in the Baltimore Longitudinal Study on Aging (BLSA). Subjects were free of endocrine, renal, hepatic, gastrointestinal, or cardiac diseases, and they were taking no medications known to interfere with the growth hormone‐IGF‐1 axis.

MEASUREMENTS: All subjects underwent a single measurement of serum IGF‐1 in the fasting state, as well as peak V̇o2 determinations during maximal treadmill exercise testing performed within one visit of the IGF‐1 determination. Dual energy X‐ray absorptiometry (DEXA) scans were performed in a subset of 171 subjects (64 women and 107 men) for determination of fat free mass (FFM).

RESULTS: In the pooled group of women and men, univariate regression analysis revealed that age was correlated strongly with decreasing IGF‐1 levels (r = −0.53, P < .001) and with peak V̇o2 r = −0.56, P < .001). IGF‐1 levels were also significantly correlated with peak V̇o2 (r = 0.29, P < .001). There were no significant gender‐related differences in these relationships. On multivariate analysis, age (β = −0.54, P < .001), but not peak V̇o2 (β = −0.01, P = .840), remained strongly associated with IGF‐1 levels. After adjustment of peak V̇o2 for FFM in subjects with DEXA scans, results were similar.

CONCLUSIONS: These findings indicate that although both peak aerobic capacity and circulating IGF‐1 levels decline with age, aerobic capacity is not independently related to circulating IGF‐1 in healthy men and women across the adult life span. J Am Geriatr Soc 48: 139–145, 2000.
Aging Is Associated with Endothelial Dysfunction in the Human Forearm Vasculature
Authors: MD Nabil Andrawis , MD Drew S. Jones , MD Darrell R. Abernethy
Published: April 2015

OBJECTIVE: Our objective was to examine the role of the endothelium in maintaining vascular tone in the basal as well as in the contracted state during aging.

DESIGN/PARTICIPANTS: Responses to brachial artery infusion of acetylcholine in presence and absence of NG‐nitro‐L‐arginine methyl ester (L‐NAME) and to angiotensin II were studied in 11 young and 12 old white subjects.

MEASUREMENTS: Strain gauge plethysmography was used to measure forearm vascular resistance (FVR). The dose of acetylcholine at 50% maximal observed decrease in forearm vascular resistance (EC50) was significantly higher (11.0 ± 1.59 vs 7.07 ± .65 μg/min, respectively; mean ± SEM; P < .05) and the FVR at maximal acetylcholine effect (Emax) remained greater (12.6 ± 1.75 vs 7.15 ± 1.25 mm Hg/100 mL tissue volume/min; P < .02) in old compared with young subjects. Acetylcholine effect was significantly reversed by concomitant administration of L‐NAME, as indicated by the increase in EC50 (old, 20.2 ± 3.69; young, 11.9 ± 1.68 μg/min).

RESULTS: There was no age‐related difference in sodium nitroprusside‐induced decrease in FVR. The EC50 and Emax for angiotensin II‐mediated increase in FVR were 7.87 ± 1.15 and 8.36 ± 1.00 ng/min (EC50) and 5.30 ± .67 vs 6.56 ± 1.25 mm Hg/100 mL tissue volume/min (Emax), and these were not different in old and young subjects, respectively.

CONCLUSIONS: These data indicate that aging is associated with impaired endothelial‐ dependent vascular relaxation and that this is selective, with no age‐related change in endothelial‐independent vascular relaxation or angiotensin II‐mediated vascular contraction. J Am Geriatr Soc 48: 193–198, 2000.
GERIATRICS IN MANAGED CARE
Authors: Brummel‐Smith Kenneth , Kane Robert L. , Huck Shirley
Published: April 2015

EverCare represents a creative approach to providing medical services to long‐stay nursing home patients. It offers a capitated package of Medicare‐covered services with more intensive primary care provided by nurse practitioners. The program's underlying premise is that better primary care will result in reduced hospital use. This work examines the implementation of the program in six locations. It identifies some of the issues that must be addressed if the program is to succeed both operationally and financially. J Am Geriatr Soc 48: 218–223, 2000.
Change in Disability Follows Inpatient Treatment for Late Life Depression
Authors: Oslin David W. , Streim Joel , Katz Ira R. , Edell William S. , TenHave Thomas
Published: April 2015

OBJECTIVES: The objective of this study was to examine the relationship between functional disability and improvement in late life depression after acute inpatient treatment.

DESIGN: The study was a longitudinal assessment of depression and disability. Patients were assessed during an initial inpatient hospitalization and then 3 months postdischarge.

SETTING: All patients were evaluated initially after admission to one of 71 inpatient psychiatric treatment facilities.

PARTICIPANTS: The study comprised of 2572 patients older than age 60 who were relatively cognitively intact and experiencing significant depressive symptoms.

MEASUREMENTS: Depressive symptoms were measured using the Geriatric Depression Scale. Disability was measured using the Instrumental Activities of Daily Living Scale and the Medical Outcomes SF‐36.

RESULTS: Depressive symptoms improved in the majority of patients. Moreover, improvement in depressive symptomatology was significantly related to improvement in instrumental activities of daily living (IADLs) and to health‐related quality of life as measured by the SF‐36. This relationship was strongest among those who initially presented with some disability in IADLs.

CONCLUSIONS: This work underscores further the disabling nature of depression. Moreover, findings from this study suggest that treatment focused on depression can lead to significant improvements in both depressive symptoms and functional abilities. However, the results also suggest that the relationship between depression and disability is complex and that the effect of treating depression is not the only factor in the reversal of disability. J Am Geriatr Soc 48: 357–362, 2000.
Selecting Target Conditions for Quality of Care Improvement in Vulnerable Older Adults
Authors: Sloss Elizabeth M. , Solomon David H. , Shekelle Paul G. , Young Roy T. , Saliba Debra , MacLean Catherine H. , Rubenstein Laurence Z. , Schnelle John F. , Kamberg Caren J. , Wenger Neil S.
Published: April 2015

OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults.

DESIGN: Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews.

METHODS: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community‐dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions.

RESULTS: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end‐of‐life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community‐dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end‐of‐life care) are not recorded as diagnoses.

CONCLUSIONS: Twenty‐one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings. J Am Geriatr Soc 48: 363–369, 2000.
The Association of Depressive Symptoms and Urinary Incontinence Among Older Adults
Authors: Dugan Elizabeth , Cohen Stuart J. , Bland Deirdre R. , Preisser John S. , Davis Cralen C. , Suggs Patricia K. , McGann Paul
Published: April 2015

OBJECTIVES: To examine the relationship of urinary incontinence (UI) and depressive symptoms (DS) in older adults.

DESIGN: A randomized, controlled trial to determine the effects of clinical practice guideline implementation on provider attitudes and behavior, and patients' UI, health status, quality of life, and satisfaction with care. Baseline and endpoint data were collected from patients via computer‐assisted telephone interviewing.

SETTING: Forty‐one nonacademic primary care practices (PCP) in North Carolina.

PARTICIPANTS: A total of 668 community‐dwelling adults (age > 60) who had visited the one of the selected PCPs.

INTERVENTION: PCPs in the intervention group were given instruction in the detection and management of UI, educational materials for providers and patients, office system supports, and academic detailing.

MEASUREMENTS: The dependent measure was assessed using an eight‐item screener for DS. UI (status, frequency, amount), health (physical, mental), and demographic (age, gender, marital status) and self‐report information about bladder control served as predictors.

RESULTS: Wilcoxon rank sum tests showed that UI status was associated with moderate to severe DS (43% vs 30%, P = .05). Multivariate analyses showed that UI status, physical and mental health, and gender were significant predictors of DS. Among UI adults (n = 230), physical and mental health, life satisfaction, and the perception that UI interfered with daily life were significant predictors of DS.

CONCLUSIONS: This study provides clear evidence that UI is related to DS in older adults. J Am Geriatr Soc 48: 413–416, 2000.
Mild Cognitive Impairment: Potential Pharmacological Treatment Options
Authors: Sherwin Barbara B.
Published: April 2015

Both mild cognitive impairment and age‐associated memory impairment are terms used to describe memory decline in otherwise healthy, intellectually intact individuals aged older than 50 years. It is estimated that up to 38% of the middle‐aged and older population fulfill diagnostic criteria for this condition. Although the memory deficits observed in these individuals are fairly mild, they can interfere with day‐to‐day functioning. This article presents a review of the types of memory decline observed in older people, the diagnostic criteria used to define memory decline, the physiological and morphological brain changes that accompany aging, and the potential pharmacological treatment options, focusing on agents that have been evaluated in mildly cognitively impaired or normal older populations. J Am Geriatr Soc 48: 431–441, 2000.
How Much Do Persons with Alzheimer's Disease Cost Medicare?
Authors: Taylor Donald H. , Sloan Frank A.
Published: April 2015

BACKGROUND: Medicare claims are increasingly being used to identify persons with chronic diseases such as Alzheimer's disease (AD) for the purpose of determining the cost to Medicare of caring for such persons. Past work has been limited by the use of only 1 or 2 years of claims data to identify cases, leading to worries that this might lead to an undercount of prevalent cases and bias cost findings.

OBJECTIVES: To analyze the average total cost to the Medicare program in 1994 of persons with a claims‐based diagnosis of AD, using a 12‐year period of claims history to identify prevalent cases, and to investigate the effect on cost of time since diagnosis.

DESIGN: A cross‐sectional design with a 12‐year retrospective period to identify persons with AD.

SETTING: Medical care practices, hospitals, and other providers of services to Medicare beneficiaries in the US in 1994.

SUBJECTS: Respondents to the screener (n = 10,858) and community (5429) and institutional (n = 1341) questionnaire of the 1994 National Long Term Care Survey, with and without a claims‐based diagnosis of AD.

MEASUREMENTS: Average total cost to Medicare in 1994, measured as the actual amount Medicare paid for inpatient, outpatient, home health, skilled nursing facility, hospice, and Part B services, including payments to physicians, and other items such as durable medical equipment. We also measured disability in a variety of ways, including cognition, activity limitations, and residence in a nursing home.

RESULTS: The average total cost to Medicare of persons with a claims‐based diagnosis of AD was $6021 versus $2310 (P < .001) for persons without a diagnosis. When adjusting for patient characteristics, the ratio of cost between persons with AD and those without was reduced to about 1.6 to 1. Time since diagnosis was an important predictor of average total cost in 1994, with each additional year since diagnosis resulting in a $248 (P = .04) decrease in total cost (about 10% of the total sample mean cost of $2426). There was mixed evidence that persons with a diagnosis of AD incurred less cost than otherwise similarly disabled Medicare beneficiaries.

CONCLUSIONS: Time since diagnosis with AD is an important predictor of cost and one that should be explicitly included in any rate‐setting formula. Expanding the period used to identify cases resulted in an increase in the unadjusted ratio of cost of a Medicare beneficiary with AD relative to one without primarily because our control group costs are lower compared with those of past work. J Am Geriatr Soc 48:639–646, 2000.
Revisiting the One‐Year Geriatric Fellowship Option: A Preliminary Assessment
Authors: Hazzard William R. , Currin Dorothy Law , Woolard Nancy
Published: April 2015

OBJECTIVE: To ascertain early opinions of geriatric fellowship program directors regarding the 1‐year clinical training option.

DESIGN: A brief mail survey of the 100 program directors listed in Graduate Medical Education, 1998–1999.

MEASUREMENTS: Answers (favorable (+), no effect (0), or negative (‐)) to questions regarding the effect on the training program, position of the director, and geriatrics as a discipline.

RESULTS: This preliminary assessment produced decidedly mixed results. Seventy‐six program directors responded (76% response rate). The clearest positive effect on the program itself was on the quantity of applicants (63% +, 4% ‐) but less so on their quality (33% +, 15% ‐). The clearest negative impact was on research aspects of the fellowship (0% +, 67%‐). Other effects on the program were either null (clinical aspects and faculty morale) or moderately negative (educational, administrative, and financial aspects and the position of the program director), with few effects on the geriatrics division as a whole. Overall, the 1‐year option was felt to have adversely affected geriatrics as a respected professional field (11% +, 41% ‐). Nevertheless, the majority (61%) answered that introduction of the 1‐year option was wise. Although not attributed to this training pathway, program directors overwhelmingly perceived (75% +) that geriatrics has enjoyed enhanced strength and attractiveness as a discipline since introduction of the 1‐year option in 1992.

CONCLUSIONS: The 1‐year geriatric fellowship option has, at best, proved a mixed blessing to program directors. However, optimism regarding the future would seem to justify continuing to offer this option because of several observations and trends: (1) the increase in quantity and also perhaps quality of applicants; (2) growth in numbers of fellows and higher percentage program fill rates; (3) success of both 1‐and two‐year fellows in passing the Certificate of Added Qualifications examination and consequent increased generation of certified fellowship‐trained geriatricians; (4) strong sentiment that geriatrics is gaining strength and attractiveness; and (5) that introduction of the 1‐year option was wise. J Am Geriatr Soc 48:686–690, 2000.
Catechol‐O‐Methyltransferase (COMT) Inhibitors in Parkinson's Disease
Authors: Waters Cheryl
Published: April 2015

Catechol‐O‐methyltransferase (COMT) inhibitors are a new therapeutic option in the treatment of patients with Parkinson's disease. COMT inhibitors act by extending the duration of action of levodopa, thus improving the amount of time a patient can experience benefit from levodopa. COMT inhibitors are only used in conjunction with levodopa. They do have a propensity to augment dopaminergic effects, such that levodopa doses might need to be adjusted downward. Other side effects of COMT inhibitors include diarrhea and liver function abnormalities. Due to the latter, recent guidelines have been developed to monitor patients on tolcapone for this rare side effect, and these guidelines will be discussed.

This article also provides representative case histories for the appropriate use of COMT inhibitors that illustrate how these drugs can be used to manage patients with a fluctuating response to levodopa. J Am Geriatr Soc 48:692–698, 2000.
Effect of Enalapril and Nifedipine on Orthostatic Hypotension in Older Hypertensive Patients
Authors: Slavachevsky Inna , Rachmani Rita , Levi Zohar , Brosh David , Lidar Merav , Ravid Mordchai
Published: April 2015

OBJECTIVE: To compare the effect of enalapril with long‐acting nifedipine on orthostatic hypotension in older patients.

DESIGN: A prospective, double blinded, cross‐over study.

SETTING: The outpatient clinic of a university hospital.

PARTICIPANTS: Thirty‐nine patients aged 65 years or older with systolic blood pressure (SBP) of 140–190 mm Hg and diastolic blood pressure (DBP) of 90–110 mm Hg.

INTERVENTION: Enalapril 5–20 mg od or nifedipine 30–90 mg od for 8 weeks, followed by 4 weeks washout and cross‐over for a second 8‐week period.

MEASUREMENTS: Supine and standing 0‐, 1‐, and 5‐minutes blood pressure was recorded before and at the end of each treatment period.

RESULTS: At baseline, SBP was 158.8 ± 8.7 mm Hg, and DBP was 97.1 ± 5.9 mm Hg. There was a decline in SBP of 6.1 ± 2.7 mm Hg and 8.4 ± 4.1 mm Hg after 1 and 5 minutes of standing, respectively.

Both agents caused a significant decline in supine blood pressure. Enalapril: supine SBP 158.8 ± 8.7 to 143 ± 7.3 mm Hg; supine DBP 97.1 ± 5.9 to 85.1 ± 5.1 mm Hg (P = .0001). The drop in SBP after standing for 5 minutes was only 2.4 ± 1.6 mm Hg with no change in diastolic values. A ≥ 10 mm Hg drop in SBP was observed in only three patients, and no patient experienced a decline of 20 mm Hg or more. Nifedipine: supine SBP: 160.3 ± 9 to 145.3 ± 8.1 mm Hg; supine DBP: 96.3 ± 5.7 to 86.3 ± 5.8 (P = .0001). Nifedipine induced an orthostatic decline in SBP values; there was an 8.7 ± 4.8 mm Hg difference between supine and 5 minutes standing values (P = .0005) without change in diastolic values. An orthostatic decline in SBP of ≥ 10 mm Hg occurred in 13 patients, and there was a drop of ≥ 20 mm Hg in six patients. The cross‐over of enalapril and nifedipine reproduced the hypotensive effect and reversed the postural effect. (P = .0002 nifedipine vs enalapril)

CONCLUSIONS: Enalapril and nifedipine were equipotent in reducing supine blood pressure levels. Enalapril also reduced the number of orthostatic episodes significantly, whereas nifedipine aggravated this phenomenon. J Am Geriatr Soc 48:807–810, 2000.
Long‐Term Continuous Use of Benzodiazepines by Older Adults in Quebec: Prevalence, Incidence and Risk Factors
Authors: Egan Mary , Moride Yola , Wolfson Christina , Monette Johanne
Published: April 2015

OBJECTIVE: To determine the prevalence and incidence of long‐term use of benzodiazepines and to assess patient‐, prescriber‐, and drug‐related risk factors.

DESIGN: Cohort study.

PARTICIPANTS: 1423 community‐dwelling older adults in Quebec who participated in the Canadian Study of Health and Aging (CSHA1).

MEASUREMENTS: Patient characteristics were obtained from the CSHA1 database. These were linked to provincial health insurance data to ascertain benzodiazepine use and prescriber characteristics.

MAIN OUTCOME MEASURE: Use of benzodiazepines for at least 135 of the first 180 days following initiation of use.

RESULTS: Twelve‐month prevalence of long‐term continuous use, standardized by age and gender to the Quebec population, was 19.8%. Twelve‐month cumulative incidence of long‐term continuous use was 1.9%. Older patients were more likely to proceed to long‐term continuous use.

CONCLUSIONS: Risk of long‐term continuous use of benzodiazepines seems to increase with age. This association was found to be independent of gender, health status, anxiety, cognitive status, benzodiazepine type, and physician characteristics. J Am Geriatr Soc 48:811–816, 2000.
Mammography Use Among Women as a Function of Age and Patient Involvement in Decision‐Making
Authors: Burack Robert C. , George Julie , Gurney James G.
Published: April 2015

OBJECTIVE: To assess the extent to which self‐reported patient involvement in decision‐making for initiation of mammography differs with age.

DESIGN: Data from the 1992 National Health Interview Survey (NHIS) Cancer Control Supplement were evaluated. Prevalences were weighted and variances were adjusted using SUDAAN software to account for the complex, multistage sampling probability design of the NHIS. Logistic regression was used to evaluate the relative likelihood of self‐reported involvement in the decision to have a mammogram within the preceding year as a function of age and other covariates.

PARTICIPANTS: Mammography use was assessed among 3863 NHIS female respondents 40 years of age or older. The analysis of decision‐making was restricted to the subgroup of 1064 women who reported a screening mammogram within the preceding year and who provided information on the other relevant variables.

MEASUREMENTS AND MAIN RESULTS: The probability of reported mammography use within the preceding year declines among older groups of interviewees. Among women with a mammogram in the preceding year, the weighted percentage of women reporting active involvement in the decision (patient decision or decided jointly with a physician) declines from 51% among women 40 to 45 years of age to 19% among those aged 75 years or older. The adjusted odds ratio comparing the likelihood of participating in the decision to have a mammogram for the oldest women, compared with the youngest, was 0.31 (95% confidence interval 0.15 to 0.61).

CONCLUSIONS: Older women are substantially less likely than younger women to report active involvement in the mammography decision‐making process. Increased use of screening mammography among older women will require greater promotion by physicians. Other interventions, such as directed educational efforts, may also be needed to increase mammography demand among older women. J Am Geriatr Soc 48:817–821, 2000.
The Association Between Vascular Risk Factor‐Mediating Medications and Cognition and Dementia Diagnosis in a Community‐Based Sample of African‐Americans
Authors: Richards Stephanie S. , Emsley Christine L. , Roberts John , Murray Michael D. , Hall Kathleen , Gao Sujuan , Hendrie Hugh C.
Published: April 2015

OBJECTIVE: To determine the association between medications that ameliorate vascular risk factors and the prevalence of cognitive impairment and dementia in an older African‐American population.

DESIGN: A community‐based survey to identify subjects with and without evidence of cognitive impairment and subsequent diagnostic evaluation of a stratified sample of these subjects using formal diagnostic criteria for dementia and Alzheimer's disease (AD).

SETTING: Urban neighborhoods in Indianapolis, Indiana.

SUBJECTS: A random sample of 2212 African‐American adults aged 65 years and older residing in 29 contiguous census tracts.

MEASUREMENTS: Subjects' scores on the Community Screening Instrument for Dementia (CSID), formal diagnostic and clinical assessments for dementia, current medication use and history of medical illnesses, both self‐report and, where possible, from an informant.

Four outcome measures were defined by the following criteria: (1) cognitive impairment as defined by the subject's performance on the CSID cognitive scale; (2) cognitive/functional impairment as defined by the total CSID score that included a relative's assessment of the subject's functional abilities; (3) dementia as defined by explicit diagnostic criteria; and (4) possible or probable Alzheimer's Disease as defined by explicit criteria.

RESULTS: The vascular risk factor mediating medications, when analyzed together, were associated with a significantly decreased risk of diagnosis of cognitive impairment after controlling for age, education, and stroke (OR 0.73, P = .01) and also a significantly decreased risk of cognitive/functional impairment (OR 0.66, P = .02). Antihypertensive agents, excluding centrally acting sympatholytic drugs were associated with a significantly reduced risk of diagnosis of cognitive impairment (OR 0.56, P < .01) and cognitive/functional impairment (OR 0.64, P = .01).

Centrally acting sympatholytic agents were associated with an increased risk of diagnosis of cognitive impairment (OR 2.24, P < .01). There was a trend toward protection from a diagnosis of AD and dementia for the vascular risk factor mediating medications and for the antihypertensive medication, but this did not reach significant levels.

CONCLUSIONS: These data suggest that the use of medications to ameliorate vascular risk factors, particularly antihypertensive medication, may also be useful in reducing the risk of cognitive impairment in older subjects. However, they also suggest that physicians should be cautious in prescribing antihypertensive drugs with centrally acting sympatholytic properties to older subjects.
A Clinimetric Evaluation of Specialized Geriatric Care for Rural Dwelling, Frail Older People
Authors: Rockwood Kenneth , Stadnyk Karen , Carver Daniel , MacPherson Kathleen M. , Beanlands Hope E. , Powell Colin , Stolee Paul , Thomas Vince Salazar , Tonks Robert S.
Published: April 2015

OBJECTIVE: To test Comprehensive Geriatric Assessment (CGA) as an adjunct to usual care.

DESIGN: A randomized controlled trial with 3, 6, and 12 months follow‐up.

SETTING: Rural communities.

PATIENTS: A total of 182 of 265 frail older patients (52 refused, 2 withdrawn, 27 ineligible, 2 deaths) referred by family practitioners with allocation to intervention (n = 95) or usual care (n = 87).

INTERVENTION: Three‐month implementation of CGA recommendations by a Mobile Geriatric Assessment Team (MGAT) with follow‐up assessments at 3, 6, and 12 months. Geriatric nurse assessors, blinded to group assignment, performed each assessment.

MAIN OUTCOME MEASURE: Goal Attainment Scaling (GAS).

RESULTS: Baseline characteristics were comparable between groups. At 3 months, the intervention group was more likely to attain their goals (GAS total: X̄ = 46.4 ± 5.9; GAS outcome X̄ = 48.0 ± 6.6) compared with controls (total: X̄ = 38.7 ± 4.1; outcome X̄ = 40.8 ± 5.6) (P < .001). Standard assessments of function (Barthel index, instrumental activities of daily living), cognition (Mini‐Mental State Examination), and quality of life (modified Spitzer quality of life index) showed no difference over 12 months. No difference in survival (intervention: X̄ = 320 days, SE = 6; control: X̄ = 294 days, SE = 6; P = .257) or time to institutionalization (intervention: 340 days, SE = 9; control: 342 days, SE = 8; log rank = 0.661; P = .416) were observed.

CONCLUSIONS: A MGAT can target rural dwelling, frail older persons, perform in‐home CGA, and develop an intervention strategy. Although the intervention did not prolong life or delay institutionalization, clinically important benefits were observed.
Chiropractic Care for Patients Aged 55 Years and Older: Report from a Practice‐Based Research Program
Authors: Hawk Cheryl , Long Cynthia R. , Boulanger Karen T. , Morschhauser Elaine , Fuhr Arlan W.
Published: April 2015

OBJECTIVE: To characterize patients aged 55 years and older and features of chiropractic care provided to them.

DESIGN: Observational, practice‐based research study.

SETTING: Chiropractic offices in the United States and Canada, 1997–1998.

PARTICIPANTS: Chiropractors in 96 practices in 32 states and two Canadian provinces collected data on 805 eligible patients aged 55 years and older during a 12‐week study period.

MEASUREMENTS: In addition to questionnaires on practice characteristics, patient demographics, chief complaints, and health habits, two standardized instruments were administered: for general health status, the Medical Outcomes Study 12‐Item Short‐Form Health Survey (SF‐12); and for disability related to chronic pain, the Pain Disability Index (PDI).

RESULTS: Of 805 study patients, 60.1% were women and 94.7% were white. Overweight patients comprised 38.6% and obese 20.6% (n = 656) of the total; 9.7% of patients were hypertensive (n = 590). Smoking was reported by 12.7% and 50.2% reported regular exercise. The Physical Component Summary scores of the SF‐12 seemed somewhat lower than population norms, whereas the Mental Component Summary scores differed very little from norms. Chief complaints were predominantly pain‐related (72.3%), most commonly back pain (32.9%). The PDI mean baseline score for chronic patients was 16.3 (scale, 0–70), and 40.6% of study patients reported using at least one pain medication (prescription or nonprescription) more than three times per week. More than half of complaints (54.9%) had onsets more than 6 weeks before the baseline visit. For 66.6% of subjects, a chiropractor was the only provider for their current complaint. In addition to manipulation, most common features of care were recommendations on exercise (41.0%), heat or cold applications (40.8%), and food supplements (24.5%). At 4 weeks, 19.6% were discharged, 58.8% continued treatment, and 20.1% had discontinued care (self‐discharged). For these three groups, those with higher PDI mean baseline scores showed more change at 4 weeks. For patients who were discharged by the doctor, the proportion of reported pain medication use decreased 7.3% from baseline to 4 weeks, increased for patients who discontinued care, and remained about the same for those continuing care.

CONCLUSIONS: Further investigation of the PDI and a decrease in pain medication use as outcome measures seems warranted. The descriptive information in this study may assist providers of care to older adults to better understand their patients' use of chiropractic care. J Am Geriatr Soc 48: 534–545, 2000.
Care for Depression in HMO Patients Aged 65 and Older
Authors: Unützer Jürgen , Simon Gregory , Belin Thomas R. , Datt Moctar , Katon Wayne , Patrick Donald
Published: April 2015

OBJECTIVE: To examine treatment for depression among older adults in a large staff model health maintenance organization (HMO).

DESIGN: A 4‐year prospective cohort study (1989–1993).

SETTING: Four primary care clinics of a large staff model HMO in Seattle, Washington.

PATIENTS: A total of 2558 Medicare enrollees aged 65 and older.

MAIN OUTCOME MEASURES: Treatment of depression was defined as primary care visits resulting in depression diagnoses, use of antidepressant medications, or specialty mental health services.

MAIN RESULTS: The older adults in our sample had low rates of treatment for depression, ranging from 4 to 7% in the entire sample and from 12 to 25% among those with probable depressive disorders. Predictors of treatment included female gender, severity, and persistence of depressive symptoms, and severity of comorbid medical illness. Even when patients were treated for depression, the intensity of treatment was very low. Overall likelihood of treatment for depression increased somewhat from 1989 to 1993, but among those treated, the rate of adequate antidepressant use remained below 30%.

CONCLUSIONS: There is still considerable need to improve care for older adults with depression in primary care. J Am Geriatr Soc 48:871–878, 2000.
Attrition in an Exercise Intervention: A Comparison of Early and Later Dropouts
Authors: Schmidt Julia A , Gruman Cynthia , King Mary B , Wolfson Leslie I
Published: April 2015

OBJECTIVE: To identify reasons for dropout and factors that may predict dropout from an exercise intervention aimed at improving physical function in frail older persons.

DESIGN/SETTING: An 18‐month randomized controlled intervention in a community setting. The intervention comprised 2 groups: class‐based and self‐paced exercise.

PARTICIPANTS: 155 community‐dwelling older persons, mean age 77.4, with mildly to moderately compromised mobility.

MEASUREMENTS: The primary outcome measure was dropout. Dropouts were grouped as: D0, dropout between baseline and 3‐month assessment, and D3, dropout after 3‐month assessment.

MEASUREMENTS: Measurements of demographics, health, and physical performance included self‐rated health, SF‐36, disease burden, adverse events, PPT‐8, MacArthur battery, 6‐minute walk, and gait velocity.

RESULTS: There were 56 dropouts (36%), 31 in first 3 months. Compared with retained subjects (R), the D0 group had greater disease burden (P = .011), worse self‐perceived physical health (P = .014), slower usual gait speed (P = .001), and walked a shorter distance over 6 minutes (P < .001). No differences were found between R and D3. Multinomial logistic regression showed 6‐minute walk (P < .001) and usual gait velocity (P < .001) were the strongest independent predictors of dropout. Controlling for all other variables, adverse events after randomization and 6‐minute walk distance were the strongest independent predictors of dropout, and self‐paced exercise assignment increased the risk of dropout.

CONCLUSIONS: We observed baseline differences between early dropouts and retained subjects in disease burden, physical function, and endurance, suggesting that these factors at baseline may predict dropout. Improved understanding of factors that lead to and predict dropout could allow researchers to identify subjects at risk of dropout before randomization. Assigning targeted retention techniques in accordance with these factors could result in decreased attrition in future studies. Therefore, the results of selective attrition of frailer subjects, such as decreased heterogeneity, restricted generalizability of study findings, and limited understanding of exercise effects in this population, would be avoided. J Am Geriatr Soc 48:952–960, 2000.
Mitral Balloon Valvotomy for the Treatment of Mitral Stenosis in Octogenarians
Authors: Sutaria Nilesh , Elder Andrew T. , Shaw Thomas R. D.
Published: April 2015

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged ≥ 80 years.

SETTING: A tertiary cardiac centre

DESIGN: A retrospective study of 20 octogenarians (mean age 83, range 80–89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYHA) symptom class III or IV. Fourteen had been judged unfit for cardiac surgery. Hemodynamic data was recorded before and after MBV. Symptomatic outcome was documented at 1 month for all patients. Outcome at 1 year was available for 16 patients.

RESULTS: Dilatation of the mitral valve was achieved in all patients without major complications. Mean mitral valve area increased 106% from 0.81 (± 0.3) to 1.67 (± 0.8) cm2, transvalvular gradient decreased from 11.8 (± 4.8) to 5.6 (± 2.9) mm Hg, cardiac output increased from 3.1 (± 0.6) to 4.1 (± 1.4) 1/min (all P < .01). Eight of these 20 patients obtained a valve area ≥ 1.5 cm2, and 16 obtained an area ≥ 1.2 cm2. One month after BMV, all patients were alive, and 16 of the 20 patients were improved by at least one NYHA class. This improvement was sustained in 7 of 16 patients followed up for 1 year. More severe mitral valve degenerative change, determined by echocardiography, was associated with poorer outcome.

CONCLUSIONS: In this group of very old and frail patients, MBV was safe and resulted in significant immediate improvement. Sustained symptomatic benefit at 1 year was obtained in those with less extensive leaflet and subvalvular disease. In patients with severe degenerative valve disease on echocardiography, but unacceptable surgical risk, MBV offers short‐term palliation. J Am Geriatr Soc 48:971–974, 2000.