bluuebunny/crossref_metadata_2025 huggingface dataset:
An Analysis of the Use of the Telephone in the Management of Patients in Skilled Nursing Facilities
Authors: Fowkes William , Christenson Diane , McKay David
Published: April 2015

OBJECTIVE: To characterize the nature of telephone communication in the care of patients in skilled nursing facilities, noting numbers of calls, reasons for communication, and the outcomes of the interactions, and to implement a voice mail system to manage the burden of communication more effectively and describe the impact of this system.

DESIGN: An archival descriptive study of phone message data covering a period of 1 year in a defined population of nursing home patients, with an intervention and an evaluation of a voice mail system at the conclusion of the year's study.

SETTING: A long‐term care practice associated with an urban family practice residency program.

PARTICIPANTS: Medical care providers, the staffs of 13 skilled nursing facilities, and an average of 207 covered patients followed for 1 year.

INTERVENTION: At the termination of the descriptive study, a voice mail system was instituted, and the impact on phone communication was documented.

MAIN OUTCOME MEASURES: Total numbers of calls were tabulated by patient and by facility. Reasons for calls, outcomes, and timing were tabulated. The impact of a voice mail system on the communication between nursing home staff and medical providers was characterized.

RESULTS: A total of 10,264 calls were received from 13 skilled nursing facilities in regard to an average of 207 continuously covered long‐term care patients, which is an average of nearly 50 calls per patient per year. Acute illness accounted for only 5% of calls, and most communications were routine. Though a new treatment was instituted about one‐third of the time, no new order was issued in response to 23% of received calls. Hospitalization occurred as the result of about one in two hundred calls. A recent tabulation of 692 calls received during 1 month revealed that 93% of calls are now received through voice mail and about one in five of these calls do not need to be returned.

CONCLUSIONS: There is a significant telephone call burden associated with care of patients in skilled nursing facilities. Most of these calls are routine, regulation driven, and often no return call is necessary. For many reasons, including poor reimbursement, much of the medical care delivered occurs as a result of these calls, and methods of managing the communication burden to allow prioritization both by the staff nurse and the physician need to be found. In the practice described, the voice mail system is a positive step in this direction.
The Impact of Thiazide Diuretics on the Initiation of Lipid‐Reducing Agents in Older People: A Population‐Based Analysis
Authors: Monane Mark , Gurwitz Jerry H. , Bohn Rhonda L. , Glynn Robert J. , Levin Raisa , Monette Johanne , Avorn Jerry
Published: April 2015

OBJECTIVE: The objective of this study was to examine how often treatment for hyperlipidemia followed the use of thiazides, compared with the use of other antihypertensive drugs, in older patients.

DESIGN: Retrospective follow‐up of all health claims filed over a 12‐month period.

SETTING: New Jersey Medicaid and Medicare programs.

PARTICIPANTS: A total of 9274 enrollees, aged 65 to 99, who were newly initiated on antihypertensive medications from 1981–1989.

MEASUREMENTS: We measured rates of lipid‐reducing agent (LRA) initiation among patients in the 2 years following antihypertensive initiation (thiazide, non‐thiazide drug, or combinations of the two) compared with rates among patients not currently taking antihypertensive agents. We used Cox regression analyses to estimate relative risks (RR), accounting for switching in antihypertensive therapy and for time when drug therapy was not currently available according to pharmacy refill records.

RESULTS: There were 226 patients (2.4%) in the cohort who were started on LRA during the follow‐up period. After adjusting for potential confounders, we found no significant relationship between LRA initiation and overall thiazide use (RR 1.47, 95% CI 0.89‐2.40), or other antihypertensive use, relative to no current exposure. However, use of high‐dose thiazides (≥50 mg) was associated significantly with LRA initiation (RR 1.97, 95% CI 1.12‐3.45). Factors associated with decreased incidence of LRA use included age ≥ 85 (RR 0.59, 95% CI 0.36‐0.96), black race (RR 0.58, 95% CI 0.37‐0.91), and nursing home residency (RR 0.20, 95% CI 0.11‐0.35).

CONCLUSION: Use of low‐cost and effective thiazide diuretics in older hypertensives was not associated with more common initiation of lipid‐reducing agents, except with high‐dose use of thiazides currently seen as inappropriate in most cases. Age and race were important determinants of LRA use.
Models of Geriatrics Practice: Post‐Hospital Sub‐Acute Care: An Example of a Managed Care Model
Authors: von Sternberg T. , Hepburn K. , Cibuzar P. , Convery L. , Dokken B. , Haefemeyer J. , Rettke S. , Ripley J. , Vosenau V. , Rothe P. , Schurle D. , Won‐Savage R.
Published: April 2015

OBJECTIVE: This article describes Transitional Care Centers (TCC), an innovative sub‐acute care program developed by a large managed care organization (HealthPartners in Minnesota) in partnership with five area nursing homes. The purpose of the TCC is to promote continuity of care for frail older members covered under a TEFRA risk contract.

DESIGN: This is a retrospective study of the experiences and outcomes of enrollees who received TCC compared with a like group of enrollees who received customary continuity care through contract services.

SETTING: The TCCs are established contractually in five area nursing homes; these facilities keep at least 15 beds available to the health plan for round‐the‐clock, 7 days per week admissions for sub‐acute care. Designated staff from these facilities and designated geriatric nurse practitioners and geriatricians from HealthPartners follow established targeting, admissions, assessment, care planning, and discharge planning procedures to provide team care for these patients at the facilities.

PARTICIPANTS: The TCC program is targeted to patients requiring rehabilitation therapy (post‐cardiovascular accident, post‐fracture/replacement) who are deconditioned, or those with uncomplicated infections (urinary tract infection, pneumonia). A total of 1144 patients participated in the TCC program in the 1‐year program under report, and 253 were surveyed in regard to their experience. One hundred Health‐Partners physicians were surveyed about the program.

RESULTS: Post‐acute length of stay in the TCC was substantially lower than that in customary care settings in contract nursing homes (14.3 versus 20.5 days). Rehospitalization rates from these units were comparable to or better than those from other sub‐acute units. Patient and primary care physician satisfaction with the units was high. The program provided economic benefit to both partners. The health plan's negotiated rate for the TCC units was 38% less than that paid in noncontractual facilities.

CONCLUSION: The TCC partnership provides rehabilitative and geriatric evaluation services in settings more conducive to and less costly than such care usually, and yields improvements in care and utilization outcomes.
Prevalence of Undiagnosed Non‐Insulin‐Dependent Diabetes Mellitus and Impaired Glucose Tolerance in a Cohort of Older Persons with Hypertension
Authors: Johnson Karen C. , Graney Marshall J. , Applegate William B. , Kitabchi Abbas E. , Runyan John W. , Shorr Ronald I.
Published: April 2015

OBJECTIVE: To determine the prevalence of undiagnosed non‐insulin‐dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in a cohort of older persons with hypertension. To examine the usefulness of screening for NIDDM in this study population.

DESIGN: Cross‐sectional study.

SETTING: University of Tennessee, Memphis and the General Clinical Research Center (GCRC).

PATIENTS: Ninety‐five participants in the Trial of Nonphar‐macologic Interventions in the Elderly (TONE) study who agreed to participate in an ancillary study.

MEASUREMENTS: A standard oral glucose tolerance test (OGTT) with insulin and C‐peptide levels was performed before the beginning of the TONE intervention.

RESULTS: In this cohort, 43 participants (45.3%) had normal glucose tolerance (NGT), 41 (43.2%) had IGT, and 11 (11.6%) had undiagnosed NIDDM. The positive predictive value for NIDDM of a fasting glucose ≥ 115 mg/dL in our participants was 57%. Hyperinsulinemia occurred in only one participant, a subject in the IGT group.

CONCLUSIONS: Our data demonstrate that undiagnosed NIDDM is common in our cohort of older persons who are being treated for essential hypertension and that impaired glucose tolerance may be more common than in the general population of the same age. Further, our data show that the vast majority of this older, obese, hypertensive cohort did not have fasting hyperinsulinemia. We also infer that a fasting glucose alone has a low positive predictive value for screening of NIDDM in our older cohort. As the prevalence of NIDDM and impaired glucose tolerance in older hypertensive patients in the general population is unknown, we believe that further investigation is needed to characterize the relationship of hypertension, glycemic status, and hyperinsulinemia in the general population.
How Older Patient Preferences Are Influenced by Consideration of Future Health Outcomes
Authors: Mazur Dennis J.
Published: April 2015

OBJECTIVE: To determine patients' willingness to accept intubation and ventilatory support (IVS) when the best outcome available is a state involving both cognitive and physical/behavioral deficits.

DESIGN: Structured interviews with patients seen consecutively in a continuity care general medicine clinic.

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

SUBJECTS: A total of 113 patients (mean age = 67.3 years, age range 42–89; mean level of formal education = 12.6 years, range 2–24).

MEASUREMENTS: Patients were asked to consider whether they would permit their physicians to intubate them and put them on ventilatory support when the best outcome to be expected was one of three future health care states, presented in the following order: State 1, where their mental and physical state of recovery would be exactly like their current mental and physical states at the time of their visit to the general medicine clinic (the patient's current baseline mental and physical functioning); State 2, involving cognitive compromise; State 3, involving both cognitive and physical/behavioral compromise.

RESULTS: One patient refused IVS on State 1; 20.4% (23/113) of patients refused IVS on State 2; 23.0% (26/113) refused IVS on State 3; and 49.6% (56/113) reported they would accept IVS resulting in all three states. Six of 113 patients (5.3%) reported they would leave the decision up to their physician beginning with State 1 and continuing through State 3. One patient reported that he would leave the decision (State 1 through State 3) up to his wife. A reported history of stroke is related to patients' expressed dislike of IVS that would leave them with residual deficits.

CONCLUSION: The results suggest that a substantial number of our older male veteran population would prefer intubation and ventilatory support if presented with a situation in which the best outcome that a physician could offer them was cognitive, physical, and behavioral dysfunction. These results also indicate that those patients who have had a stroke seem to be less inclined to accept IVS in more severe outcomes states.
Do Acute Care for Elders Units Increase Hospital Costs? A Cost Analysis Using the Hospital Perspective
Authors: Covinsky Kenneth E. , King Joseph T. , Quinn Linda M. , Siddique Reshmi , Palmer Robert , Kresevic Denise M. , Fortinsky Richard H. , Kowal Jerome , Landefeld C. Seth
Published: April 2015

OBJECTIVE: To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self‐care activities with the costs of usual care.

DESIGN: A randomized controlled study.

PARTICIPANTS: A total of 650 medical patients (mean age 80 years, 67% women, 41% nonwhite) assigned randomly to either the intervention unit (n = 326) or usual care (n = 324).

MEASURES: The hospital's resource‐based cost of caring for patients was determined from the hospital's cost‐accounting system. The cost of the intervention program was estimated and included in the intervention patients' total hospital cost.

RESULTS: The development and maintenance costs of the intervention added $38.43 per bed day to the intervention patients' hospital costs. As a result, the cost per day to the hospital was slightly higher in the intervention patients than in the control patients ($876 vs $847, P = .076). However, the average length of stay was shorter for intervention patients (7.5 vs 8.4 days, P = .449). As a result, the hospital's total cost to care for intervention patients was not greater than caring for usual‐care patients ($6608 in intervention patients vs $7240 in control patients, P = .926). Sensitivity analysis demonstrated that the cost of the intervention program would need to be 220% greater than estimated before intervention patients would be more expensive then control patients. There were no examined subgroups of patients in whom care on the intervention unit was significantly more expensive than care on the usual‐care unit. Ninety‐day nursing home use was lower in intervention than control patients (24.1% vs 32.3%, P = .034). Ninety‐day readmission rates (36.7% vs 41.1%, P = .283) and caregiver strain scores (3.3 vs. 2.7, P = .280) were similar.

CONCLUSION: Caring for patients on an intervention ward designed to improve functional outcomes in older patients was not more expensive to the hospital than caring for patients on a usual‐care ward even though the intervention ward required a commitment of hospital resources.
Acute Upper Gastrointestinal Hemorrhage in Older People: A Prospective Study in Two Neighboring Districts
Authors: Nankhonya J. M. , Datta‐Chaudhuri M. L. , Bhan G. L.
Published: April 2015

OBJECTIVE: To study the distribution of mucosal lesions and outcomes in older people with acute upper gastrointestinal hemorrhage (UGIH).

DESIGN: Prospective case study.

SETTING: Two neighboring district hospitals with similar admission policies.

SUBJECTS: Consecutive patients aged 75 years or older admitted with hematemesis and/or melena during the study period.

OUTCOME MEASURES: Length of hospital stay, mortality, surgical intervention, and transfusion requirements.

RESULTS: A total of 109 patients were entered into the study. Of these, 106 (97%) underwent gastroscopy, and bleeding sites were identified in 98%. Upper gut malignancies were identified in eight patients, ulcerative esophagitis in 32, benign gastric ulcers in 24, and duodenal ulcers in 23 patients. Forty‐seven percent had severe anemia on admission (Hb <10 g/dL). Thirty‐eight patients were referred for surgery, and eight were operated on, with one postoperative death. Six other patients died, five of whom had malignancies. The overall mortality of 6% reduced to 2% if those with malignancy were excluded. The 92 patients discharged had a median hospital stay of 15 days (range 2–30).

CONCLUSIONS: Older people with acute UGIH have advanced upper gut pathology with preponderance of esophageal lesions. Classical symptoms seem lacking, but mortality can be decreased despite adverse comorbid factors. Lower thresholds for endoscopy are advocated in older adults, and comparative studies of UGIH symptoms with younger patients are required.
Viral Hepatitis in Older Adults
Authors: Marcus Esther‐Lee , Tur‐Kaspa Ran
Published: April 2015

The objective of this paper is to review the epidemiology, manifestations, therapy, and prevention of viral hepatitis in older people and to discuss issues of prevention and management.

In developed countries a significant portion of the adult population is not immune to Hepatitis A virus (HAV). Morbidity and mortality from HAV infection increases with age. A safe and effective hepatitis A vaccine is available and health authorities should consider immunization early in life and for healthy adults as well as for potential high risk groups such as nursing home residents.

Acute hepatitis due to Hepatitis B virus (HBV)is rare in older people and is usually a mild disease. Most older patients with chronic HBV infection who suffer from advanced liver disease have no evidence of ongoing viral replication. Therefore, they are not candidates for interferon therapy. Those with evidence of ongoing viral replication and compensated liver disease should be offered interferon or be included in clinical trials with new antiviral drugs such as lamivudine. Since the response rate to hepatitis B vaccination decreases with age, developing vaccines with greater immunogenicity is crucial.

Hepatitis C virus (HCV) is the most frequent cause of acute viral hepatitis in older people. Acute hepatitis C is usually a mild disease in this age group. Because many older patients with chronic HCV infection have compensated liver disease, they could benefit from antiviral therapy. In light of the low response rate to interferon in older patients with chronic hepatitis C and the side effects of the drug, interferon therapy should be reserved for those with the best chance of response. “Combination” antiviral therapy should be on trial for older patients with chronic HCV infection who do not respond to interferon.

The recently discovered RNA virus, Hepatitis G (HGV), has been associated with liver disease in older people. It's role in the pathogenesis of liver injury remains to be elucidated.
A Geriatric Consultation Team in the Emergency Department
Authors: Gold Susan , Bergman Howard
Published: April 2015

BACKGROUND: The proportion and absolute number of older patients presenting to emergency departments (EDs) are increasing. Older ED patients tend to have multiple medical and psychosocial problems that make their care in the ED problematic. Despite this, there have been no previous descriptions of geriatric ED consultative services.

SETTING: The Sir Mortimer B. Davis Jewish General Hospital is a 628‐bed tertiary care McGill University teaching hospital. It serves a population of about 160,000, of which 23% are aged 65 and older. In response to the special needs of this group, the Division of Geriatric Medicine at the Jewish General Hospital has developed, among its clinical and teaching services, an ED consultation team.

PROGRAM DESCRIPTION: The consultation team is composed of a geriatrician, a full‐time nurse clinician, and part‐time physical and occupational therapists. Consultations are received from referring, primarily ED physicians and encompass all aspects of medical and psychosocial issues. Geriatric assessment is geared toward decision making for rapid disposition: discharge home or admission to acute geriatrics ward or other services. Thus, the service functions as a gatekeeper for admission to the acute geriatrics ward, as well as coordinating geriatric follow‐up both in‐hospital (for patients admitted to other services) and in the community (for patients discharged home), via the outpatient geriatric clinic, home visits, or linkage to other community resources.
Effects of a Restraint Reduction Intervention and OBRA '87 Regulations on Psychoactive Drug Use in Nursing Homes
Authors: Siegler Eugenia L. , Capezuti Elizabeth , Maislin Greg , Baumgarten Mona , Evans Lois , Strumpf Neville
Published: April 2015

OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

METHODS:A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre‐ and 6 months' post‐intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subject as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis.

RESULTS: While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA‐approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home.

CONCLUSIONS: Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.
Deaths Caused by Bedrails
Authors: Parker Kara , Miles Steven H.
Published: April 2015

OBJECTIVES: To determine how bedrails cause death in order to suggest clinical and ergonomic changes to prevent such deaths and to promote research to improve the use and design of bed systems.

DESIGN: A review of reports of adult deaths and injuries from bedrails contained in the United States Consumer Product Safety Commission Death Certificate File and its Reported Incidents File and its National Injury Information Clearinghouse Accident Investigations from 1993 to 1996. Deaths involving the use of vest restraints were excluded. We reconstructed, reenacted, and have graphically depicted major patterns of deaths. A review of the literature to 1966 was also done.

RESULTS: The 74 deaths described are categorized into three types: (1) 70% were entrapments between the mattress and a rail so that the face was pressed against the mattress, (2) 18% were entrapment and compression of the neck within the rails, and (3) 12% were deaths caused by being trapped by the rails after sliding partially off the bed and having the neck flexed or the chest compressed.

CONCLUSIONS: Deaths from bedrails are underrecognized and preventable clinical events that can occur in any medical setting. Preventing these events will require a unified redesign of the relationships between rails, mattresses, and beds, which are now often assembled and used as separate products. Clinicians can prevent many of these deaths by using bedrails much more judiciously, confirming the proper relationships between beds, rails and mattresses, and using alarms.
Reduced Systemic Arterial Compliance Is Associated with Left Ventricular Hypertrophy and Diastolic Dysfunction in Older People
Authors: Rajkumar Chakravarthi , Cameron James D. , Christophidis Nicholas , Jennings Garry L. , Dart Anthony M.
Published: April 2015

OBJECTIVES: To study the relationship between left ventricular diastolic function and systemic arterial compliance in the older population.

DESIGN: Cross‐sectional survey.

PARTICIPANTS: A total of 67 older volunteer participants (aged 67 ± 5.4 years).

MEASUREMENTS: Systemic arterial compliance (SAC) was measured using applanation tonometry and aortic velocimetry, and diastolic function was assessed using Doppler filling. Left ventricular mass was determined echocardiographically.

RESULTS: There were significant univariate correlations between diastolic filling, as measured by E/A ratio, systemic arterial compliance (0.34, P < .01), and left ventricular mass (‐0.41, P < .001). In multiple regression analysis, using diastolic filling as the dependent variable and heart rate, age, left ventricular mass corrected for body surface area, systolic and diastolic blood pressures, and arterial compliance as independent variables, the major determinants of diastolic filling were heart rate, left ventricular mass, and diastolic blood pressure. Arterial compliance did not make a significant independent contribution.

CONCLUSION: This study demonstrates a positive relationship between diastolic filling and arterial compliance in the older population. However, in multiple regression analysis, heart rate, diastolic blood pressure, and left ventricular mass were the independent predictors of diastolic filling (E/A), whereas arterial compliance was not. These findings imply that therapeutic modulation of aortic stiffness would not, of itself, contribute to improvement in diastolic function.
Glucose Metabolism in Older Adults: A Study Including Subjects More Than 80 Years of Age
Authors: Garcia Gloria V. , Freeman Rosario V. , Supiano Mark A. , Smith Maria J. , Galecki Andrzej T. , Halter Jeffrey B.
Published: April 2015

OBJECTIVE: This study was undertaken to understand the dynamics of glucose metabolism in healthy non‐diabetic subjects older than age 80 (old‐old) compared with subjects aged 61 to 79 (young‐old), as well as to compare healthy older subjects with impaired glucose tolerance (IGT) with older subjects with normal glucose tolerance (NGT).

DESIGN: A cross sectional, observational study.

SETTING: A university hospital clinical research center.

PARTICIPANTS: There were 28 community‐dwelling adults, 10 older than age 80 and 18 aged 61 to 79. Thirteen of these people had NGT and 15 had IGT. Subjects were not taking any medication that interfered with glucose tolerance.

MEASUREMENTS: Status of glucose tolerance was determined by an oral glucose tolerance test categorized as NGT or IGT according to WHO criteria. Insulin sensitivity (SI and glucose effectiveness (SG) were assessed using a tolbutamide‐assisted intravenous glucose tolerance test (IVGTT). The data were analyzed using the Minmod modeling program. Glucose tolerance (Kg) and the acute insulin response to glucose (AIRg) were calculated from the IVGTT.

RESULTS: There were no significant differences between the young‐old and old‐old in body mass index or in plasma glucose, insulin, or C‐peptide levels in the fasting state or during the OGTT. Values for Kg, SI SG, and AIRg from the IVGTT were similar in the two age groups. When the subjects were classified by glucose tolerance status, the subjects with NGT had age, gender, and body mass index similar to the subjects with IGT. Older people with IGT had a lower Kg and tended to have higher fasting glucose and similar fasting insulin compared with people with NGT. IGT subjects had lower S] and tended to have lower SG. The AIRg in IGT subjects tended to be low rather than high when compared with older people with NGT.

CONCLUSION: Otherwise healthy adults more than 80 years of age have measures of glucose metabolism similar to people aged 61 to 79. The presence of IGT in older adults is associated with insulin resistance, regardless of patient age. We hypothesize that the lack of pancreatic islet compensation for insulin resistance may contribute to impaired glucose tolerance in older adults.
The Burden of Parkinson's Disease on Society, Family, and the Individual
Authors: Whetten‐Goldstein Kathryn , Sloan Frank , Kulas Elizabeth , Cutson Toni , Schenkman Margaret
Published: April 2015

OBJECTIVE: To examine the burden of Parkinson's Disease (PD) on society, family, and the individual.

SETTING: In‐home interviews in Central North Carolina.

DESIGN: A cross‐sectional, descriptive study.

PARTICIPANTS: A total of 109 people with PD.

MEASURES: Standard instruments used to assess income, health status, health‐related costs, and household activities.

SAMPLE: The sample was weighted toward individuals who were within the first 5 years of post‐PD diagnosis.

RESULTS: The total per capita societal burden was approximately $6000 per year, the greatest single element of which was compensation for earnings loss for those less than age 65. Government insurance covered 85% of our sample. The largest components of family burden were the burden of providing informal caregiving and that of earnings loss. Spouses providing informal care did so a mean of 22 hours per week. Compared with a random sample of older people, our respondents spent much less time on house and yard work.

CONCLUSION: The direct costs of the disease reflect a small portion of the burden. The hidden costs, in the form of lost wages, informal care, and changing roles are substantial. Their magnitude is even more important when we consider that the family generally lives on a fixed income, and the caregiver is an older aged spouse. Medical practitioners will best be able to intervene if they look holistically at the patient with this disease. When treating symptoms themselves, practitioners need to be aware of the high level of pain, fatigue, and depression associated with PD, even in the early stages. The results demonstrate clearly that family relationships are affected early, indicating the importance of providing early referrals to services such as home health, social workers/counseling, and well as PD support groups.
Osteoarthritis of the Knee: Report of a Task Force of the International League of Associations for Rheumatology and the Osteoarthritis Research Society
Authors: Dieppe Paul , Altman Roy , Lequesne Michel , Menkes Joel , Pelletier Jean‐Pierre , Martel‐Pelletier Johanne
Published: April 2015

Osteoarthritis (OA) is the most common articular rheumatic disease. A Task Force addressed the (1) present status of osteoarthritis referable to diagnosis, outcome measures, and therapy and (2) the gaps in our knowledge and future research priorities referable to epidemiology, risk factors, prospects for prevention, basic sciences, measurable outcomes, and therapeutics. There has been dramatic improvement in our understanding of the etiopathogenesis and methods of measuring progression in OA, with a clear separation in the goals of therapy into symptom and structure modification. The future is opening to a new era of diagnostics with the prospect of altering the course of the disease.
Comparison of Subcutaneous and Intravenous Administration of a Solution of Aminoacids in Older Patients
Authors: Ferry Monique , Leverve Xavier , MD Thierry Constans
Published: April 2015

OBJECTIVE: To compare the plasma amino acid (AA) concentrations obtained by the infusion of an AA solution (660 mOsm/L, pH 7) using the subcutaneous (SC) with that using the intravenous (IV) route in older patients.

DESIGN: A prospective, randomized, cross‐over study.

SETTING: A hospital geriatric ward.

PARTICIPANTS: Six patients with a mean age of 84 years.

MEASUREMENTS: The infusion of the AA solution (IV or SC) lasted 6 hours. Blood was sampled at 0,2,4,6, 8,10,14, 18, and 24 hours from the start of the infusion to determine plasma AA level by the phenyl‐isothiocyanate method.

RESULTS: Compared with baseline values, plasma AA concentrations increased to a significantly higher level from the second to the tenth hour and from the second to the fourteenth hour during IV and SC infusions, respectively. Plasma AA levels did not differ between the two routes. SC infusion was well tolerated.

CONCLUSION: Assuming that nutritional sufficiency is the desired result of plasma AA infusion, we conclude the SC route is well tolerated and offers the possibility of nitrogen supplementation for older patients over short periods of time, when oral protein intake is transiently insufficient or impossible, as a way to limit, but not to treat, protein‐energy malnutrition.
Underutilization of Beta‐Blockers in Older Patients With Prior Myocardial Infarction or Coronary Artery Disease in an Academic, Hospital‐Based Geriatrics Practice
Authors: Mendelson Gad , Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of beta‐blocker use in older persons with prior myocardial infarction (MI) or coronary artery disease (CAD) without contraindications to beta‐blockers in an academic hospital‐based geriatrics practice.

DESIGN: A retrospective analysis of charts from all older patients seen during January 1996 through March 1997 at an academic, hospital‐based geriatrics practice was performed to investigate the prevalence of beta‐blocker use in older patients with prior MI or CAD without contraindications to beta blockers.

SETTING: An academic, hospital‐based, primary care geriatrics practice staffed by fellows in a geriatrics training program and full‐time faculty geriatricians.

PATIENTS: One hundred thirty‐nine women and 84 men, mean age 82 ± 8 years (range 67 to 96), were included in the study.

MEASUREMENTS AND MAIN RESULTS: Of 233 patients with CAD, 53 patients (23%) were receiving beta‐blockers. Of 180 patients with CAD not receiving beta‐blockers, 34 patients (19%) had contraindications to beta‐blockers. Of 199 patients with CAD without contraindications to beta‐blockers, 53 patients (27%) were receiving beta blockers. Of 162 patients with prior MI, 38 patients (23%) were receiving beta‐blockers. Of 124 patients with prior MI not receiving beta‐blockers, 19 patients (15%) had contraindications to beta‐blockers. Of 143 patients with prior MI without contraindications to beta‐blockers, 38 patients (27%) were receiving beta‐blockers.

CONCLUSIONS: There is marked underutilization of beta‐blockers in treating older patients with prior MI or CAD in an academic, hospital‐based geriatrics practice. J Am Geriatr Soc 45:1360–1361, 1997.
The Soluble Interleukin‐2 Receptor Predicts Mortality in Older Hospitalized Men
Authors: Rosenthal Amy J. , McMurtry Cynthia T. , Sanders Karen M. , Jacobs Mary , Thompson David , Adler Robert A.
Published: April 2015

BACKGROUND: There is an inverse relationship between the soluble interleukin‐2 receptor (sIL‐2R) and serum albumin, cholesterol, transferrin, prealbumin, and hemoglobin. Inasmuch as low serum albumin and cholesterol have been associated with excess mortality, we hypothesized that elevated sIL‐2R would predict mortality in older adults.

OBJECTIVE: To determine if elevated sIL‐2R predicts mortality in patients on a geriatric rehabilitation unit.

DESIGN: Prospective cohort.

SETTING: University‐affiliated VA medical center.

PARTICIPANTS: Seventy‐two male patients aged greater than 60 years admitted to a geriatric rehabilitation unit. Patients with severe hepatic or renal disease were excluded.

MEASUREMENTS: We measured serum albumin, prealbumin, cholesterol, transferrin, hemoglobin, body mass index (BMI), C‐reactive protein (CRP), and sIL‐2R upon admission. Subjects were followed for 1 year.

RESULTS: Low serum albumin, prealbumin, and hemoglobin and high sIL‐2R and CRP predicted 1‐year mortality on univariate analysis. When these predictors were included as covariates in a Cox regression model, only sIL‐2R was a significant independent predictor of mortality (P = .043). Multiple linear regression with the above covariates revealed that only sIL‐2R predicted time to death at (P = .003).

CONCLUSIONS: High sIL‐2R and CRP and low albumin, prealbumin, and hemoglobin predicted mortality using univariate analysis on a rehabilitation unit. However, with multivariate analysis, sIL‐2R was the sole predictor of mortality. J Am Geriatr Soc 45:1362–1364, 1997.
Geriatric Rehabilitation: State of the Art
Authors: Hoenig Helen , Nusbaum Neil , Brummel‐Smith Kenneth
Published: April 2015

OBJECTIVES: To provide a clinically useful conceptual framework for the evaluation and treatment of disability in older persons, to review the rehabilitation of common conditions affecting function in older persons, and to discuss the effects of the ongoing changes in the healthcare system on geriatric rehabilitation.

METHODS: MedLine search and review of relevant texts for information on (1) geriatric disability and its treatment, (2) recent high quality research, guidelines, and review articles relevant to the rehabilitation of conditions commonly causing geriatric disability, (3) effects of recent changes in the healthcare system on geriatric rehabilitation.

RESULTS: Several pertinent models for geriatric disability were identified. These are explicated, along with information on the epidemiology of geriatric disability and its causes and relevant clinical applications. Rehabilitation is reviewed for musculoskeletal disorders, stroke and peripheral vascular disease, amputation, cardiopulmonary disorders, hip fracture, and deconditioning. Changes in the healthcare system appear to be affecting geriatric rehabilitation, especially the advent of managed care; relevant articles and opinions are reviewed, along with strategies to accommodate these changes.

CONCLUSIONS: Our understanding of the causes of disability in the older population has improved significantly over the last decade. There has also been noteworthy progress in our knowledge about the effects of selected rehabilitation interventions, especially exercise‐related interventions. However, the cost‐effectiveness of many rehabilitative interventions remains unclear, particularly for differing patient groups across the continuum of care. More research will be needed to evaluate the effects of managed care on rehabilitation outcomes in older persons. J Am Geriatr Soc 45:1371–1381, 1997.
Predictors of Decline in Manual Performance in Older Adults
Authors: Hughes Susan , Gibbs James , Dunlop Dorothy , Edelman Perry , Singer Ruth , Chang Rowland W.
Published: April 2015

OBJECTIVE: To determine factors that predict decline in manual performance using a multivariate model of determinants of functional limitation.

DESIGN: Longitudinal observational study.

SETTINGS: Ambulatory general medicine clinics, residences of homebound individuals, and a continuing care retirement community.

PARTICIPANTS: Subjects were 485 persons more than 60 years of age and included continuing care retirement community (CCRC) residents (n = 215), chronically homebound older persons (n = 65), and ambulatory older adults (n = 205). Mean age at baseline was 78 years.

MEASUREMENT: Independent variables included demographics, physician measures of upper‐extremity joint impairment, comorbidities derived from physical examination and chart abstract, self‐assessed arthritis pain, depression, and anxiety. The major dependent variable was 2‐year decline in timed manual performance below a threshold associated with need for long‐term care services.

RESULTS: The proportion of subjects who exceed a Timed Manual Performance Test threshold of 350 seconds increased slowly from baseline through Year 4 for all age groups but rose rapidly from Year 4 to Year 6 for the oldest group (>85 years at baseline). Using a discrete survival model, we found that age, education, grip strength, and psychological status predicted crossing the manual performance threshold within a 2‐year period.

CONCLUSIONS: The findings, coupled with earlier findings that upper extremity joint impairment predicted both grip strength and manual performance, suggest that joint impairment may be an important risk factor for future functional limitation. Since diminished hand function has been shown to predict dependency, development and testing of interventions to maintain or restore upper extremity joint function and reduce pain would appear to be a high research priority.
Medical Practice with Nursing Home Residents: Results from the National Physician Professional Activities Census
Authors: Katz Paul R. , Karuza Jurgis , Kolassa John , Hutson Alan
Published: April 2015

OBJECTIVE: The study describes the prevalence of medical nursing home practice. Further, it examines the extent to which physician characteristics and local county health care resources predict nursing home involvement. This information is relevant to evaluating and devising strategies that address the future provision of medical care in institutionalized long‐term care.

DESIGN: A cross‐sectional survey.

SETTING: A national sample of all licensed practicing physicians was obtained from a special Professional Activities (PPA) survey conducted by the American Medical Association (AMA) in 1991.

PARTICIPANTS: Respondents were 21,578 physicians involved in direct patient care.

MEASURES: The typical number of hours spent weekly caring for nursing home patients was obtained from the PPA survey, and physician demographics were obtained from the AMA Masterfile. County health care resources were obtained from the National Institutes of Health Area Resources File.

RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients. In all disciplines, a majority of physicians with a nursing home practice spent less than 2 hours per week with patients. Logistic regressions indicted that family practitioners and internists were most likely to have a nursing home practice, but general practitioners were most likely to spend more time in practice. Only 15% of specialists reported having a nursing home practice. Prevalence of practice was greatest among solo practitioners and physicians in partnerships and least among academic and hospital‐based physicians and physicians in group practice or employed by the government. Most county of practice resources were not associated or were modestly associated with nursing home practice, but having a nursing home practice became much more likely as the number of nursing home residents increased and hospital beds decreased. A pattern was found for nursing home practice to be slightly less likely as the county's per capita income and the proportion of proprietary nursing facilities increased.

CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.
Changes in Hospitalization Associated with Introducing the Resident Assessment Instrument
Authors: Mor Vincent , Intrator Orna , Fries Brant E. , Phillips Charles , Teno Joan , Hiris Jeffrey , Hawes Catherine , Morris John
Published: April 2015

OBJECTIVE: To compare the rates of hospitalization among cohorts of nursing home residents assembled before and after the implementation of the federally mandated Resident Assessment Instrument (RAI).

SAMPLE: Subjects were nursing home residents chosen from 268 facilities in major Metropolitan Statistics Areas in 10 states and representing more than 1500 facilities and 60,000 residents. Two resident cohorts (1990 and 1993) were sampled (8 to 16 residents per facility, depending upon facility size) as part of an evaluation of the impact of implementing the RAI.

METHODS: Research nurses reviewed records, interviewed staff, observed patients, and completed an RAI at baseline and 6 months later. All transitions during this interval (hospital admissions, nursing home transfers, returns home, death, etc.) were tracked. Using polytomous logistic regression, we tested the effect of cohort on the probability of being hospitalized in light of the competing risks of dying or remaining in the home, controlling for demographic and case‐mix variables, and having a DNR order in the chart.

RESULTS: A total of 4196 residents were studied, 2118 in 1990 (age 81.3, female 77.7%, LOS 6+ months 49.8%) and 2078 in 1993 (age 81.7, females 75.5%, LOS 6+ months 50.2%). The unadjusted probability of hospitalization dropped from .205 to .151. Multivariate analyses revealed a significant adjusted odds of hospitalization of .74 (95% CI .60‐.91) and no cohort effect on home discharge or death. Among severely cognitively impaired residents, the adjusted odds of hospitalization in 1993 compared with the 1990 cohort was 0.74 (.53–1.03). Finally, among survivors in both cohorts who had a follow‐up MDS performed, and whose ADL remained stable, 15.9% were hospitalized in 1990, whereas only 10.9% were hospitalized in 1993. On the other hand, ADL decliners were more likely to have been hospitalized in 1993 than in 1990 (40.6% vs 25.2%).

CONCLUSIONS: Although other changes in the industry, clinical practice, and health care policy may have influenced hospitalization of nursing home residents, the substantial reductions observed among the cognitively impaired and those with stable ADL suggest superior and uniform assessment information in the form of the RAI contributed significantly to this decline.
A Randomized Trial of Group Outpatient Visits for Chronically Ill Older HMO Members: The Cooperative Health Care Clinic
Authors: Beck Arne , Scott John , Williams Patrick , Robertson Barbara , Jackson Deborrah , Gade Glenn , Cowan Pamela
Published: April 2015

OBJECTIVE: To compare the impact of group outpatient visits to traditional “physician‐patient dyad” care among older chronically ill HMO members on health services utilization and cost, self‐reported health status, and patient and physician satisfaction.

DESIGN: A 1‐year randomized trial.

SETTING: A group model HMO in the Denver Metropolitan area.

PARTICIPANTS: Three hundred twenty‐one members aged 65 and older, randomized to a group visit intervention (n = 160) or to usual care (n = 161).

INTERVENTION: Patients with high health services utilization and one or more chronic conditions had monthly group visits with their primary care physician and nurse. Visits included health education, prevention measures, opportunities for socialization, mutual support, and for one‐to‐one consultations with their physician, where necessary.

MEASUREMENTS: Health services utilization and associated cost, health status, and patient and physician satisfaction.

RESULTS: Outcome measures obtained after a 1‐year follow‐up period showed that group participants had fewer emergency room visits (P = .009), visits to subspecialists (P = .028), and repeat hospital admissions per patient (P = .051). Group participants made more visits (P = .021) and calls (P = .038) to nurses than control group patients and fewer calls to physicians (P = .019). In addition, a greater percentage of group participants received influenza and pneumonia vaccinations (P < .001). Group participants had greater overall satisfaction with care (P = .019), and participating physicians reported higher levels of satisfaction with the groups than with individual care. No differences were observed between groups on self‐reported health and functional status. Cost of care per member per month was $14.79 less for the group participants.

CONCLUSIONS: Group visits for chronically ill patients reduce repeat hospital admissions and emergency care use, reduce cost of care, deliver certain preventive services more effectively, and increase patient and physician satisfaction.