bluuebunny/crossref_metadata_2025 huggingface dataset:
Identification and Intervention for Urinary Incontinence by Community Physicians and Geriatric Assessment Teams
Authors: McDowell B. Joan , Silverman Myrna , Martin David , Musa Donald , Keane Christopher
Published: April 2015

Objective: To determine the difference in the recognition and intervention/referral rates for urinary incontinence (UI) by out‐patient Geriatric Assessment Units (GAUs) and private physicians in community‐based practices (CMDs).

Design: A multi‐site, randomized, controlled study where block randomization was utilized to assign subjects 65 years of age and older to either a GAU or a CMD for assessment.

Setting: One academic and three hospital‐based GAUs and CMDs in private practice in a large metropolitan area.

Participants: Three hundred sixty‐four community‐dwelling frail men (14%) and women (86%) with a mean age of 75 years.

Measurements: The independent variable was the type of out patient care, either CMD or GAU, to which the subjects were randomized. The dependent variables were recognition of UI by the health care providers and intervention or referral for the problem of UI once it was identified. Instruments included a structured in‐home interview performed before randomization designed to uncover health problems such as urinary incontinence, as well as a medical record review form used post‐assessment to ascertain recognition rates and intervention for UI by CMDS and GAUs. Both of the instruments were developed and piloted by the investigators in a preliminary study.

Main Results: Of the 364 subjects, 151 (41.5%) reported UI during the in‐home interviews. Recognition rates for UI were significantly better for GAUs (48 of 81, 59.3%) than CMDs (11 of 70, 15.7%) (P < 0.001). This was true for mild (<3 times/week) 44.2% vs 2.1% (P < 0.000005) as well as severe UI (>3 times/week) 86.2% vs 43.5% (P = 0.00111) for GAUs and CMDs, respectively. There were no significant differences in the rate of referral/intervention for recognized cases of UI by GAUs or CMDs. GAUs referred/treated five (21.7%) cases of mild UI and 10 (40%) cases of severe UI while CMDs referred/treated three (30%) cases of severe UI but did not offer intervention for the one recognized case of mild UI. GAUs were more likely to refer to Continence Programs (12, 25%) compared with CMDs who were more likely to refer (3, 100%) to a urologist. A majority of the subjects with UI did not receive treatment or referral for their problem (8, 72.7% CMDs and 33, 68.6% of GAUs).

Conclusions: GAUs out performed CMDs in the identification of subjects with both mild and severe UI. However, the intervention/referral rates were low for both GAUs and CMDs. The outcome of this study points to the need for increased emphasis on UI in curriculum preparing physicians and other health providers as well as the need for continuing education for those already in practice.
Subjective Memory Complaints and Personality Traits in Normal Elderly Subjects
Authors: Hänninen Tuomo , Reinikainen Kari J. , Helkala Eeva‐Liisa , Koivisto Keijo , Mykkänen Leena , Laakso Markku , Pyörälä Kalevi , Riekkinen Paavo J.
Published: April 2015

Objective: To evaluate the relationship between objectively measured memory functions and subjective complaints of memory disturbance and whether subjective complaints are affected by some personality traits or affective states.

Design: Cross‐sectional two‐group comparison.

Setting: The city of Kuopio in Eastern Finland, considered representative of the urban elderly population of Finland.

Participants: Originally 403 subjects aged 67–78 years from the random sample and then two matched study groups initially including eighteen subjects but only ten in the final analysis.

Measurements: Screening and follow‐up examinations of subjects with and without subjective memory complaints: (1) Memory functions: Benton's visual retention test and the paired‐associated learning subtest of Wechsler Memory Scale. (2) Memory complaints: Memory Complaint Questionnaire. (3) Personality traits and affective state: Two subscales from Minnesota Multiphasic Personality Inventory and Geriatric Depression Scale.

Results: Complaints of memory loss did not correlate with the actual memory performance in the tests. However, those subjects who most emphatically complained of memory disturbance had greater tendencies toward somatic complaining, higher feelings of anxiety about their physical health, and more negative feelings of their own competence and capabilities than those who did not complain of memory deterioration associated with aging.

Conclusions: The study suggests that subjective feelings of memory impairment are more closely associated with personality traits than with actual memory performance in normal elderly people. J Am Geriatr Soc 42:1–4, 1994
The Relationship of Chronic Diseases and Health Status to the Health Services Utilization of Older Americans
Authors: Blaum Caroline S. , Liang Jersey , Liu Xian
Published: April 2015

OBJECTIVE: To study simultaneously the relationships among chronic diseases and physical health status as they affect health services utilization of older adults.

DESIGN: Secondary analysis of a large, cross‐sectional health interview survey, the Supplement on Aging of the 1984 National Health Interview Survey, using multiple equation methods to evaluate disease‐specific impacts on physical health status, the direct impact of specific diseases on utilization of physician services and hospital care, and the indirect impact of specific diseases on utilization, mediated through physical health status.

PARTICIPANTS: A total of 11,497 people aged 65 and older, representing a complex, multistage sample of the noninstitutionalized, older adult population of the United States.

MEASUREMENTS: Predictor variables included specific chronic diseases (hypertension, arthritis, diabetes, cancer, and atherosclerotic heart disease), self‐rated health status, and total number of disabilities. Control variables included age, gender, race, education, social integration. Outcome variables were physician visits and hospital stays.

MAIN RESULTS: It was shown that different diseases have different relative impacts on physical health status, probability of utilization, and amount of utilization, if any, and different chronic diseases have a different mix of direct and indirect effects on utilization.

CONCLUSION: The impact of chronic disease on health services utilization in a community‐dwelling population is not a simple or direct relationship. Diseases vary according to their impact on different types of utilization, their impact on the probability of any health services use versus the amount of use, and on how much their effect on utilization is mediated through health status.
Cognitive Screening of Nursing Home Residents: Factor Structures of the Mini‐Mental State Examination
Authors: Abraham Ivo L. , Manning Carol A. , Snustad Diane G. , Brashear H. Robert , Newman Maureen C. , Wofford Amy B.
Published: April 2015

OBJECTIVE: To examine factor structures of the Mini‐Mental State Examination, attempting first to replicate any of previously proposed 2‐factor solutions; and to explore, secondly, the presence of clinically more differentiated and statistically stable factor structures representing common neurocognitive dimensions.

DESIGN: Factor analytic investigation of descriptive dataset collected on nursing home residents. Two factor analyses were performed, one in which the number of factors was fixed at 2 in an effort to replicate previous studies, and one in which the number of factors to retain was determined by the scree test. Both factor analyses used established methods for judging the adequacy of the correlation matrix and the significance of factor loadings, and both applied principal components analysis for initial factor extraction and the equamax criterion for orthogonal rotation.

SETTING: Seven nursing homes with a total of 894 beds.

PARTICIPANTS: 922 assessments on nursing home residents were performed, of which 892 were complete and entered into the factor analyses. The observation‐to‐variable ratio exceeded 81:1, assuring the statistical stability of factor solutions derived.

MEASUREMENT: The Mini‐Mental State Examination, with standardization of words to be recalled and the inverted spelling of “world” as the mental reversal task.

MAIN RESULTS: Two factor structures were derived. A 2‐factor solution, explaining 36.5% of the variance and statistically and conceptually different from those obtained in previous studies, distinguished between Perceptual‐Organizational and Psychomotor skills. A 4‐factor solution, which explained 56.1% of the variance, included a factor named Executing Psychomotor Commands, while also further differentiating the perceptual‐organizational processes into the factors of Memory, Concentration, and Language.

CONCLUSION: The 2‐factor solution shows that, notwithstanding previous claims to the contrary, the MMSE can make stable and independent distinctions between psychomotor and perceptual‐organizational processes. However, this solution is statistically and conceptually limited and, therefore, of limited clinical and scientific relevance. The 4‐factor solution of the MMSE maps well onto commonly recognized dimensions of neurocognitive ability. It offers a stable, intuitively sound, and statistically supported framework for clinical differentiation of cognitive screening data into independent clinical dimensions of neurocognitive functioning. Thus, it offers clinicians and researchers a 4‐dimensional framework for interpreting data obtained by means of the MMSE. Studies with other populations of cognitively impaired and intact elderly are recommended to validate and extend the present findings.
Body Weight Estimation of Elderly Patients by Nomogram
Authors: Atiea J.A. , Haboubi N.Y. , Hudson P.R , Sastry B.D.
Published: April 2015

OBJECTIVE To determine a safe and easy way to estimate body weight (BW) accurately in nonambulant elderly patients.

DESIGN An anthropometric study of ambulant patients.

PARTICIPANTS Two hundred eleven ambulant inpatients, 108 males and 103 females.

SETTING Inpatient departments of the University Department of Geriatric Medicine, Cardiff, Wales, UK.

MEASUREMENTS Skinfold thickness of chin, triceps, forearm, wrist, subscapular, sternal angle, waist, suprailiac, knee, and calf; circumference of arm, forearm, thigh and calf; body weight, chest girth, abdominal girth, upper limb length, leg length, and body weight. Measurements were carried out by means of Harpenden Skin‐Fold Caliper, tape measure, and bathroom scale.

RESULTS Measured body weight in males was highly correlated with both arm circumference and chest girth. In females, measured body weight was highly correlated with waist skinfold thickness and thigh circumference. Nomograms for weight estimation in males and females were constructed from the regression equations for these measurements.

CONCLUSIONS Convenient estimation of body weight in nonambulant patients may be carried out using nomograms, which, themselves, may be used as progress sheets to assess the effect of dietary supplementation on body weight.
Genetics, Ethics, and Alzheimer Disease
Authors: Post Stephen G.
Published: April 2015

This article considers the emerging research on Alzheimer disease (AD) genetics in relation to ethical questions surrounding presymptomatic and prenatal genetic testing. Given the rapid advance in AD genetics over the past 8 years, it is likely that the attention of clinicians and ethicists will increasingly turn to genetic issues. After a survey of current genetic knowledge, this article addresses 3 areas of likely ethical concern. While AD genetic screening programs are currently rare and restricted to specific pedigrees, they will become more common in the future. It is, therefore, imperative that society and clinicians begin to consider the ethical issues this raises.
Does Age Play a Role in Clinical Presentation of Hypothyroidism?
Authors: Doucet J. , Trivalle Ch. , Chassagne Ph. , Perol M‐B. , Vuillermet P. , Manchon N‐D. , Menard J‐F. , Bercoff E.
Published: April 2015

OBJECTIVE: To determine if aging modifies the clinical presentation of hypothyroidism.

DESIGN: Comparison of 24 clinical signs of hypothyroidism between elderly patients (≥ 70 years of age) and younger patients (≤ 55 years of age).

SETTING: Prospective study of patients with chemically confirmed overt hypothyroidism.

PATIENTS: Sixty seven elderly patients (79.3 ± 6.7 years) and 54 younger patients (40.8 ± 9 years) were included in the study.

RESULTS: Neither mean duration of evolution nor mean thyroid‐stimulating hormone (TSH) level were different between the 2 groups. Two signs were found in more than 50% of the elderly patients (fatigue and weakness). Four signs were significantly less frequent in elderly patients (chilliness, paresthesiae, weight gain, and cramps). Mean number of clinical signs in the elderly (6.6 ± 4) was significantly smaller than in young patients (9.3 ± 4.7) (P < 0.01).

CONCLUSIONS: Our results suggest that the presentation of hypothyroidism is altered in the elderly in comparison with young patients in that there are (1) fewer signs or symptoms and (2) diminished frequency of some classical signs. Our results underline the importance of TSH measurement in the elderly.
Physicians' Knowledge of Drug Costs for the Elderly
Authors: Glickman Lillian , Bruce Ellen A. , Caro Francis G. , Avorn Jerry
Published: April 2015

OBJECTIVE: To measure physicians' knowledge of the costs of commonly used medications in geriatric practice and how such awareness influences their prescribing decisions.

DESIGN: A survey of pharmacies to determine the prices of 14 commonly used brand name and generic drugs and an in‐person survey of physicians asking them to price these drugs.

SETTING: Eastern Massachusetts

PARTICIPANTS: One hundred thirty‐two primary care practitioners were surveyed during hospital rounds and medical society meetings.

MEASUREMENT: The study examined physician awareness of patients' ability to afford drugs, the use of generic drugs, clinical decision‐making practices, and the physicians' level of knowledge of drug costs. Actual drug prices were measured by surveying 22 pharmacies.

RESULTS: Of the 132 respondents, 85% reported that inability to afford medications was a problem for some of their patients. One in five indicated that they did not believe generic drugs to be as safe or effective as brand name drugs, and 30% reported that they rarely or never had access to information about drug costs. Of the 99 physicians who estimated drug prices, there was a marked trend toward underestimation of the prices of more expensive drugs as well as overestimation of the prices of less costly drugs. Physician estimates of prices were highly variable; their estimates were much more variable than pharmacy prices. Younger physicians were more likely than older physicians to make correct estimates, and specialists in internal medicine were less likely to make correct estimates than physicians in other specialties.

CONCLUSIONS: These data indicate that substantial knowledge deficits exist in physicians' understanding of the economic implications of the prescriptions they write. Considerable educational activity will be necessary in this area if clinicians are to function as cost‐effective prescribers under health care reform.
Blinking and the Release Reflexes: Are They Clinically Useful?
Authors: Thomas Robert Joseph
Published: April 2015

Objective: To review the clinical utility of blinking and the release reflexes, palmomental, glabellar, grasp, and snout, as an important part of the bedside neurological examination.

Design: Articles published from 1966 to 1993 that addressed blinking or the release reflexes were identified by searching the MEDLINE database. Thirty‐seven references provided clinically useful and applicable information.

Results: There is controversy regarding the optimal method of clinical elicitation of these reflexes. The release reflexes are frequently seen as an incidental abnormality in the elderly. A positive grasp reflex, especially if asymmetrical, is sensitive but not specific for abnormal brain function. Lack of habituation is more important than the mere presence or absence of a reflex. The brainstem circuits involved in the regulation of blinking and the release reflexes are discussed, as are their abnormalities in a variety of clinical settings.

Conclusion: Blinking and the release reflexes have clinical utility in the diagnosis and bedside clinical assessment of diseases as diverse as frontal lobe lesions, hydrocephalus, multiple sclerosis, Parkinson's disease, Alzheimer's disease and other dementias, falls in the elderly, ageing, HIV‐encephalopathy, schizophrenia, tumors in the region of the sylvian aqueduct and recovery from head trauma.
Guidelines, Practice Policies, and Parameters: The Case for Geriatrics
Authors: Rudberg Mark A. , Barr Gwendolyn , Cassel Christine K. , Hayward Robert S. A. , Sussman Elliot J. , Roizen Michael F.
Published: April 2015

Objective: As the population ages, the care of older persons becomes more important. At the same time, practice guidelines that provide recommendations for appropriate care are being published in greater numbers. The purpose of this work is to determine the proportion of guidelines that contain specific information about older persons.

Design: Through a random sample of published guidelines listed in the AMA Directory of Practice Parameters, 1992 Edition, we determined the proportion of guidelines that contain specific age‐related information. We also determined if, over time, there was a difference in the proportion of practice guidelines containing information about older persons.

Results: 45.9% (95% CI, range 33.4–58.4) of guidelines that could conceivably pertain to older persons contain no age information; 24.6% (95% CI, range 13.8–35.4) of guidelines contain information only about persons less than 65 years of age; 29.5% (95% CI, range 18.1–41.0) of guidelines contain specific information about older persons. Moreover, there were no secular trends in the proportion of guidelines pertaining to older persons.

Conclusions: Only a minority of practice guidelines contain information about older persons. Possible causes and solutions to this shortfall are discussed.
Improving Compliance with Immunization in the Older Adult: Results of a Randomized Cohort Study
Authors: Herman Carla J. , Speroff Theodore , Cebul Randall D.
Published: April 2015

OBJECTIVE: To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients.

DESIGN: Randomized controlled trial using three parallel group practices at a public urban teaching hospital.

SETTING: Public teaching hospital.

SUBJECTS: All patients 65 years of age and older (n = 1202) seen by resident physicians (n = 66) attending three ambulatory medical practices from October 1, 1989 to March 31, 1990.

INTERVENTIONS: All three provider groups received intensive education in immunization standards. The control group received no further intervention. Staff in the second group offered education to patients at their visits. In the third group, the prevention team, a flowsheet was used, patient education offered, and staff had their tasks redefined to facilitate compliance; for vaccinations, eg, nurses could vaccinate independent of MD initiative.

MEASUREMENTS AND MAIN RESULTS: Medical records were reviewed for the 1202 patients seen, including 756 patients seen during both the 1988‐89 and 1989‐90 influenza seasons, to determine documented offering and receipt of vaccinations. During the intervention period (1989‐90), influenza vaccinations were offered significantly more frequently to prevention team patients (68.3%) than to patients in either the patient education (50.4%) or control (47.6%) groups (P = 0.006), even after adjusting for the patients' prior vaccination status, age, gender, race, and high‐risk co‐morbidity and for physicians' level of training. Likewise, pneumococcal vaccinations were offered more frequently to previously unvaccinated prevention team patients (28.3%) than to patient education (6.5%) or control (5.4%) group patients (P = 0.001), even after adjusting for the factors using multivariate analysis. Compliance rates did not differ between patient education and control subjects for either vaccine. Pre‐intervention physician surveys documented higher perceived than actual compliance for both vaccines, with 89.0% and 52.8% of physicians believing that they complied with influenza and pneumococcal vaccination guidelines, respectively.

CONCLUSIONS: The results of this trial provide strong support for organizational changes that involve non‐physician personnel to enhance vaccination rates among older adults.
The MDS Cognition Scale: A Valid Instrument for Identifying and Staging Nursing Home Residents with Dementia Using the Minimum Data Set
Authors: Hartmaier Susan L. , Sloane Philip D. , Guess Harry A. , Koch Gary G.
Published: April 2015

OBJECTIVE: We report the development and validation of an MDS‐based cognitive index, the MDS Cognition Scale (MDS‐COGS), by evaluating it against two popular dementia rating scales, the Global Deterioration Scale (GDS) and the Mini‐Mental State Examination (MMSE).

DESIGN: A Cross‐sectional study.

PARTICIPANTS: Two hundred nursing home residents.

MEASUREMENTS: Each study participant was assessed on the GDS and the MMSE by trained medical students. At the same time, but independent of the medical students, a geriatric nurse completed the Minimum Data Set (MDS) instrument on each participant.

MAIN RESULTS: The Cognitive Performance Scale (CPS), a categorical measure of cognition that uses MDS items, was compared with the GDS in 133 subjects, using a split‐sample technique. The GDS was found to be more appropriate as a 4‐stage than a 7‐stage scale, with GDS stages 1–4 acting as a single stage. The CPS showed very poor percent agreement with GDS stages 5 and 7 (50% or less) and, therefore, was revised by adding other MDS predictors. The new instrument, designated MDS‐COGS, is a 0–10 point scale generated from eight MDS cognitive items. The MDS‐COGS was then validated against the 4‐stage GDS and MMSE in the remaining 67 nursing home residents. Chance‐corrected agreement (kappa) between the MDS‐COGS and GDS in the 67 subjects was 0.80 (95% CI = 0.70, 0.88), and percent agreement with GDS stages 5 and 7 was 60% and 85%, respectively. The MDS‐COGS was also demonstrated to be a valid measure of cognitive impairment as defined by the MMSE, with sensitivity, specificity, chance‐corrected agreement (kappa), and area under the ROC curve, all above 0.80.

CONCLUSIONS: The MDS Cognition Scale, the MDS‐COGS, provides a valid measure of the presence and severity of cognitive impairment in nursing home residents using items from the Minimum Data Set.
Is Geriatrics a Primary Care or Subspecialty Discipline?
Authors: Reuben David B. , Zwanziger Jack , Bradley Thomas B. , Beck John C.
Published: April 2015

Objective: To determine how much of the clinical care provided to older persons by geriatricians is primary versus consultative.

Design: National Survey.

Participants: Candidates for the 1988 certifying examination in geriatrics, physicians who expressed interest in the examination but did not register for the examination, and physicians who expressed no interest in the examination (comparison group physicians).

Results: Based on a 72% response rate, 78% of the care rendered by certified internal medicine geriatricians and 90% of the care rendered by certified family practice geriatricians to older persons was primary care. Internal medicine geriatricians spent a greater percentage of their care of older persons providing primary care compared with internists with no interest in geriatrics. Although internist geriatricians who were formally trained or had additional subspecialty certification provided less of their care as primary care compared with geriatricians who had no formal training, the majority of care (approximately 70%) provided by each of these two subgroups was primary care.

Conclusions: The vast majority of care provided to older persons by geriatricians is primary care, and these physicians should be considered as generalists for health policy and educational purposes.
Incidence of Injury‐Causing Falls Among Older Adults by Place of Residence: A Population‐Based Study
Authors: Luukinen Heikki , Koski Keijo , Honkanen Risto , Kivelä Sirkka‐Liisa
Published: April 2015

OBJECTIVE: To describe the incidence and associated factors of injury‐causing falls by place of residence.

DESIGN: A prospective population‐based study.

SETTING: Five municipalities in northern Finland.

PARTICIPANTS: All persons in the five communities aged 70 years or older living at home (n = 1016) and in long‐term institutionalized care (n = 143).

MEASUREMENTS: We recorded all fall incidents during a 2‐year period by occurrence and severity of injury, using diary reporting and regular calls and by examining the medical and nursing records of all participants. The times, places, circumstances, and medical treatment needed were recorded as well.

RESULTS: Men living at home experienced 71 minor injuries/1000 person years (PY), 42 major soft tissue injuries/1000PY, and 12 fractures/1000PY; women at home experienced 175 minor injuries/1000PY, 65 major soft tissue injuries/1000PY, and 33 fractures/1000PY. Institutionalized older men had 272 minor injuries/1000PY, 122 major soft tissue injuries/1000PY, and 41 fractures/1000PY; institutionalized women had 292 minor injuries/1000PY, 131 major soft tissue injuries/1000PY, and 58 fractures/1000PY. Falls causing injury to older adults in long‐term institutionalized care were more evenly distributed by time of day than those that occurred at home. The majority of the injuries sustained in long‐term institutionalized care were injuries to the head. The incidence rate of fall injuries requiring medical attention in women, 113/1000PY, was twice that in men, 57/1000PY.

CONCLUSIONS: Injury‐causing falls are more frequent in older people living in long‐term institutionalized care, and the time‐distribution and some circumstances differ from those of injury‐causing falls in home‐dwelling older people. J Am Geriatr Soc 43:871–876, 1995.
Antipsychotic Prescribing Patterns and the Treatment of Extrapyramidal Symptoms in Older People
Authors: Kalish Susan C. , Bohn Rhonda L. , Mogun Helen , Glynn Robert J. , Gurwitz Jerry H. , Avorn Jerry
Published: April 2015

OBJECTIVES: We have previously identified antipsychotic use as a risk factor for the use of both dopaminergic and anticholinergic antiparkinsonian drugs in older people. This study examines whether and how such antipsychotic regimens were adjusted before the addition of an antiparkinsonian drug.

DESIGN: Retrospective comparison study

PARTICIPANTS: There were 1307 antipsychotic users begun on anticholinergic antiparkinsonian drugs and 345 antipsychotic users begun on dopaminergic drugs; 1864 antipsychotic users not prescribed antiparkinsonian drugs served as comparison subjects. Data were drawn from health care claims of patients aged 65–99 in the New Jersey Medicaid Program from 1981 to 1990.

MEASUREMENTS: We determined if antipsychotic regimens were discontinued, reduced in dosage, or modified to reduce extrapyramidal toxicity before the institution of antiparkinsonian therapy.

RESULTS: Thirty‐five percent of the patients begun on dopaminergic drugs had their antipsychotic medication discontinued before beginning antiparkinsonian therapy; the antipsychotic was discontinued in only 12% of patients who started anticholinergic medications (P < .001). Among the smaller subset of patients with sufficient duration of antipsychotic exposure to examine changes in dose, 54% of patients begun on dopaminergic agents had their antipsychotic regimen reduced or discontinued before antiparkinsonian therapy, whereas 33% of patients begun on anticholinergic agents had one of these regimen changes (P < .001). Controlling for potential clinical and demographic confounders using multivariate logistic regression did not substantively alter these results.

CONCLUSIONS: These data indicate that physicians frequently fail to discontinue or modify an antipsychotic regimen before adding a new drug to treat probable drug‐induced extrapyramidal symptoms. Such prescribing patterns preceding use of dopaminergic antiparkinsonian drugs suggest that addition of such drugs may represent an inappropriate attempt to treat presumed idiopathic Parkinson's disease in many cases.
Potential for Adverse Drug‐Alcohol Interactions Among Retirement Community Residents
Authors: Adams Wendy L.
Published: April 2015

OBJECTIVES: Medications and alcohol are both used commonly by older people. Thus, the potential for adverse drug‐alcohol interactions is very high in this population, but data on actual concurrent use of alcohol and medicines likely to interact with alcohol are lacking. The objectives of this study were to determine the frequency of alcohol and medication use and the potential for specific adverse drug‐alcohol interactions in residents of retirement communities.

DESIGN: Cross‐sectional study using a mailed survey.

SETTING: Three retirement communities in suburban Milwaukee, Wisconsin.

PARTICIPANTS: All 454 independently living residents of the communities were surveyed. Of these, 311 residents (68%) returned completed questionnaires. Mean age of respondents was 83 ± 6 years, 100% were white, 77% were female.

MEASUREMENTS: The questionnaire included alcohol use questions adapted from the Khavari questionnaire and the CAGE questionnaire to screen for alcohol abuse. Respondents were asked to list all prescription and nonprescription medications.

RESULTS: Thirty‐eight percent of the population reported using both alcohol and a high risk medication. Six percent had seven or more drinks per week and took a high risk medication. High risk drugs commonly used by drinkers were antihypertensives in 50%, aspirin in 27%, nonsteroidal antiinflammatory drugs in 20%, medication for congestive heart failure in 18%, antacids or H2 blockers in 16%, sedatives in 11%, narcotics in 5%, and warfarin in 5%.

CONCLUSIONS: Concurrent use of alcohol and medications is common in residents of these retirement communities. Many of the drugs taken by regular drinkers have potential for adverse drug‐alcohol interactions even at moderate levels of alcohol use. This represents a strong possibility of adverse outcomes and a need for increased awareness on the part of both the public and physicians of the potential for interactions between drugs and alcohol.
Screening for Alcohol Use Disorders in the Nursing Home
Authors: Joseph Carol L. , Ganzini Linda , Atkinson Roland M.
Published: April 2015

OBJECTIVES: To determine the prevalence of Alcohol Use Disorders (AUDs) among residents of a Veterans Affairs (VA) nursing home (NH) using DSM‐III‐R criteria for alcohol abuse and dependence, and to examine the demographic variables associated with AUDs among NH residents. A third objective was to assess the sensitivity, compared with DSM‐III‐R criteria, of three screening tests for AUDs in the NH: the CAGE, the MAST‐G, and the two‐question instrument developed by Cyr and Wartman.

DESIGN: A cross‐sectional design, with DSM‐III‐R criteria determined by the alcohol module of the Diagnostic Interview Schedule (DIS) as the criterion standard.

PATIENTS: Patients older than age 50 admitted consecutively to a VA NH, n = 117.

MAIN OUTCOME MEASURES: Sensitivities, specificities, positive predictive values for the CAGE, MAST‐G, and Cyr and Wartman Screening questionnaires; receiver operating characteristic (ROC) curves for the CAGE and MAST‐G.

MAIN RESULTS: Forty‐nine percent of study participants met DSM‐III‐R criteria for lifetime alcohol abuse or dependence (18% active, 31% inactive). The sensitivities and specificities of the three screening questionnaires were as follows: CAGE‐82% and 90%; MAST‐G‐93% and 65%; Cyr and Wartman‐70% and 92%, respectively. The area under the ROC curve was 0.94 for the CAGE and 0.90 for the MAST‐G.

CONCLUSIONS: The prevalence of lifetime alcohol abuse and dependence was high in this VA NH population. Both the CAGE and MAST‐G are sensitive to AUDs in this setting. The areas under the ROC curves were not significantly different and indicate both tests discriminated well between NH residents with and without AUDs.
Immediate and Long‐Term Survival After Intra‐aortic Balloon Pumping: Is Advanced Age an Independent, Unfavorable Prognostic Factor?
Authors: Marchionni Niccoló , Fumagalli Stefano , Di Bari Mauro , Boncinelli Lorenzo , Ferrucci Luigi , Tarantini Francesca , Matteucci Luca , Masotti Giulio
Published: April 2015

OBJECTIVE: To determine whether advanced age is an independent prognostic factor that may increase the risk of complications and reduce the immediate and long‐term survival after treatment with intra‐aortic balloon pumping (IABP) for acute ischemic heart disease.

DESIGN: Retrospective analysis of a clinical series and long‐term follow‐up study.

PATIENTS: A total of 142 patients (age range 23–86 years) in whom IABP was indicated following a standardized protocol.

MEASUREMENTS: Univariate analysis of the association between age and anamnestic, clinical, and hemodynamic data significantly affecting prognosis; multivariate logistic regression analysis of variables showing significant associations.

RESULTS: IABP‐related complications were independent of age. At univariate analysis, pre‐existing, noncardiac, associated conditions (chronic renal failure, stroke, bronchopulmonary disease) (P < .001), an indication to IABP for hemodynamic complications of acute myocardial infarction rather than for medically refractory myocardial ischemia (P < .001), a lack in hemodynamic response to IABP (P < .002), a prolonged delay to IABP initiation (P < .003), and advanced age (P < .025) were all predictors of in‐hospital mortality. However, older patients were also more frequently affected by chronic comorbid conditions and by acute left ventricular failure as an indication to IABP. When these variables were entered into logistic regression models, the association between age and mortality was no longer statistically significant. Similarly, advancing age was associated (P < .012) with an increased mortality rate during an average follow‐up of 94 ± 9 months, but, again, such a significant association disappeared when simultaneously adjusting for New York Heart Association functional class, which was the single most important predictor of long‐term mortality.

CONCLUSIONS: Several anamnestic and clinical variables, rather than advanced age itself, are independent, prognostic factors negatively affecting the outcome of treatment with IABP. Technique‐related complications are independent of age. Thus, old age should not be considered as a criterion to exclude any patient, a priori, from the potential benefits of this type of cardiocirculatory assistance.
Effect of Sustained Resistance Training on Basal Metabolic Rate in Older Women
Authors: Taaffe Dennis R. , Pruitt Leslie , Reim Jennifer , Butterfield Gail , Marcus Robert
Published: April 2015

OBJECTIVE: To determine if basal metabolic rate (BMR) could be elevated in older women undertaking a program of progressive resistance exercise of up to 52‐weeks duration.

DESIGN: Randomized controlled trial with subjects assigned to either a control (CO), high‐intensity (HI), or low‐intensity (LO) training group for 15 weeks. BMR, body composition, energy intake and expenditure, and muscle strength were assessed at baseline and after 15 weeks. Subjects were encouraged to continue in their assigned exercise group for an additional 37 weeks, after which time they were reevaluated.

SETTING: An exercise facility at a medical center.

SUBJECTS: Thirty‐six community‐dwelling healthy women aged 65 to 79 years.

INTERVENTION: Exercise groups performed three sets of 10 exercises, 3 days/week, at either 80% of one‐repetition maximum (1‐RM) for seven repetitions (HI) or 40% of 1‐RM for 14 repetitions (LO).

MEASURES: BMR by indirect calorimetry, body composition by dual energy X‐ray absorptiometry, energy intake and expenditure from 4‐day dietary and activity records, and dynamic muscle strength by 1‐RM.

RESULTS: Muscle strength increased, on average (±SEM), by 40 ± 6% and 36 ± 7% in the HI and LO groups after 15 weeks, respectively, compared with 4 ± 1% in the nonexercising subjects (P = .0001). Fat mass decreased after 15 weeks in LO exercisers by 1.0 kg (P < .05), whereas there was a trend for fat‐free mass (FFM) to increase in the HI group by 0.7 kg (P = .08). No change occurred in any group for BMR. From weeks 15 to 52, muscle strength increased a further 9 ± 2% and 11 ± 2% in HI and LO groups, respectively, compared with 3 ± 1% in nonexercisers (P < .005). There was no change in BMR or any body composition parameter during this time period.

CONCLUSIONS: Neither training program significantly altered BMR and both produced only minimal changes in body composition. However, both the HI and LO exercise regimens resulted in similar and substantial gains in upper and lower body muscle strength that persisted over the course of the year. This suggests that either exercise regimen may prove an effective strategy for preventing frailty and maintaining functional independence in older adults.
Protein‐Energy Undernutrition and the Risk of Mortality Within One Year of Hospital Discharge: A Follow‐Up Study
Authors: Sullivan Dennis H. , Walls Robert C. , Bopp Melinda M.
Published: April 2015

OBJECTIVE: The primary objective of this study was to confirm the results of a previous study that demonstrated a strong independent correlation between the severity of protein‐energy undernutrition and the risk of 1‐year postdischarge mortality in a population of older rehabilitation patients.

DESIGN: Prospective survey (cohort study)

SETTING: The Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital

PARTICIPANTS: Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population, of whom 99% were male, and 75% were white. The average age of the study patients was 76 years.

MEASUREMENTS: At admission and again at discharge, each patient completed a comprehensive medical, functional, neuropsychological, socioeconomic, and nutritional assessment. After discharge, each subject was tracked for 1 year.

MAIN RESULTS: Within the 1‐year posthospital discharge follow‐up period, 64 study subjects (20%) died. This included 17% of the patients discharged home and 34% of the patients discharged to a nursing home (P < .01). Based on the Cox Proportional Hazards survival model, the variable most strongly associated with mortality was the discharge serum albumin, followed by discharge weight expressed as a percentage of ideal, self‐dressing ability, and a discharge diagnosis of cardiac arrhythmia (usually atrial fibrillation). When all four of these variables were included in the analysis, the model was able to differentiate the survivors from those who died by years end with a sensitivity of 69%, a specificity of 69%, and an overall predictive accuracy of 69%. When tested using the data from the previous study, the model differentiated the patients who died from those who had not at a sensitivity of 62%, a specificity of 68%, and an overall predictive accuracy of 64%.

CONCLUSIONS: Protein‐energy undernutrition appears to be a strong independent risk factor for 1‐year postdischarge mortality.
Older Nursing Home Residents Have a Cardiac Arrest Survival Rate Similar to That of Older Persons Living in the Community
Authors: Ghusn Husam F , Teasdale Thomas A , Pepe Paul E. , Ginger Vicki F.
Published: April 2015

OBJECTIVE: To determine the survival rates of older nursing home residents after cardiopulmonary resuscitation (CPR) and to compare it with that of older persons who experienced cardiac arrest in an outpatient setting. To identify patient characteristics, arrest characteristics, and effort characteristics that are associated with higher survival rates.

DESIGN: Retrospective review of emergency medical service charts and hospital medical records of a cohort of older nursing home residents (n = 114) after cardiopulmonary resuscitation and a matched cohort of community‐residing older persons (n = 228) matched on age, gender, and year of cardiac arrest.

SETTING: A large metropolitan city served by a tiered emergency medical service.

MEASUREMENTS: Independent variables related to patient, cardiac arrest, and resuscitation effort characteristics. Dependent variables were defined as immediate survival after cardiopulmonary resuscitation and survival status at discharge.

RESULTS: The mean age of nursing home residents was 80.3 years; 62.3% were females. The majority of cardiac arrests for both groups were unwitnessed (67%) and had agonal rhythms (asystole and electromechanical dissociation). Emergency medical service efforts were similar for the two cohorts. Among nursing home residents, 26.3% had a return of blood pressure for more than 5 minutes, 70.2% were pronounced dead in the emergency room, and 10.5% were discharged from hospitals alive. In the matched community‐residing subjects, 22.7% had a return of blood pressure, 78.1% were pronounced dead in the emergency room, and 9.2% were discharged alive. Between‐group comparisons of these variables revealed no significant differences even though our sample size was adequate.

CONCLUSIONS: We conclude that survival after cardiac arrest of older persons residing in nursing homes is low; however, with an appropriate CPR/DNR selection process and an effective emergency medical system, survival of certain groups of nursing home residents following cardiac arrest could be comparable to that of community‐residing older persons. Despite the reasonably good survival rates for older persons seen above, our analyses indicated that patients who have unwitnessed arrests are not likely to survive to discharge and that patients with initial rhythms such as asystole or electromechanical dissociation rarely survive. These data suggest that patients who have an unwitnessed arrest in the nursing home should not receive resuscitation attempts, and in those patients for whom paramedics are called, resuscitation efforts should not proceed any further if their original rhythm is asystole or electromechanical dissociation. Thus, modification in nursing home policies regarding CPR efforts is needed.
Does the ECA Underestimate the Prevalence of Late‐Life Depression?
Authors: Heithoff Kim
Published: April 2015

OBJECTIVE: This research addresses the most frequently cited methodological criticism of the Epidemiologic Catchment Area (ECA) surveys ‐ which might lead to significantly lower estimates of true prevalence rates for late‐life depression ‐ the inability of the Diagnostic Interview Schedule (DIS) to distinguish between somatic symptoms of depression that result from physical causes and those that result from psychiatric causes.

DESIGN: The data for this study come from the ECA Wave Two surveys sponsored by the National Institute of Mental Health. In this analysis, symptoms of depression the respondent always attributed to physical causes are recoded to be equivalent to those having a psychiatric cause. The third edition of the Diagnostic and Statistical Manual (DSM‐III) scoring algorithm for depression (i.e., dysphoria plus four of the eight Criterion B symptoms) was then applied to the recoded data set.

RESULTS: Recoding somatic symptoms of depression, originally attributed to physical or medical explanations, to psychiatric symptoms does not result in a disproportionate rise in diagnosable depression in the older age groups.

CONCLUSIONS: This analysis provides additional support for the ECA survey's prevalence estimate of late‐life depression. This research failed to find evidence that the highly structured nature of the DIS makes it unsuitable for ascertaining symptoms of depression in the elderly.
Code Status Decision‐Making in a Nursing Home Population
Authors: Kellogg F. Russell , Ramos Aida
Published: April 2015

OBJECTIVES: To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions.

DESIGN: Retrospctive uncontrolled observational study carried out through record review.

SETTING: A single skilled‐level teaching NH and its affiliated university hospital.

PATIENTS: All of the 350 individuals who resided at the NH during a 2‐year period.

MAIN RESULTS: Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do‐not‐resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short‐term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non‐DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in‐patient hospital use was less for the DNR group, and most of these died at the nursing home.

CONCLUSIONS: Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.
Minimal Trauma Fractures in Older Nursing Home Residents: The Interaction of Functional Status, Trauma, and Site of Fracture
Authors: Kane Richard S. , Burns Edith A. , Goodwin James S.
Published: April 2015

OBJECTIVE: This study was conducted to determine the incidence of long bone fractures in institutionalized older persons and to describe preceding traumatic events and the functional status of individuals sustaining fractures.

DESIGN: A 1‐year, prospective, cumulative incidence survey.

SETTING: Eleven skilled nursing care facilities in the state of Wisconsin.

PATIENTS: All residents of the 11 facilities.

MEASUREMENTS: All incident reports of long bone fractures, description of events preceding the fractures, and functional status of the fracture cases. In addition, demographic and medical information was collected on fracture cases and the general nursing home population.

MAIN RESULTS: Overall long bone fracture incidence was 3.52 per 100 subjects per year. Minimal trauma fracture incidence was 0.84 per 100 subjects per year. Fracture location was significantly related to type of trauma. Functional status was significantly related to fracture location and to the type of trauma preceding the fracture. Minimal trauma fractures occurred in individuals who were less mobile and more likely to be bed‐bound, and the location was more likely to be the lower extremity below the hip.

CONCLUSION: This is the first prospective survey of long bone and spontaneous fracture incidence rates in multiple nursing home facilities. Minimal trauma fractures are common in the nursing home, and most have no clear precipitating factors other than severely impaired mobility.