bluuebunny/crossref_metadata_2025 huggingface dataset:
Phakometric measurement of ocular surface radii of curvature, axial separations and alignment in relaxed and accommodated human eyes
Authors: Kirschkamp Thomas , Dunne Mark , Barry Jean‐Cyriaque
Published: December 2004

Measurements (autokeratometry, A‐scan ultrasonography and video ophthalmophakometry) of ocular surface radii, axial separations and alignment were made in the horizontal meridian of nine emmetropes (aged 20–38 years) with relaxed (cycloplegia) and active accommodation (mean ± 95% confidence interval: 3.7 ± 1.1 D). The anterior chamber depth (−1.5 ± 0.3 D) and both crystalline lens surfaces (front 3.1 ± 0.8 D; rear 2.1 ± 0.6 D) contributed to dioptric vergence changes that accompany accommodation. Accommodation did not alter ocular surface alignment. Ocular misalignment in relaxed eyes is mainly because of eye rotation (5.7 ± 1.6° temporally) with small amounts of lens tilt (0.2 ± 0.8° temporally) and decentration (0.1 ± 0.1 mm nasally) but these results must be viewed with caution as we did not account for corneal asymmetry. Comparison of calculated and empirically derived coefficients (upon which ocular surface alignment calculations depend) revealed that negligible inherent errors arose from neglect of ocular surface asphericity, lens gradient refractive index properties, surface astigmatism, effects of pupil size and centration, assumed eye rotation axis position and use of linear equations for analysing Purkinje image shifts.
Transient pattern Visual Evoked Potentials in children with Down's syndrome
Authors: Suttle Catherine M. , Turner Anne M.
Published: December 2004

Visual acuity and contrast sensitivity are lower in children with Down's syndrome than in those developing normally. In many cases, this difference might be accounted for by the relatively high incidence of ocular abnormalities (including refractive error and strabismus) in Down's syndrome. However, abnormal spatial vision persists in children with Down's syndrome in the absence of ocular abnormality, suggesting that abnormal retino‐cortical visual processing explains reduced visual function in this group. The aim of the present study was to assess retino‐cortical function in children with Down's syndrome by recording transient visual evoked potentials (VEPs) in response to pattern stimuli. Responses from children with Down's syndrome were compared with those recorded from children developing normally. Response latency is similar in the two groups, but morphology differs, with the N75 component being clearly present in the normal responses, but diminished or undetectable in responses from children with Down's syndrome. Our findings may suggest a cortical abnormality specific to the source of the N75 component of pattern‐reversal achromatic VEPs.
Health care assistants’ role, function and development: results of a national survey
Authors:   The British Association of Critical Care Nurses
Published: December 2004

Intensive care has developed as a speciality since the 1950s; during this time there have been major technological advances in health care provision leading to a rapid expansion of all areas of critical care

The ongoing problem of recruiting appropriately qualified nurses has affected staffing levels in many units and continues to be a national problem. For many, the answer lies in employing health care assistants to support the work of registered nurses

A key aim of the British Association of Critical Care Nurses is to promote the art and science of critical care nursing by providing representation for its members, by responding to political and professional change and by producing and publishing position statements

A primary component of the work surrounding the development of this second position statement was the gathering of contemporary information in relation to the role of health care assistants within critical care units throughout the UK, through a survey of 645 critical care units within the UK

At present the impact upon the role of the critical care nurse is not fully understood, with research in this area suggesting that although there is a role for the health care assistant in the critical care environment, this should only be undertaken with a full analysis of this impact upon the work of the registered nurse
Effects of Exercise Training on Frailty in Community‐Dwelling Older Adults: Results of a Randomized, Controlled Trial
Authors: Binder Ellen F. , Schechtman Kenneth B. , Ehsani Ali A. , Steger‐May Karen , Brown Marybeth , Sinacore David R. , Yarasheski Kevin E. , Holloszy John O.
Published: December 2004

OBJECTIVES: Although deficits in skeletal muscle strength, gait, balance, and oxygen uptake are potentially reversible causes of frailty, the efficacy of exercise in reversing frailty in community‐dwelling older adults has not been proven. The aim of this study was to determine the effects of intensive exercise training (ET) on measures of physical frailty in older community‐dwelling men and women.

DESIGN: Randomized controlled trial.

SETTING: Medical school research center.

PARTICIPANTS: One hundred fifteen sedentary men and women (mean age ± standard deviation = 83 ± 4) with mild to moderate physical frailty, as defined by two of the following three criteria: Modified Physical Performance Test (modified PPT) score between 18 and 32, peak oxygen uptake (.VO2 peak) between 10 and 18 mL/kg/min, and self‐report of difficulty or assistance with one basic activity of daily living (ADL), or two instrumental ADLs.

INTERVENTION: Participants were randomly assigned to a control group that performed a 9‐month low‐intensity home exercise program (control) or an exercise‐training program (ET). The control intervention primarily consisted of flexibility exercises. ET began with 3 months of flexibility, light‐resistance, and balance training. During the next 3 months, resistance training was added, and, during the next 3 months, endurance training was added.

MEASUREMENTS: Modified PPT score, .VO2 peak, performance of ADLs as measured by the Older Americans Resources and Services instrument, and the Functional Status Questionnaire (FSQ).

RESULTS: ET resulted in significantly greater improvements than home exercise in three of the four primary outcome measures. Adjusted 95% confidence bounds on the magnitude of improvement in the ET group compared with the control group were 1.0 to 5.2 points for the modified PPT score, 0.9 to 3.6 mL/kg/min for .VO2 peak, and 1.6 to 4.9 points for the FSQ score.

CONCLUSIONS: Our results show that intensive ET can improve measures of physical function and preclinical disability in older adults who have impairments in physical performance and oxygen uptake and are not taking hormone replacement therapy better than a low‐intensity home exercise program.
Heterogeneity in Older People: Examining Physiologic Failure, Age, and Comorbidity
Authors: Gray Lawrence K. , Smyth Kathleen A. , Palmer Robert M. , Zhu Xiaofeng , Callahan Joyce M.
Published: December 2004

OBJECTIVES: To derive a clinically relevant age‐independent physiologic failure scoring system and to use this system to examine aspects of the association of physiologic failure, age, and comorbidity with inpatient mortality.

DESIGN: Retrospective, secondary analysis of a derivation and validation cohort selected from the Cleveland Health Quality Choice Coalition data set.

SETTING: Thirty hospitals in greater Cleveland.

PARTICIPANTS: Thirty‐one thousand nine hundred seventy‐six inpatients aged 50 and older discharged in 1993 with a diagnosis of congestive heart failure, pneumonia, or stroke.

MEASUREMENTS: The Inpatient Physiologic Failure Score (IPFS) was developed and used to calculate physiologic failure. Forty‐four candidate variables were examined for their association with inpatient mortality, and 12 were selected. A point value (2, 3, 4, or 6) based on adjusted odds ratio was assigned for an abnormal result for each of the 12 common physiologic variables. Each patient's abnormal physiology points were summed to produce a physiologic failure score (range 0–39). Comorbidity was quantified using the Patient Management Category Severity Scale. The association between mortality and increasing physiologic failure, increasing age and comorbidity, and distribution of physiologic failure with increasing age and comorbidity were examined. A threshold age was sought. Models for predicting inpatient mortality were developed.

RESULTS: Twelve physiologic variables constitute the IPFS. Increasing physiologic failure, age, and comorbidity were associated with increasing mortality. Increasing physiologic failure was not associated with increasing age or comorbidity. We did not find a threshold age. The area under the receiver operating characteristic (ROC) curve for predicting inpatient mortality for IPFS was 0.730, and for comorbidity was 0.741 (not significant). The area under the ROC curve for a mortality prediction model based on age was significantly less (0.603). Accounting for patient age did not significantly improve the predictive ability of the IPFS model (area = 0.752, P < .05). The complete model best predicted mortality (0.829).

CONCLUSIONS: The IPFS represents a clinically relevant method for scoring physiologic failure. Physiologic failure, age, and comorbidity are independently and differently associated with inpatient mortality. Physiology fails independent of age and comorbidity.
Cognitive and Functional Decline in Adults Aged 75 and Older
Authors: Black Sandra A. , Rush Ronald D.
Published: December 2004

OBJECTIVES: To simultaneously examine the influence of functional disability on the development of cognitive impairment and the influence of cognitive status on the development of functional disability over time and compare findings across ethnic groups.

DESIGN: A population‐based longitudinal study.

SETTING: Galveston County, Texas.

PARTICIPANTS: Three hundred sixty‐five community‐dwelling Hispanic Americans, African Americans, and non‐Hispanic whites, aged 75 and older.

MEASUREMENTS: Baseline measures included demographics, self‐reported chronic medical conditions, functional disability, and cognitive status. Longitudinal measures included functional decline and cognitive decline.

RESULTS: Substantial functional decline was associated with each additional error on the mental status measure; substantial cognitive decline was associated with each additional antecedent disability. These findings were evident across all three ethnic groups, even when taking into account the effects of demographic factors and chronic health conditions, although the specific chronic health conditions that influenced cognitive and functional decline were found to vary across the three ethnic groups.

CONCLUSION: Our findings suggest that, rather than simply being correlated markers of increasing frailty, cognitive and functional decline appear to influence the development of one another. Clinicians need to be aware of these associations, which may affect the direction of preventive care and rehabilitation in the oldest old. Appropriate intervention may result in the prevention or delay of functional disability and cognitive decline. Awareness of the specific chronic health conditions that increase the risk for cognitive or functional decline in various ethnic groups, and the effect of comorbid disease, may also help efforts to prevent decline in older adults.
Nursing Home Facility Risk Factors for Infection and Hospitalization: Importance of Registered Nurse Turnover, Administration, and Social Factors
Authors: Zimmerman Sheryl , Gruber‐Baldini Ann L. , Hebel J. Richard , Sloane Philip D. , Magaziner Jay
Published: December 2004

OBJECTIVES: Determine the relationship between a broad array of structure and process elements of nursing home care and (a) resident infection and (b) hospitalization for infection.

DESIGN: Baseline data were collected from September 1992 through March 1995, and residents were followed for 2 years; facility data were collected at the midpoint of follow‐up.

SETTING: A stratified random sample of 59 nursing homes across Maryland.

PARTICIPANTS: Two thousand fifteen new admissions aged 65 and older.

MEASUREMENTS: Facility‐level data were collected from interviews with facility administrators, directors of nursing, and activity directors; record abstraction; and direct observation. Main outcome measures included infection (written diagnosis, a course of antibiotic therapy, or radiographic confirmation of pneumonia) and hospitalization for infection (indicated on medical records).

RESULTS: The 2‐year rate of infection was 1.20 episodes per 100 resident days, and the hospitalization rate for infection was 0.17 admissions per 100 resident days. Except for registered nurse (RN) turnover, which related to both infection and hospitalization, different variables related to each outcome. High rates of incident infection were associated with more Medicare recipients, high levels of physical/occupational therapist staffing, high licensed practical nurse staffing, low nurses' aide staffing, high intensity of medical and therapeutic services, dementia training, staff privacy, and low levels of psychotropic medication use. High rates of hospitalization for infection were associated with for‐profit ownership, chain affiliation, poor environmental quality, lack of resident privacy, lack of administrative emphasis on staff satisfaction, and low family/friend visitation rates. Adjustment for resident sex, age, race, education, marital status, number of morbid diagnoses, functional status, and Resource Utilization Group, Version III score did not alter the relationship between the structure and process of care and outcomes.

CONCLUSIONS: The association between RN turnover and both outcomes underscores the relationship between nursing leadership and quality of care in these settings. The relationship between hospitalization for infection and for‐profit ownership and chain affiliation could reflect policies not to treat acute illnesses in house. The link between social factors of care (environmental quality, prioritizing staff satisfaction, resident privacy, and facility visitation) and hospitalization indicates that a nonmedical model of care may not jeopardize, and may in fact benefit, health‐related outcomes. All of these facility characteristics may be modifiable, may affect healthcare costs, and may hold promise for other, less‐medical, forms of residential long‐term care.
Total Plasma Homocysteine, Age, Systolic Blood Pressure, and Cognitive Performance in Older People
Authors: Budge Marc M. , De Jager Celeste , Hogervorst Eva , Smith A. David , The Oxford Project To Investigate Memory Ageing (OPTIMA)
Published: December 2004

OBJECTIVES: To investigate the relationship between total plasma homocysteine (tHcy) levels, blood pressure (BP) variables, renal function, and measures of cognitive performance in older people.

DESIGN: Initial cross‐sectional analysis of a prospective cohort.

SETTING: United Kingdom (Oxfordshire) community sample.

PARTICIPANTS: One hundred fifty‐eight community‐dwelling volunteers aged 60 to 91.

MEASUREMENTS: Neuropsychological tests (Cambridge Examination for Mental Disorders of the Elderly—Cognitive Section (CAMCOG), Mini‐Mental State Examination (MMSE), and Geriatric Depression Scale), biochemical studies (tHcy, serum folate, vitamin B12, and serum cystatin C), BP, and other vascular risk factors.

RESULTS: tHcy, age, systolic BP (SBP), and CAMCOG performance were significantly interrelated. tHcy was negatively associated with total CAMCOG score independent of years of education, serum folate, vitamin B12, and cystatin C levels. Older participants with higher tHcy levels had lower CAMCOG scores—especially men aged 70 and older. Higher tHcy levels were associated with poorer performance on the memory and perception subscores of CAMCOG but not with the other cognitive subscales or MMSE score. SBP also demonstrated a significant negative association with total CAMCOG and MMSE scores.

CONCLUSIONS: These results suggest independent associations between tHcy (modified by age and sex) and SBP and cognitive performance in older people. Further longitudinal study will define whether optimization of tHcy and systolic BP contributes to the maintenance of cognitive performance with successful aging.
Managing End‐of‐Life Care: Comparing the Experiences of Terminally Ill Patients in Managed Care and Fee for Service
Authors: Slutsman Julia , Emanuel Linda L. , Fairclough Diane , Bottorff Debra , Emanuel Ezekiel J.
Published: December 2004

There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient‐physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end‐of‐life care, care needs, and economic burdens.

Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P = .02), spend more than 10% of their income on medical care (P = .02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P = .03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P = .59). Despite concerns about the threats of MCOs to the physician‐patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.
Effectiveness of a Multifaceted Intervention on Falls in Nursing Home Residents
Authors: Becker Clemens , Kron Martina , Lindemann Ulrich , Sturm Elisabeth , Eichner Barbara , Walter‐Jung Barbara , Nikolaus Thorsten
Published: December 2004

OBJECTIVES:   To evaluate the effectiveness of a multifaceted, nonpharmaceutical intervention on incidence of falls and fallers.

DESIGN:   Prospective, cluster‐randomized, controlled 12‐month trial.

SETTING:   Six community nursing homes in Germany.

PARTICIPANTS:   Long‐stay residents (n = 981) aged 60 and older; mean age 85; 79% female.

INTERVENTIONS:   Staff and resident education on fall prevention, advice on environmental adaptations, progressive balance and resistance training, and hip protectors.

MEASUREMENTS:   Falls, fallers, and fractures.

RESULTS:   The incidence density rate of falls per 1,000 resident years (RY) was 2,558 for the control group (CG) and 1,399 for the intervention group (IG) (relative risk (RR) = 0.55, 95% confidence interval (CI) = 0.41–0.73). Two hundred forty‐seven (52.3%) fallers were detected in the CG and 188 (36.9%) in the IG (RR = 0.75, 95% CI = 0.57–0.98). The incidence density rate of frequent fallers (>2/year) was 115 (24.4%) for the CG and 66 (13.0%) for the IG (RR = 0.56, 95% CI = 0.35–0.89). The incidence density rate of hip fractures per 1,000 RY was 39 for the CG and 43 for the IG (RR = 1.11, 95% CI = 0.49–2.51). Other fractures were diagnosed with an incidence density rate of 52 per 1,000 RY for CG and 41 per 1,000 RY for IG (RR = 0.78, 95% CI = 0.57–1.07).

CONCLUSION:   The incidence density rate of falls and fallers differed considerably between the control and intervention groups. The study was underpowered to demonstrate a significant difference of hip or nonhip fractures. Because of a low fracture rate in both groups, the investigation of fracture rates would have required a larger sample size to detect an effect of the intervention.
Baseline Balance and Functional Decline in Older Adults with Knee Pain: The Observational Arthritis Study in Seniors
Authors: Marsh Anthony P. , Rejeski W. Jack , Lang Wei , Miller Michael E. , Messier Stephen P.
Published: December 2004

OBJECTIVES: To examine the cross‐sectional and longitudinal effect of baseline balance, independent of multiple covariates (sociodemographic variables, comorbidities), on self‐reported disability and several measures of functional performance.

DESIGN:  Observational Arthritis Study in Seniors was a community‐based longitudinal study.

SETTING:  Data collection was conducted at an exercise science research laboratory.

PARTICIPANTS:  A cohort of 245 women and 235 men, aged 65 and older, with self‐reported knee pain.

MEASUREMENTS:  Measurements of balance, self‐reported disability, functional performance, strength, sociodemographic characteristics, disease burden (including radiographic knee osteoarthritis (OA)), and functional limitations were obtained on participants at baseline and 30 months. The four outcome measures (self‐reported disability, stair climb time, car time, preferred walking speed) were also collected at 15 months.

RESULTS:  In cross‐sectional analyses, baseline balance was significantly associated with each of the four outcome measures before adjusting for baseline knee strength. After adjusting for knee strength, baseline balance remained significantly associated with all functional performance outcomes and self‐reported disability. In longitudinal analyses, baseline balance had a significant effect on car‐time performance, whereby individuals in the lowest quartile of baseline balance scores declined in a quadratic manner from baseline to Month 30.

CONCLUSION:  Baseline balance, independent of strength and various other covariates, is an important component of performance for transfer and ambulatory tasks and for self‐reported disability. Balance was predictive of change in performance over time only in a task that presented a significant challenge to the lateral mobility/stability of participants. Balance was not predictive of decline in ambulatory performance‐based tasks or in self‐reported disability.
Effect of Low‐Dose Thiazide Diuretics on Plasma Lipids: Results from a Double‐Blind, Randomized Clinical Trial in Older Men and Women
Authors: Ott Susan M. , LaCroix Andrea Z. , Ichikawa Laura E. , Scholes Delia , Barlow William E.
Published: December 2004

OBJECTIVES:  To determine the effects of low doses of hydrochlorothiazide (HCTZ) on plasma lipids in healthy older men and women.

DESIGN:   Randomized, double‐blind, placebo‐controlled clinical trial for 3 years followed by a 1 year extension without medication.

SETTING:   Research clinic of a nonprofit health maintenance organization.

PARTICIPANTS:   Two hundred five women and 115 men aged 60 to 79 with normal blood pressure, bone density within two standard deviations of mean for age, and low‐density lipoprotein cholesterol (LDL‐C) levels less than 190 mg/dL.

INTERVENTION:   Placebo or HCTZ 12.5 or 25 mg/d.

MEASUREMENTS:   Plasma cholesterol, LDL‐C, high‐density lipoprotein cholesterol, triglycerides.

RESULTS:   There were no significant differences in the change in the plasma lipids between placebo and either group. The mean changes ± standard deviation in LDL‐C after 3 years in men were −5.2 ± 3.9 mg/dL (placebo), −4.6 ± 3.7 (12.5 mg), and 1.1 ± 3.8 (25 mg) and in women were 1.3 ± 2.8 (placebo), −1.1 ± 2.8 (12.5 mg), and −6.8 ± 2.8 (25 mg). No significant differences were seen when analysis was done only for subjects who adhered to study medication.

CONCLUSION:   This study provides evidence that low doses of thiazide diuretics have minimal effects on cholesterol metabolism in healthy older adults. Therefore, effects on lipid levels need not limit use of thiazides for prevention of osteoporotic fractures.
The Effects of an Exercise and Incontinence Intervention on Skin Health Outcomes in Nursing Home Residents
Authors: Bates‐Jensen Barbara M. , Alessi Cathy A. , Al‐Samarrai Nahla R. , Schnelle John F.
Published: December 2004

OBJECTIVES:  To examine skin health outcomes of an exercise and incontinence intervention.

DESIGN:   Randomized controlled trial with blinded assessments of outcomes at three points over 8 months.

SETTING:   Four nursing homes (NHs).

PARTICIPANTS:   One hundred ninety incontinent NH residents.

INTERVENTION:   In the intervention group, research staff provided exercise and incontinence care every 2 hours from 8:00 a.m. to 4:30 p.m. (total of four daily care episodes) 5 days a week for 32 weeks. The control group received usual care from NH staff.

MEASUREMENTS:   Perineal skin wetness and skin health outcomes (primarily blanchable erythema and pressure ulcers) as measured by direct assessments by research staff, urinary and fecal incontinence frequency, and percentage of behavioral observations with resident engaged in standing or walking.

RESULTS:   Intervention subjects were significantly better in urinary and fecal incontinence, physical activity, and skin wetness outcome measures than the control group. However, despite these improvements, differences in skin health measures were limited to the back distal perineal area, which included the sacral and trochanter regions. There was no difference between groups in the incidence rate of pressure ulcers as measured by research staff, even though those residents who improved the most on fecal incontinence showed improvement in pressure ulcers in one area.

CONCLUSION:   A multifaceted intervention improved four risk factors related to skin health but did not translate into significant improvements in most measures of skin health. Even if they had adequate staffing resources, NHs might not be able to improve skin health quality indicators significantly if they attempt to implement preventive interventions on all residents who are judged at risk because of their incontinence status.
Visual Risk Factors for Hip Fracture in Older People
Authors: Ivers Rebecca Q. , Optom B , Cumming Robert G. , Mitchell Paul , Simpson Judy M. , Peduto Anthony J.
Published: December 2004

OBJECTIVES:  To determine the association between poor vision and risk of hip fracture in the Blue Mountains Eye Study.

DESIGN:   Prospective population‐based cohort study.

SETTING:   Two post code areas in the Blue Mountains, west of Sydney, Australia.

PARTICIPANTS:   Three thousand six hundred fifty‐four community‐dwelling Australians aged 49 and older.

MEASUREMENTS:   At baseline, subjects had an extensive eye examination, including refraction, contrast sensitivity and visual field testing, photographs of the lens and retina, and an interview. Hip fractures during the 5‐year follow‐up were identified by self‐report and review of medical records and were radiologically confirmed.

RESULTS:   For 2‐year follow‐up (17 hip fractures), the adjusted hazard ratio (HR) for risk of hip fracture in those with corrected visual acuity worse than 20/60 was 8.4 (95% confidence interval (CI) = 1.5–48.5, population attributable risk (PAR) = 27%); for presence of posterior subcapsular cataract, the adjusted HR was 5.0 (95% CI = 1.1–23.0, PAR = 24%); and for visual field loss, the adjusted HR was 5.5 (95% CI = 1.0–29.8, PAR = 55%). In those aged 75 and older, visual acuity worse than 20/60 gave an adjusted HR of 40.6 (95% CI = 5.6–292.5, PAR = 49%). Visual impairment of any type did not predict risk of hip fracture after a 2‐year follow‐up.

CONCLUSION:   Visual impairment is strongly associated with risk of hip fracture in the next 2 years but not over a longer period of time.
Estimating Hip Fracture Morbidity, Mortality and Costs
Authors: Braithwaite R. Scott , Col Nananda F. , Wong John B.
Published: December 2004

OBJECTIVES: To estimate lifetime morbidity, mortality, and costs from hip fracture incorporating the effect of deficits in activities of daily living.

DESIGN:  Markov computer cohort simulation considering short‐ and long‐term outcomes attributable to hip fractures. Data estimates were based on published literature, and costs were based primarily on Medicare reimbursement rates.

SETTING:  Postacute hospital facility.

PARTICIPANTS:  Eighty‐year‐old community dwellers with hip fractures.

MEASUREMENTS:  Life expectancy, nursing facility days, and costs.

RESULTS:  Hip fracture reduced life expectancy by 1.8 years or 25% compared with an age‐ and sex‐matched general population. About 17% of remaining life was spent in a nursing facility. The lifetime attributable cost of hip fracture was $81,300, of which nearly half (44%) related to nursing facility expenses. The development of deficits in ADLs after hip fracture resulted in substantial morbidity, mortality, and costs.

CONCLUSION:  Hip fractures result in significant mortality, morbidity, and costs. The estimated lifetime cost for all hip fractures in the United States in 1997 likely exceeded $20 billion. These results emphasize the importance of current and future interventions to decrease the incidence of hip fracture.
Hospital Readmissions After Hospital Discharge for Hip Fracture: Surgical and Nonsurgical Causes and Effect on Outcomes
Authors: Boockvar Kenneth S. , Halm Ethan A. , Litke Ann , Silberzweig Stacey B. , McLaughlin MaryAnn , Penrod Joan D. , Magaziner Jay , Koval Kenneth , Strauss Elton , Siu Albert L.
Published: December 2004

OBJECTIVES:  To examine the causes of hospital readmission after hip fracture and the relationships between hospital readmission and 6‐month physical function and mortality.

DESIGN:   Prospective, multisite, observational cohort study.

SETTING:   Four hospitals in the New York City metropolitan area.

PARTICIPANTS:   Five hundred sixty‐two patients hospitalized for hip fracture aged 50 and older and discharged alive in 1997–1998.

MEASUREMENTS:   Patient demographic characteristics, type of fracture and repair, comorbid conditions, postoperative complications, do not resuscitate status, and active clinical problems at the time of hospital discharge. Prefracture and 6‐month mobility were measured using the Functional Independence Measure. Hospital readmissions and International Classification of Diseases, Ninth Revision principal diagnoses were ascertained from hospital admission/discharge databases, the New York Statewide Planning and Research Cooperative System, medical record review, and patient self‐report.

RESULTS:   Eighty‐two percent of participants were women, and 93% were white. Within 6 months after hospital discharge, 178 (32%) patients were readmitted to the hospital, with 45 (8%) readmitted more than once. Forty‐seven of 233 readmissions (20%) occurred within the first 2 weeks after discharge, and 80 (34%) occurred within 4 weeks. Over 6 months, 89% of readmissions were for nonsurgical problems, of which infectious (21%) and cardiac (12%) diseases were the most common. In multivariate analyses, patients who were readmitted were more likely to require total assistance with ambulation at 6 months (odds ratio (OR) = 2.7, 95% confidence interval (CI) = 1.6–4.6) and to die (OR = 4.0, 95% CI = 2.2–7.3) than those not readmitted.

CONCLUSION:   Hospital readmissions after hip fracture are largely due to nonsurgical illness and are associated with increased morbidity and mortality.
Sociodemographic and Health Characteristics of Older Chinese on Admission to a Nursing Home: A Cross‐Racial/Ethnic Study
Authors: Huang Zheng‐Bo , Neufeld Richard R. , Likourezos Antonios , Breuer Brenda , Khaski Albert , Milano Evelin , Libow Leslie S.
Published: December 2004

OBJECTIVES:  To investigate sociodemographic characteristics (SDCs) and health status of older Chinese newly admitted to a nursing home (NH) and to compare them with the characteristics of residents from other racial/ethnic groups.

DESIGN:   Secondary analysis of the admission Minimum Data Set Plus (MDS+).

SETTING:   A New York City municipal NH near Chinatown.

PARTICIPANTS:   Two hundred fifty‐eight (125 Chinese, 57 white, 53 Hispanic, and 23 black) of 292 residents consecutively admitted from November 1992 to May 1997 were selected after excluding those younger than 60 or transferred from another NH.

MEASUREMENTS:   SDCs, health status parameters (cognitive performance, physical functioning, mood/behavior patterns, and psychosocial well‐being), and morbidity information (most‐frequent diagnoses/conditions and medication use) documented in or generated from the MDS+.

RESULTS:   The majority of these Chinese were first‐generation immigrants and spoke primarily Cantonese or Mandarin Chinese. Compared with whites, they were more likely to be married, less likely to have lived alone, more likely to be using Medicaid, less likely to make medical decision alone, and more likely to depend on family members for decision‐making. Nearly three‐quarters of Chinese had cognitive impairment. There was an underdiagnosis of dementia in the Chinese subjects on admission. Severe dependence in activity of daily living was identified in more than one‐third of Chinese. Fewer Chinese were using psychotropic medications on admission than the whites. Similar to other groups, many of the Chinese subjects were incontinent of bowel and bladder and had chewing or swallowing problems, hypertension, anemia, and stroke.

CONCLUSION:   This is the first systematic report of the SDCs and health status of a group of newly admitted older Chinese to an urban NH in the United States using the Minimum Data Set database. These findings suggest that Chinese residents are as frail as other racial/ethnic residents on admission. NHs care for older Chinese need to be sensitive to the presence of dementia and require a staff that can speak Cantonese and Mandarin Chinese and is comfortable negotiating with families who are more likely to be the designated decision makers.
Association Between Dementia and Midlife Risk Factors: the Radiation Effects Research Foundation Adult Health Study
Authors: Yamada Michiko , Kasagi Fumiyoshi , Sasaki Hideo , Masunari Naomi , Mimori Yasuyo , Suzuki Gen
Published: December 2004

OBJECTIVES:  To investigate the association between midlife risk factors and the development of vascular dementia (VaD) or Alzheimer's disease (AD) 25 to 30 years later.

DESIGN:   A prevalence study within a longitudinal cohort study.

SETTING:   Subjects in the Adult Health Study (a prospective cohort study begun in 1958) have been followed through biennial medical examinations in Hiroshima, Japan.

PARTICIPANTS:   One thousand seven hundred seventy‐four subjects in Hiroshima, Japan born before September 1932 (1,660 with no dementia, 114 with dementia (51 with AD, and 38 with VaD) diagnosed from 1992 to 1997 according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria).

MEASUREMENTS:   The subjects were examined for effect on dementia of sex, age, education, atomic bomb radiation dose, and midlife factors associated with risk (smoking, alcohol intake, physical activity, dietary habits, systolic blood pressure (SBP), body mass index, and history of diabetes mellitus) that had been evaluated in 1965–1970.

RESULTS:   VaD prevalence increased significantly with age, higher SBP, and lower milk intake. The odds ratios of VaD for age (in 5‐year increments), SBP (10 mmHg increments), and milk intake (almost daily/less than four times a week) were 1.29, 1.33, and 0.35, respectively. The risk factors for VaD were compatible with the risk factors for stroke in this study population. AD prevalence increased significantly with age and lower education. Other midlife factors and radiation dose did not show any significant association with VaD or AD.

CONCLUSION:   Increased SBP and low milk intake in midlife were associated with VaD detected 25 to 30 years later. Early behavioral control of the risk factors for vascular disease might reduce the risk of dementia.
Delirium in Older Emergency Department Patients Discharged Home: Effect on Survival
Authors: Kakuma Ritsuko , Du Fort Guillaume Galbaud , Arsenault Louise , Perrault Anne , Platt Robert W. , Monette Johanne , Moride Yola , Wolfson Christina
Published: December 2004

OBJECTIVES: To determine whether prevalent delirium is an independent predictor of mortality in older patients seen in emergency departments (EDs) and discharged home without admission.

DESIGN: Prospective study with 18 months of follow‐up.

SETTING: EDs in two Montreal hospitals.

PARTICIPANTS: From a cohort study of prognosis for delirium (107 delirious and 161 nondelirious subjects), 30 delirious and 77 nondelirious subjects aged 66 and older who were discharged home without admission were identified.

MEASUREMENTS: Detailed interviews with patients and their proxies and review of medical charts were performed at enrollment. Trained lay interviewers determined delirium status using the Confusion Assessment Method. Subjects were followed up at 6‐month intervals for a total of 18 months. Dates of death were obtained from the Ministère de la Santé et des Service Sociaux (Ministry of Health and Social Services). Survival analysis was performed using the Cox proportional hazards modeling adjusting for potential confounding variables.

RESULTS: The analysis revealed a statistically significant association between delirium and mortality after adjustments for age, sex, functional level, cognitive status, comorbidity, and number of medications for the first 6 months of follow‐up (hazard ratio = 7.24; 95% confidence interval = 1.62–32.35). The subjects whose delirium was not detected by the ED physician or nurse had the highest mortality over 6 months (30.8%). The mortality of delirious subjects detected in the ED was similar to that of the nondelirious subjects (11.8 vs 14.3%).

CONCLUSION: The results of this study suggests that nondetection of delirium in the ED may be associated with increased mortality within 6 months after discharge. Further research is necessary to examine the effectiveness of improving detection on subsequent prognosis of older patients with delirium.
The Last 2 Years of Life: Functional Trajectories of Frail Older People
Authors: Covinsky Kenneth E. , Eng Catherine , Lui Li‐Yung , Sands Laura P. , Yaffe Kristine
Published: December 2004

OBJECTIVES: To characterize the functional trajectories during the last 2 years of life of patients with progressive frailty, with and without cognitive impairment, and to assess whether it was possible to identify discrete functional indicators that signal the end of life.

DESIGN: A retrospective analysis of functional trajectories during the last 24 months of life.

SETTING: Twelve demonstration sites of the Program of All‐inclusive Care for the Elderly (PACE). PACE cares for frail older people who meet criteria for nursing home placement, with the goal of keeping the patient at home.

PARTICIPANTS: Nine hundred seventeen patients who died while enrolled in PACE.

MEASURES: At PACE entry and every 3 months thereafter, data were collected about the degree of dependence (none, partial, or full) in bathing, eating, and walking and the degree of incontinence (none, bladder, or bowel). Cognitive impairment was defined as six or more errors on the Short Portable Mental Status Questionnaire. To describe the end‐of‐life trajectories of patients, data were analyzed from observational windows of time, beginning with the patients' dates of death and extending backward in time to 24 months before death. Each analytical window was 3 months in duration. For each of the functional measures, the probability of functional deterioration in the last 2 years of life in patients with (64%) and without (36%) cognitive impairment was also compared.

RESULTS: The mean age at death was 84; 69% of patients were women. For patients with and without cognitive impairment, a prolonged, steady increase in the rates of functional dependence that were evident at least 1 year before death, rather than sudden increases in functional dependence shortly before death, characterized the functional trajectories. It was not possible for any of the four measures to detect a time point before death at which there was an abrupt decline in function likely to signal impending death.

For each measure, patients with cognitive impairment declined earlier, were more likely than patients without cognitive impairment to have the maximal level of dependence in the 0‐ to 3‐month window before death (e.g., 56% vs 30% for mobility, P < .001), and were more likely to decline in the 2 years before death (e.g., 56% vs 36% for mobility, P < .001).

CONCLUSION: Patients with advanced frailty, with or without cognitive impairment, have an end‐of‐life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end‐of‐life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.
Prevalence and Correlates of Anxiety Symptoms in Well‐Functioning Older Adults: Findings from the Health Aging and Body Composition Study
Authors: Mehta Kala M. , Simonsick Eleanor M. , Penninx Brenda W. J. H. , Schulz Richard , Rubin Susan M. , Satterfield Suzanne , Yaffe Kristine
Published: December 2004

OBJECTIVES: To determine the prevalence and correlates of anxiety symptoms in the absence of depression, in older black and white people.

DESIGN: Cross‐sectional study.

SETTING: Baseline assessment of a biracial cohort of community‐resident well‐functioning men and women aged 70 to 79 participating in the Health Aging and Body Composition study.

PARTICIPANTS: Three thousand forty‐one participants (mean age 74, 52% women, 58% white).

MEASUREMENTS: Participants were asked about three major anxiety symptoms (feeling fearful, tense/keyed‐up, or shaky/nervous) derived from the Hopkins Symptom Checklist. Participants were considered to have anxiety symptoms if they reported feeling at least two anxiety symptoms “a little” or one symptom “quite a bit” in the past week. Logistic regression models were used to identify demographic, psychosocial, and health‐related correlates of anxiety symptoms.

RESULTS: Anxiety symptoms occurred in 15% of older people without depression and 43% of those with depression. Of nondepressed older people, women were more likely to have anxiety symptoms than men (P < .01), especially white women (20% prevalence). After multivariate adjustment, the chronic conditions of urinary incontinence (odds ratio (OR) = 1.5, 95% confidence interval (CI) = 1.1–1.9), hearing impairment (OR = 1.4, 95% CI = 1.0–2.1), hypertension (OR = 1.3, 95% CI = 1.0–1.7) and poor sleep (OR = 1.7, 95% CI = 1.3–2.4) were associated with a higher prevalence of anxiety symptoms. Persons with poorer psychosocial functioning, low personal mastery (OR = 2.0, 95% CI = 1.6–2.5) and the need for more emotional support (OR = 2.2, 95% CI = 1.7–2.8), also had higher rates of anxiety symptoms.

CONCLUSION: Anxiety symptoms are common in depressed and nondepressed older people. Given the high prevalence and coexistence with depressive symptoms, it will be important to conduct longitudinal studies that assess depressive and anxiety symptoms to clarify the direction and influence and disentangle the health‐related consequences of these two conditions.
Prescription and Dosage of Analgesic Medication in Relation to Resident Behaviors in the Nursing Home
Authors: Allen Rebecca S. , Thorn Beverly E. , Fisher Susan E. , Gerstle John , Quarles Karen , Bourgeois Michelle S. , Dijkstra Katinka , Burgio Louis D.
Published: December 2004

OBJECTIVES: To examine correlates of analgesic medication prescription and administration in communicative, cognitively impaired nursing home residents. Residents' behaviors were assessed using computer‐assisted real‐time observations as potential adjunctive indicators of pain.

DESIGN: Cross‐sectional study over a 4‐week period.

SETTING: Five nursing homes in the greater Birmingham, Alabama, area.

PARTICIPANTS: Ninety‐two residents (mean age ± standard deviation = 83.86 ± 8.55) with a mean Mini‐Mental State Examination (MMSE) score of 13.81 ± 6.34.

MEASUREMENTS: Data were obtained via chart review, resident assessments, questionnaire completion by certified nursing assistants familiar with residents' care, and direct observation of residents' daily behaviors.

RESULTS: Receipt of analgesic medication was related to self‐report of pain (F2,89 = 9.89, P = .0001), MMSE (F2,88 = 3.98, P = .022), and time spent inactive (F2,89 = 3.04, P = .053). Residents who received analgesic medication reported greater intensity of pain than other residents. Residents who received analgesics had higher MMSE scores than those who did not receive analgesics. Residents who received analgesics spent less time being inactive than those not prescribed analgesics. Receipt of higher dosage of opioid analgesic medication was associated with more time spent with others in verbal interaction (r = .22, P = .03).

CONCLUSION: This study refines the methodology of measuring analgesic medication dosage and its effect on resident behavior. Analgesic prescription and administration patterns are related to time residents spend being inactive. Results suggest that opioid analgesics may hold particular promise in alleviating pain, as indicated by resident behaviors.
Consensus Statement on Improving the Quality of Mental Health Care in U.S. Nursing Homes: Management of Depression and Behavioral Symptoms Associated with Dementia
Authors:   American Geriatrics Society and American Association for Geriatric Psychiatry
Published: December 2004

The American Geriatrics Society and American Association for Geriatric Psychiatry Expert Panel on Quality Mental Health Care in Nursing Homes developed this consensus statement.

The following organizations were represented on the expert panel and have reviewed and endorsed* the consensus statement:

Alzheimer's Association, American Association for Geriatric Psychiatry, American Association of Homes and Services for the Aging, American College of Health Care Administrators, American Geriatrics Society, American Health Care Association, American Medical Directors Association, American Society on Aging, American Society of Consultant Pharmacists, Gerontological Society of America, National Association of Directors of Nursing Administration in Long‐Term Care, National Citizen's Coalition for Nursing Home Reform, National Conference of Gerontological Nurse Practitioners.

The following organizations were also represented on the expert panel and reviewed and commented on the consensus statement:

American Psychiatric Association: Council on Aging, American Psychological Association.