bluuebunny/crossref_metadata_2025 huggingface dataset:
Skin Disorders and Moisture in Incontinent Nursing Home Residents: Intervention Implications
Authors: Schnelle John F. , Adamson Greg M. , Cruise Patrice A. , Al‐Samarrai Nahla , Sarbaugh Frank C. , Uman Gwen , Ouslander Joseph G.
Published: April 2015

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population.

DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60‐day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders.

SETTING: Four nursing homes.

PARTICIPANTS: One hundred incontinent nursing home residents.

MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions.

RESULTS: All subjects had at least one skin condition identified during the 60‐day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty‐one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence.

CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.
Accuracy of Patient Care Staff in Estimating and Documenting Meal Intake of Nursing Home Residents
Authors: Pokrywka Helene S. , Koffler Karen H. , Remsburg Robin , Bennett Richard G. , Roth Jesse , Tayback Matthew , Wright Jonelle E.
Published: April 2015

OBJECTIVES: To determine the accuracy of patient care staff estimates and documentation of food intake of residents in nursing homes.

DESIGN: Prospective, observed, unblinded cohort study.

SETTING: Three urban nursing home facilities.

SUBJECTS: Staff estimation and documentation of 27 nursing home residents' meal intake.

MEASUREMENTS: Actual amount consumed by 27 nursing home residents was ascertained by weighing food and caloric fluids on resident trays before and after one lunch time meal. Staff estimates and documentation of percent of meal consumed was compared with actual intake. RESULTS: Patient care staff estimates differed from actual intake by approximately 20%, and in most instances intake was overestimated. Almost one‐third of the residents at risk for nutritional problems were not identified correctly by staff. Chart documentation of meal intake frequently did not reflect either actual amount of meal consumed or the staff's estimation of what was eaten.

CONCLUSION: Study findings indicate that the present system used to document nursing home residents' intake is inadequate and that a more accurate mechanism or an entirely different process for identifying residents at risk for nutritional problems should be developed and implemented.
Attitudes Toward Life‐Sustaining Treatment of Older Persons in Hong Kong
Authors: Hui Elsie , Ho Suzanne C. , Tsang June , Lee S.H. , Woo Jean
Published: April 2015

OBJECTIVES: There have been few studies of the attitudes of older Asians toward life‐sustaining therapy. This paper presents the knowledge of and attitudes toward cardiopulmonary resuscitation (CPR) and life support in a group of subjects in Hong Kong.

DESIGN: Cross‐sectional, desciptive study.

PARTICIPANTS: Of the 543 subjects, 382 were old‐age home residents and 161 were in‐patients of geriatric wards.

MEASURMENTS: Sociodemographic data, functional ability (using the Barthel Index), self‐perceived health scale, knowledge of life‐sustaining procedures, and subjects' preferences for such treatments were studied. They were also asked to give the most important reason for wanting or declining CPR, and to indicate who they believe should be the decision‐maker(s) regarding whether they should receive life‐ sustaining treatment.

RESULTS: Approximately 80% of old‐age home residents and 60% of hospitalized patients had no knowledge of life‐sustaining therapy. The success rate of CPR was overestimated by older subjects, and most wished to be resuscitated. However, up to 20% changed their minds and declined CPR after they knew the true outcome of the procedure. Half of the subjects wanted life support. Univariate analysis found that advanced age and not having a spouse were associated significantly with CPR preference, whereas subjects' knowledge was associated with preference for life support. Multivariate analysis revealed that advanced age, not having a spouse, and female sex were independently associated with a tendency to decline CPR. A considerable proportion of older people wished to be involved in decision‐making regarding life‐sustaining treatment.

CONCLUSION: Knowledge of life‐sustaining procedures was poor among older people in Hong Kong compared with their counterparts in western countries. Although most older subjects wanted CPR, a number of them changed their minds after they knew the poor outcome. Therefore, older patients should be given more information about life‐sustaining therapy and encouraged to take part in their treatment plans.
The Prevalence of Potentially Remediable Urinary Incontinence in Frail Older People: A Study Using the Minimum Data Set
Authors: Brandeis Gary H. , Baumann Margaret M. , Hossain Monir , Morris John N. , Resnick Neil M.
Published: April 2015

OBJECTIVES: To use the Minimum Data Set (MDS) to describe the frequency and correlates of potentially treatable causes of urinary incontinence among a representative sample of American nursing home residents. To describe current management practices of urinary incontinence in the same population.

DESIGN: Cross‐sectional study using the dataset that was part of the Health Care Financing Administration (HCFA) evaluation of the MDS.

SETTING: 270 Medicaid‐certified nursing homes in 10 states.

PARTICIPANTS: A total of 2014 nursing home residents 60 years or older (mean = 84.3 ± 8.7), 75.5% women, 81.9% white, who lived in a nursing home during the fall of 1990 were randomly selected to sample a fixed number of residents for each facility based on facility size.

MEASUREMENTS: Incontinence was defined as the presence of at least two episodes of urinary leakage per week in the previous 2 weeks. Management techniques (toileting, pads/briefs, catheters) were those listed in the MDS. Potentially remediable causes of urinary incontinence available in the MDS were: medications (antipsychotics, antidepressants, and antianxiety/hypnotics); congestive heart failure; diabetes mellitus; pedal edema; delirium; depression; and impairments in activities of daily living (ADLs) (transferring, locomotion, dressing, toileting; bedrails; trunk restraints; and chair restraints).

RESULTS: Forty‐nine percent of residents were incontinent. Of these, 84.0% were managed by pads/briefs, 38.7% by scheduled toileting, 3.5% by indwelling catheter, and 1.2% by external catheter. Of the potentially reversible causes, bivariate analysis revealed associations (P < .1) with use of antidepressants, antipsychotics, and antianxiety/hypnotics; delirium; bedrails; trunk restraints; chair restraints; and ADL impairment. Dementia was also associated with incontinence (P < .1). Multivariate analysis revealed that urinary incontinence was independently associated with impairment in ADLs (OR = 4.2; CI = 3.2, 5.6), dementia (OR = 2.3; CI = 1.8, 3.0), restraints‐trunk (OR = 1.7; CI = 1.5, 2.0), chair (OR = 1.4; CI = 1.2, 1.6), bedrails (OR = 1.3; CI = 1.1, 1.5), and use of antianxiety/hypnotic medications (OR = .7; CI = .5, 1.0) (all P < .04).

CONCLUSIONS: Current management practices for urinary incontinence are inconsistent with advocated guidelines. These data also confirm the association between incontinence and several potentially remediable conditions and suggest that, even in the nursing home setting, urinary incontinence may respond to efforts to improve conditions not directly related to bladder function. This study underscores the need to examine the impact on urinary incontinence of strategies to address such conditions.
Predictors of Perceived Health in Hospitalized Older Persons: A Cross‐Sectional and Longitudinal Study
Authors: Kim Seung H. , Wolde‐Tsadik Girma , Reuben David B.
Published: April 2015

OBJECTIVES: To identify the predictors of perceived health and predictors of changes in perceived health in frail hospitalized older persons during the year after hospitalization.

DESIGN: Both cross‐sectional and longitudinal multivariate analysis of data from a cohort followed for 1 year.

SETTING: Six hospitals in a group practice model health maintenance organization (HMO) in Southern California.

PARTICIPANTS: A total of 1889 persons aged 65 or older who met at least one of 13 inclusionary criteria for a randomized trial of Comprehensive Geriatric Assessment consultation at admission and completed three Functional and Health Status Questionnaires (FHSQ) during a 12‐month period.

MEASUREMENTS: Functional and health status measures included basic and intermediate activities of daily living (BADL and IADL) and social activities (SA) scales from the Functional Status Questionnaire as well as the mental health index (MHI) and current health perception (CHP) scales from the Medical Outcomes Study short form. Subject's severity of disease was measured by the Resource Demand Scale (RD Scale).

RESULTS: In the cross‐sectional analyses, MHI score, IADL score, RD Scale, history of falls during the 3 months before hospitalization, and female gender were significant predictors of perceived health in all models for each time point. BADL score, age, presence of incontinence, and ethnicity were significant in the model for baseline only, and SA score was significant in models for 3 months and 12 months only. In the longitudinal analyses, the baseline CHP score and the changes in MHI, IADL, and BADL score predicted CHP change from 0 to 3 months and from 3 to 12 months.

CONCLUSIONS: Functional and psychosocial health indicators are the most important and most consistent predictors of perceived health. Our study showed that several predictors of perceived health in cross‐sectional analysis did not predict changes in perceived health over a 1‐year period. Hence, to fully understand the medical and social contributors to perceived health, a comprehensive approach using both cross‐sectional and longitudinal analyses is necessary.
Circadian Rest‐Activity Rhythms in Demented and Nondemented Older Community Residents and Their Caregivers
Authors: Pollak Charles P. , Stokes Peter E.
Published: April 2015

OBJECTIVE: Disruptive nocturnal behaviors (DNBs) of older people often threaten the caregiving arrangements on which their community tenure depends. Dementing disorders are especially prone to result in disrupted sleep and agitated behaviors (“sundowning”). The objective here was to develop an objective correlate of DNBs, by which their severity and effects on caregivers can be measured.

DESIGN: Quantitative comparison of subjective sleep and motor activity patterns in older people and their caregivers. It was hypothesized that older people with reported DNBs would be more motorically active at night than their caregivers.

SETTING: Subjects' homes.

PARTICIPANTS: Twenty‐five demented and 18 nondemented older day‐care participants and their paired caregivers.

MEASUREMENTS: Older subjects and caregivers simultaneously kept daily sleep logs and recorded wrist motor activity every .5 minute for 9 days. A novel method was devised to identify and exclude from analysis periods when the activity monitor was not being worn. Such periods were common. Activity data were analyzed by computing hourly means and by fitting cosine models by least squares.

RESULTS: Demented older people were not significantly more active at night than their caregivers, though group differences varied by time of night. They were significantly less active in the daytime than were their caregivers. Nondemented older people were significantly more active at night than their caregivers and were as active by day as their caregivers. The caregivers of demented and nondemented older people had similar rest‐activity patterns. The mean amplitudes of cosine models were smaller in the older adults. Acrophases (peaks) fell between 2 and 3 pm and did not differ significantly among the groups.

CONCLUSIONS: As a result of increased nighttime motor activity and decreased daytime activity, rest‐activity rhythms were flatter in older adults than in caregivers. This was not explained fully by age and does not necessarily imply that the output of a circadian pacemaker was low. Decreased daytime activity may have resulted from deficient physical stimulation or frailty. Frailty may also explain why nighttime activity was not more elevated in the demented older people. Increased nighttime activity is probably explained by depression, sleep‐schedule disturbances, restless legs, or other sleep disorders. Judging by their shared variations of activity, caregivers interacted mainly with the demented older people at bedtime and at rising time in the morning.
To Treat Or Not To Treat: Issues in Decisions Not To Treat Older Persons with Cognitive Impairment, Depression, and Incontinence
Authors: Silverman Myrna , McDowell B. Joan , Musa Donald , Rodriguez Eric , Martin David
Published: April 2015

OBJECTIVES: To examine decisions not to treat problems identified during outpatient geriatric assessment, particularly problems of cognitive impairment, depression, or urinary incontinence.

DESIGN: A descriptive study using patients' medical charts and survey data and interviews with clinical staff. SETTING: Four hospital‐based, ambulatory, geriatric assessment clinics in Allegheny County, PA. PARTICIPANTS: The sample comprised 128 older adults, recruited to a randomized, controlled clinical trial, who had problems associated with cognitive impairment, depression, or urinary incontinence.

RESULTS: Although treatment was recommended for most of the problems relating to cognitive impairment, depression, and/or incontinence experienced by this group, slightly more than one‐third of cognitive impairment and depression problems and nearly one‐half of incontinence did not receive treatment recommendations. Treatment rates varied considerably by condition and combination of comorbidity. Decisions not to treat are classified into six categories: patient or family refused treatment, the assessment was not completed, an intervention was already in place, concurrent problems or comorbities might have interfered with treatment, there was no documented diagnosis or there was a documented consideration and rule out of the problem, or no documented reason.

CONCLUSION: Outpatient geriatric assessment units are designed to deal with the multiple problems experienced by their geriatric patients, and they identify successfully most problems presented by their frail constituents. However, identification of the patient's problems is only the first step in the assessment process and does not necessarily lead to either a documented diagnosis or to a treatment recommendation. Multiple social, cultural, environmental, and medical factors complicate the assessment process and, hence, the decision clinicians face when they decide whether to make recommendations to treat. These clinicians must weigh all medical and non‐medical factors, including the patient's receptivity to treatment, when prioritizing the problems they deem to be treatable and making recommendations to treat. J Am Geriatr Soc 45:1094–1101, 1997.
Can Money Buy Happiness? Depressive Symptoms in an Affluent Older Population
Authors: West Catherine G. , Reed Dwayne M. , Gildengorin Ginny L.
Published: April 2015

OBJECTIVES: To determine if the inverse association between depressive symptoms and income reported in predominantly low‐ and middle‐income older populations is present in a more affluent population of older adults and to determine if this pattern is independent of other known correlates of depressive symptoms such as medical problems, physical disability, and social support.

DESIGN: Cross‐sectional analysis within a prospective cohort study.

SETTING: An ongoing, community‐based cohort study conducted by an independent research institution in an affluent Northern California county.

PARTICIPANTS: A total of 1948 randomly selected, noninstitutionalized county residents 55 years of age and older who completed the baseline questionnaire and physical performance tests.

MEASUREMENTS: The outcome measure was high level of depressive symptoms (score ≥ 16) using the Center for Epidemiologic Studies‐Depression scale (CES‐D).

RESULTS: The prevalence of high levels of depressive symptoms (CES‐D score ≥ 16) was lower than in most other population‐based samples using an identical CES‐D scale. In age‐adjusted, sex‐specific analyses, increasing income level was associated significantly with lower levels of depressive symptoms, but the nature of the relationship appeared quadratic rather than linear (Men: odds ratio (OR) income .80, 95% confidence interval (CI) .68–.94; income2 OR 1.006, 95% CI 1.001–1.011. Women: OR income .80, 95% CI .69–.91; income2 OR 1.007, 95% CI 1.002–1.011). In multivariate regression analyses including potential confounding risk factors, the magnitude of the association between depressive symptoms and income decreased and was not statistically significant when measures of health conditions, physical disability, and social support were included in the model (Men: OR income .90, 95% CI .75–1.06; income2 OR 1.003, 95% CI .998–1.009. Women: OR income .90, 95% CI .78–1.05; income2 OR 1.003, 95% CI .998–1.008).

CONCLUSION: These findings suggest that poor health, physical disability, and social isolation are the major factors responsible for the observed inverse relationship between income and symptoms of depression in affluent, as well as economically disadvantaged, older populations.
Prognostic Factors in Very Old Demented Adults: A Seven‐Year Follow‐Up From a Population‐Based Survey in Stockholm
Authors: Agüero‐Torres Hedda , Fratiglioni Laura , Guo Zhenchao , Viitanen Matti , Winblad Bengt
Published: April 2015

OBJECTIVE: To detect prognostic factors in very old demented subjects with Alzheimer's disease (AD), vascular dementia (VaD), and other types of dementia (OD).

DESIGN: Follow‐up clinical examinations of dementia patients from a population‐based study after 3‐ and 7‐year intervals.

SETTING AND PARTICIPANTS: In an established population aged 75 years and older in Stockholm, Sweden, there were 133 cases of AD, 52 of VaD, and 38 of OD.

MAIN OUTCOME MEASURES: Predictors of survival at 3‐and 7‐year follow‐up examinations were evaluated by Cox proportional hazard models. Progression was measured as the annual rate of change in Mini‐Mental State Examination (MMSE) scores. Linear models were used to evaluate predictors of progression.

RESULTS: Older age, male gender, low education, comorbidity, and functional disability predicted shorter 7‐year survival in the 223 prevalent dementia cases. Other factors, including type of dementia, dementia severity, and duration of the disease were not significant. The average rate of cognitive decline in the 81 mild to moderate demented subjects who survived 3 years was 2.4 MMSE points per year. Type of dementia (AD vs OD), higher baseline cognitive function, and greater functional disability predicted faster decline. Despite similar survival probability, predictors of death varied as a function of dementia type: Older age (for AD and VaD), comorbidity (for AD and OD), and functional dependency (for VaD). In AD, prognostic factors were similar to those described for the combined dementia groups, with the exception of an accelerated cognitive decline among women.

CONCLUSIONS: Although methodological difficulties exist, it is possible to identify demented subjects with worse prognoses (shorter survival and faster cognitive decline) by using clinical and demographic data. Clinicians and healthcare planners should be aware of the potential usefulness of functional dependence as a prognostic indicator. Finally, the need for careful clinical examinations of demented subjects is stressed by the increased mortality found among those demented who are also affected by other chronic conditions.
Nighttime Urinary Incontinence and Sleep Disruption Among Nursing Home Residents
Authors: Ouslander Joseph G. , Buxton William G. , Al‐Samarrai Nahla R. , Cruise Patrice A. , Alessi Cathy , Schnelle John F.
Published: April 2015

OBJECTIVE: To examine the relationship of urinary incontinence episodes to sleep disruption in a sample of nursing home residents.

DESIGN: Descriptive, case series.

SETTING: Three community nursing homes.

PARTICIPANTS: Seventy‐three incontinent residents of three nursing homes participating in a trial of a behavioral intervention for nighttime urinary incontinence.

MEASUREMENTS: Data were collected during a baseline and repeat baseline period about 2 months later in nursing homes serving as controls for the intervention homes. Incontinence episodes were identified by incontinence pads, which were wired to detect wetness of 10 mL or more. Sleep was monitored by wireless wrist actigraphs. Noise and light changes were monitored by bedside recording devices.

MAIN RESULTS: Recordings covered 403 nights, during which 1715 awakenings from 10 consecutive minutes of sleep were detected as were 1168 incontinent episodes. Only 4% of the awakenings were associated with an incontinence episode, and only 23% of the incontinence episodes occurred during periods of at least 10 consecutive minutes of sleep. Of the latter episodes, only 12% appeared to awaken the resident.

CONCLUSIONS: Our data raise questions about the relevance of incontinence episodes to sleep disruption among chronically incontinent nursing home residents. Our findings must be interpreted cautiously because of limitations in the technologies and definitions we used to identify sleep, awakenings, and incontinence episodes. Although logistically and technically difficult to perform, studies using polysomnographic recordings of sleep are needed to examine further these important associations.
Factors Associated With Six‐Month Mortality in Recipients of Community‐Based Long‐Term Care
Authors: Fried Terri R. , Pollack Daphna M. , Tinetti Mary E.
Published: April 2015

OBJECTIVES: To determine factors associated with short‐term mortality in recipients of community‐based long‐term care (CBLTC).

DESIGN: A cohort study.

SETTING: A Medicaid home‐ and community‐based waiver and state‐funded homecare program.

PARTICIPANTS: All persons age 65 and older newly admitted to the program from January 1, 1988, to March 31, 1991.

MEASUREMENTS: Demographics, functional, cognitive, and health status, depression, and social support were obtained in an admission assessment. Six‐month mortality data were obtained by linking assessment data to a state mortality registry.

RESULTS: There were 718 deaths among 6784 CBLTC clients. Male sex (AOR 1.8, 95% CI 1.5–2.1), the presence of cancer (AOR 3.2, CI 2.6–3.9), heart disease (AOR 1.3, CI 1.1–1.5), chronic obstructive pulmonary disease (AOR 1.8, CI 1.4–2.2), or nutritional problems (AOR 1.7, CI 1.4–2.0), functional impairment (AOR for lowest compared to highest quartile 2.9, CI 2.0–4.1), severe cognitive impairment (AOR 1.6, CI 1.3–2.1), self‐assessment of health as poor (AOR 1.5, CI 1.1–2.0), feeling depressed (AOR 1.2, CI 1.1–1.3), and hospitalization (AOR 2.7, CI 2.2–3.2) were independently associated with 6‐month mortality in bivariate and multivariate analyses.

CONCLUSIONS: Clinical data obtained during routine assessment of CBLTC clients can be used to assess short‐term mortality. Six‐month mortality is associated with poor functional and cognitive status, the presence of cancer, heart disease, COPD, and nutritional problems, depression, perception of poor health, and hospitalization.
Urinary Antibody Level and Survival in Bacteriuric Institutionalized Older Subjects
Authors: Nicolle L. E. , Duckworth H. , Brunka J. , Urias B. , Kennedy J. , Murray D. , Harding G.K.M.
Published: April 2015

OBJECTIVE: In a previous study, elevated urine antibody levels in institutionalized subjects with asymptomatic bacteriuria were associated with decreased survival. This study was undertaken to confirm the previous observation in a prospective study in a larger cohort and to explore selected other variables that may be associated with survival.

DESIGN: A prospective, 24‐month, observational cohort study.

SETTING: Three large nursing homes in Winnipeg, Manitoba.

PARTICIPANTS: Permanent residents were identified by initial screening urine cultures and subjects with bacteriuria were enrolled. The median age of subjects was 76 years, 51% were women, and the median duration of residence before enrollment was 26 months. Subjects were highly functionally impaired.

MEASUREMENTS: Monthly urine specimens were collected for culture, leukocyte count, and urine antibody. Serum specimens for antibody to uropathogens and IL6 were obtained at enrollment and every 6 months. Anthroporphometric tests of nutritional status and functional and mental status were also measured every 6 months. Residents were stratified as having elevated or not elevated urine antibody, based on the initial urine specimen. The mean urine antibody for all of each subject's specimens was also calculated, and subjects were stratified as low, intermediate, or elevated urine antibody. Outcomes measured included mortality, infection and antibiotic use, and functional, mental, and nutritional decline.

RESULTS: Ninety‐eight bacteriuric subjects were enrolled in the study; 34 (35%) had elevated urine antibody and 64 (65%) had not elevated urine antibody. The two groups did not differ in demographic features, co‐morbidities, functional status, medication use, or infecting organisms. Survival was significantly (P <.001) poorer in the group with elevated urine antibody. At 24 months, 35% of subjects with an elevated urine antibody were alive compared with 75% with a low urine antibody level. This survival difference was consistent when the two groups were stratified by sex, institution, and presence of a chronic indwelling catheter. Subjects with elevated urine antibody had no evidence for accelerated functional or nutritional decline during the study period compared with the group with low urine antibody. These subjects did, however, have an increased incidence of episodes of symptomatic urinary infection and infections at non‐urinary sites.

CONCLUSIONS: Older, bacteriuric, institutionalized subjects with elevated urine antibody had decreased survival rates compared with subjects with lower urine antibody levels. There is no clinical evidence to support accelerated decline caused by chronic infection to explain this observation. Urine antibody may be a marker for immune dysregulation, which precedes death in older impaired subjects. J Am Geriatr Soc 46:947–953, 1998.
How Accurate is the Terminal Prognosis in the Minimum Data Set?
Authors: Finne‐Soveri U. Harriet , Tilvis Reijo S.
Published: April 2015

OBJECTIVES: To determine the sensitivity and specificity of terminal prognosis in institutional long‐term care (LTC)

DESIGN: The Minimum Data Set (MDS 1.0). Data in regard to deaths were collected 6 and 12 months after the assessment.

SETTING: A geriatric hospital responsible for all hospital‐based LTC services in one health district (population 71,000) in Helsinki, Finland.

PARTICIPANTS: All LTC patients (N = 656; 81% female; mean age = 83 years) in treatment during a 1‐week period.

RESULTS: One‐fourth (n = 164) of the 656 LTC patients had a terminal prognosis. Of these patients, 70.7% survived 6 months, and 58.5% were still alive after 1 year. Consequently, terminal prognosis was associated with a four‐fold risk of 6‐month mortality. The sensitivity of the terminal prognosis diagnosis was only 29%, whereas the specificity was 89%. The positive predictive accuracy was 47%, but the negative predictive accuracy was 79%.

CONCLUSIONS: Terminal prognosis was clearly overdiag‐nosed. More information is needed about short‐term mortality in terminal prognosis patients and whether this diagnosis affects survival rates. J Am Geriatr Soc 46:1023–1024, 1998.
Paget's Disease of Bone (Osteitis Deformans)
Authors: Ankrom Michael A. , Shapiro Jay R.
Published: April 2015

Paget's disease of bone is important in geriatric populations because it is the second most common bone disorder after osteoporosis.1 In older people, it may be responsible for chronic back pain and joint pain, skeletal deformities, hearing loss, and cranial nerve compression.2 Paget's disease can reduce both function and mobility in the older people.3

In addition to newer tests for assessing the activity of Paget's disease, effective therapy is available in the form of salmon calcitonin for nasal administration and new third generation bisphosphonates.4 Frequently, treatment can reverse the course of the disease. For these reasons, it is feasible for the physician to adopt an aggressive approach to diagnosis and treatment. The objective should be to relieve pain, improve mobility, and forestall debilitating complications. This review will focus on the manifestations and clinical management of Paget's disease. Two cases are presented that illustrate common management problems in older patients. J Am Geriatr Soc 46:1025–1033, 1998.
The Clinical Utility of a Six‐Minute Walk Test in Peripheral Arterial Occlusive Disease Patients
Authors: Montgomery Polly S. , Gardner Andrew W.
Published: April 2015

OBJECTIVES: To determine the test‐retest reliability of the distance covered and the steps taken to complete a 6‐minute walk test by peripheral arterial occlusive disease (PAOD) patients with intermittent claudication. To determine the relationship between the total distance and steps covered during the 6‐minute walk test and clinical measures of PAOD severity.

DESIGN: Cross‐sectional design.

SETTING: The Claude Pepper Older Americans Independence Center at the University of Maryland at Baltimore.

PARTICIPANTS: Sixty‐four PAOD patients between the ages of 45 and 88 years (age = 68 ± 7 years, ankle/brachial index (ABI) = .61 ± .19) were recruited from the Vascular Clinic at the Baltimore Veterans Affairs Medical Center and from radio and newspaper advertisements.

MEASUREMENTS: Patients were assessed on a 6‐minute walk test and a treadmill graded exercise test. A second 6‐minute walk test was administered approximately 1 week later. Patients also were characterized in regard to blood pressure in the arms and legs, ABI, anthropometry, body composition, and physical activity.

RESULTS: The distances walked during the two 6‐minute walk tests were similar (350 ± 78 m vs 360 ± 73 m), resulting in a high reliability coefficient (R = .94) and a low coefficient of variation (10.4%). The total steps taken during the 6‐minute walk test also were similar (562 ± 113 steps vs 587 ± 107 steps), resulting in a high reliability coefficient (R = .90) and a low coefficient of variation (11.7%). Furthermore, the 6‐minute walking distance correlated with the distances to onset (r = .346, P = .007) and with maximal claudication pain (r = .525, P < .001) during the treadmill test as well as with ABI (r = .552, P < .001).

CONCLUSION: The 6‐minute walk test yields highly reliable measurements, which are related to the functional and hemodynamic severity of PAOD, in patients with intermittent claudication.
Epilepsy in Older Adults: Causes, Consequences and Treatment
Authors: Sirven Joseph I.
Published: April 2015

OBJECTIVES: Seizures and epilepsy are common problems in older adults. Although, the highest incidence of seizures and epilepsy occurs in individuals more than 65 years of age, the magnitude of this public health problem, and its consequences on the quality of life of older adults, are not appreciated. Moreover, there is no consensus on the most appropriate way to diagnose or manage epilepsy in this population. This report reviews the current literature on all aspects of epilepsy in older people.

DESIGN/METHODS: The medical literature was reviewed for all articles pertaining to pathophysiology, diagnosis, and treatment of epilepsy in older people.

RESULTS: Epidemiology, etiology, diagnosis, use of diagnostic tests including EEG and imaging, new medical and surgical treatments, and psychosocial issues as they relate to older epilepsy patient are discussed. Several questions that merit future systematic investigation are presented.

CONCLUSION: Seizures and epilepsy in older people are much more common than is generally known. There are unique issues related to this population with regard to diagnosis and treatment. Several new medical and surgical therapies are now available for all epilepsy patients, some of which may be helpful for the older epilepsy patient.
Therapy for Acute Myocardial Infarction in Older Persons
Authors: Rich Michael W.
Published: April 2015

OBJECTIVE: To review the early management of acute myocardial infarction (AMI) in older adults.

METHODS: Recently published studies relevant to the early management of AMI were systematically reviewed. When possible, the impact of older age on complication rates and clinical outcomes was evaluated.

RESULTS: In general, AMI therapies that are effective in younger patients are also effective in older patients. Conversely, older age is associated with an increased risk of complications from therapy, implying that careful patient selection is required to optimize outcomes while minimizing risks. The principal limitation of currently available data is that relatively few patients older than the age of 80 have been enrolled in prospective randomized clinical trials.

CONCLUSIONS: Thrombolysis and primary angioplasty are effective in establishing reperfusion and improving clinical outcomes in older patients with AMI. In the absence of contraindications, aspirin and beta blockers should be considered standard therapy in AMI patients of all ages, whereas heparin, nitrates, and angiotensin converting enzyme inhibitors are indicated in selected subgroups. At the present time, calcium channel blockers, magnesium, and antiarrhythmic agents are not recommended for routine use in the AMI setting, and the role of glycoprotein II/IIIa inhibitors, low molecular weight heparin, and other newer agents await the results of ongoing clinical trials.
Community‐Acquired Pneumonia in the Intensive Care Unit: Epidemiological and Prognosis Data in Older People
Authors: Leroy Olivier , Bosquet Christophe , Vandenbussche Christian , Coffinier Cécile , Georges Hughes , Guery Benoit , Alfandari Serge , Thevenin Didier , Beaucaire Gilles
Published: April 2015

OBJECTIVES: To compare epidemiological data, etiology, and prognosis of severe community‐acquired pneumonia (CAP) in the intensive care unit (ICU) according to age (< or ≥ 65 years) and to determine prognostic factors of CAP in older people.

DESIGN: A retrospective (1987–1992) and prospective (1993‐95) multicenter study.

SETTING: Six ICUs in the north of France.

PATIENTS: Five hundred five patients admitted to an ICU for severe CAP.

MEASUREMENTS: Patient characteristics were compared with regard to age. Prognosis of CAP in older patients was studied by stepwise discriminant analysis.

RESULTS: Two hundred seventy‐eight patients (55%) were aged 65 years or older. Comparison of epidemiological data between older and younger patients revealed a higher prevalence of women (38% vs 29%), more severe underlying comorbidities (anticipated death within 5 years: 59% vs 26%), and more frequent chronic respiratory insufficiency (48% vs 33%) in the older patients. In this study group, 224 organisms were isolated from 172 patients (62%); those identified most frequently were Gram‐negative bacilli (34%), S. pneumoniae (32%), and Staphylococcus sp. (19%). Compared with younger patients, no significant differences in bacteriological data were observed. However, crude and attributable mortality rates were significantly higher in the older patients (33% vs 21% and 30% vs 19%, respectively). Prognosis analysis identified four independent predictors of mortality in the older patients: initial septic shock (relative risk (RR) = 3), sepsis‐related complications (RR = 4.3), hospital‐acquired lower respiratory tract superinfections (RR = 2), and nonspecific pneumonia‐related complications (RR = 2.8).

CONCLUSION: The bacterial etiology provides some approaches to empirical therapy for older patients with severe community‐acquired pneumonia. In addition, the inappropriateness of withholding intensive care for reasons of age alone is emphasized. J Am Geriatr Soc 47:539–546, 1999.
Changes in Blood Pressure and Risk Factors for Cardiovascular Disease Among Older Mexican‐Americans from 1982–1984 to 1993–1994
Authors: Stroup‐Benham Christine A. , Markides Kyriakos S. , Espino David V. , Goodwin James S.
Published: April 2015

OBJECTIVE: To determine the 10‐year changes in blood pressure and cardiovascular risk factors among older Mexican‐Americans.

DESIGN: Comparative analyses of the Hispanic Health and Nutrition Examination Survey (HHANES) and the Hispanic EPESE (Established Populations for Epidemiologic Studies of the Elderly). Both of these were population‐based studies using a multistage stratified probability sampling design of noninstitutionalized persons.

SETTING: Five US states in the southwest: Arizona, California, Colorado, New Mexico, and Texas.

PARTICIPANTS: A total of 216 Mexican‐Americans aged 65 to 74 from the 1982–1984 HHANES and 3050 Mexican‐ Americans aged 65+ from the 1993–1994 Hispanic EPESE. MEASUREMENTS: Mean systolic and diastolic blood pressure; cigarette smoking; high levels of alcohol use; body mass index and obesity; self‐reported heart attack, stroke, and diabetes; hypertension.

RESULTS: Among 65‐ to 74‐year‐old Mexican‐Americans, there was a decrease over time in the percent of those who smoked cigarettes from 27.60% to 13.96% and a decrease in mean systolic blood pressure level. The percent of subjects categorized as obese or severely obese increased significantly, as did the prevalence of diagnosed diabetes, increasing from 20.06% in 1982–1984 to 29.82% in 1993–1994. Mean diastolic blood pressure increased from 77.15 mm Hg in 1982–1984 to 81.21 mm Hg in 1993–1994.

CONCLUSIONS: Our findings suggest major changes in cardiovascular risk factors between 1982–1984 and 1993‐ 1994 among older Mexican‐Americans.
Management of the Older Person with Ventricular Arrhythmias
Authors: Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To review the prognosis and management of ventricular arrhythmias (VA) in persons with and without heart disease, with emphasis on older adults.

DATA SOURCES: A computer‐assisted search of the English language literature (MEDLINE database) followed by a manual search of the bibliographies of pertinent articles.

STUDY SELECTION: Studies on the prognosis and management of VA in persons with and without heart disease were screened for review. Studies in older persons and recent studies were emphasized.

DATA EXTRACTION: Pertinent data were extracted from the reviewed articles. Emphasis was placed on studies involving older persons. Relevant articles were reviewed in depth.

DATA SYNTHESIS: Available data on the prognosis and management of VA in persons with and without heart disease, with emphasis on studies in older persons, were summarized.

CONCLUSIONS: Ventricular arrhythmias in older persons without heart disease should not be treated with antiarrhythmic drugs, nor should Class I antiarrhythmic drugs be used to treat VA in older persons with heart disease. Beta‐blockers should be used to treat complex VA in older persons with ischemic or nonischemic heart disease without contraindications to beta‐blockers. Amiodarone should be reserved for life‐threatening ventricular tachyarrhythmias in older persons who cannot tolerate or who do not respond to beta‐ blockers. Angiotensin‐converting enzyme inhibitors should be used to treat older persons with heart failure, an anterior myocardial infarction, or a left ventricular ejection fraction < 40%. If older persons have life‐threatening recurrent ventricular tachycardia (VT) or ventricular fibrillation (VF) resistant to antiarrhythmic drugs, invasive intervention should be performed. The automatic implantable cardioverter‐defibrillator is recommended in older persons who have medically refractory sustained VT or VF.
Effectiveness of Inactivated Influenza Vaccine Among Nursing Home Residents During an Influenza Type A (H3N2) Epidemic
Authors: Ohmit Suzanne E. , Arden Nancy H. , Monto Arnold S.
Published: April 2015

OBJECTIVES: To evaluate the use of influenza vaccine in nursing homes and its effectiveness in reducing the likelihood of influenza‐like illness.

DESIGN: A retrospective case‐control study with active identification of influenza infection.

SETTING: All nursing homes in a seven‐county study area in southern lower Michigan were eligible for participation. Analyses were based on data collected from 23 homes with documented influenza transmission.

PARTICIPANTS: Persons aged 65 years or older who were residents of the nursing homes under study during the influenza type A(H3N2) outbreak in 1989–1990.

MEASUREMENTS: Residents were identified as cases or controls based on occurrence of febrile respiratory illness meeting a case definition. Demographic and underlying illness information were gathered as were data on the use of influenza vaccine, antibiotics, and antivirals. Characteristics of the nursing homes were also recorded. Logistic regression analyses were carried out to determine vaccine effectiveness.

MAINRESULTS: Determinants of vaccine use were different from those observed in a parallel community‐based study. In a multivariate model that considered the effects of resident and nursing home characteristics, vaccinated residents were significantly less likely than those who were not vaccinated to have an influenza‐like illness (OR = .58 (95% CI, .43‐.78), P < .001, imputed vaccine effectiveness estimate of 42%). Vaccination was more effective in younger residents (those aged 65 to 84) then in older residents (those older than 84 years).

CONCLUSIONS: Influenza vaccination was effective in reducing the likelihood of influenza‐like illness in nursing home residents. Effectiveness appeared to be related to age, which may function as a surrogate for related immunologic factors. Older nursing home residents should be targeted for newer vaccines and/or potential prophylactic use of antivirals. J Am Geriatr Soc 47:165–171, 1999.
Body Mass Index and Mortality Among Older People Living in the Community
Authors: Landi Francesco , Zuccala Giuseppe , Gambassi Giovanni , Incalzi Raffaele Antonelli , Manigrasso Luca , Pagano Francesco , Carbonin PierUgo , Bernabei Roberto
Published: April 2015

OBJECTIVES: To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study.

DESIGN: A prospective cohort study.

SETTING: Rovereto, a town in northern Italy.

PARTICIPANTS: A consecutive sample of 214 patients aged 81.2 ± 7.3 years receiving community care services.

MAIN OUTCOME MEASURES: Malnutrition and mortality.

RESULTS: According to logistic regression analysis, malnutrition status, expressed by a BMI < 22 Kg/m2., was correlated with dependency in Activity of Daily Living (odds ratio 1.21; 95% confidence interval (CI) 1.01‐1.45). Only a low BMI was associated with 1‐year survival in Cox regression analysis, after adjusting for potential confounders (relative risk 0.85; 95%CI, 0.74‐0.97). A high BMI (>27 Kg/m2) was not significantly related to risk of mortality.

CONCLUSIONS: Nutrition variables are a cardinal component of comprehensive geriatric assessment. Our results suggest that BMI, a simple anthropometric measure of nutritional status, is an important predictor of mortality among older people living in the community. Even when controlling for clinical and functional variables, a low BMI remained a significant and independent predictor of shortened survival. J Am Geriatr Soc 47:1072–1076, 1999.
Intraindividual Variability in Orthostatic Blood Pressure Changes Among Older Adults: The Influence of Meals
Authors: Puisieux Francois , Boumbar Youssef , Bulckaen Helene , Bonnin Eric , Houssin Florence , Dewailly Philippe
Published: April 2015

OBJECTIVES: To examine the influence of time of day and of meals on postural blood pressure (BP) changes in older adults.

DESIGN: Prevalence study of BP changes in response to orthostasis.

SETTING: A geriatric short‐stay department

PARTICIPANTS: A total of 126 inpatients (91 women and 35 men; mean age: 81.4 ± 7.9, range 61–95 years) were included in the study.

MEASUREMENTS: Two sets of BP and heart rate measurements were obtained for each subject by one examiner using a standard mercury manometer: (1) in mid‐morning (between 10:00 and 10:30 a.m.) and (2) within 30 to 60 minutes after lunch (between 1:00 and 1:30 p.m.). Orthostatic hypotension (OH) was defined as a systolic blood pressure (SBP) decline ≤ 20 mm Hg within 3 minutes after standing.

RESULTS: Sixty‐one participants (48%) experienced significant orthostatic BP decline on at least one reading. Among them, 46 (37%) had OH in the mid‐morning, and 32 (25%) had OH after lunch (P = .05). Only 17 (13%) had OH on both readings (persistent OH). Forty‐four patients (35%) had variable OH. Patients with persistent OH were more likely to exhibit symptoms of dizziness and had a lower body mass index and a higher mean basal supine SBP. There was a positive correlation between basal supine SBP and postural SBP decline.

CONCLUSIONS: Because of the variability of postural BP changes, the diagnosis of OH should not be based on a single orthostatic BP measurement but requires repeated testing, at best under circumstances similar to those in which the symptoms occurred. The postprandial period is not particularly favorable to OH, suggesting that the ingestion of a meal does not worsen orthostatic BP changes in most aged patients. J Am Geriatr Soc 47:1332–1336,1999.