bluuebunny/crossref_metadata_2025 huggingface dataset:
Underutilization of Controller and Rescue Medications Among Older Adults with Asthma Requiring Hospital Care
Authors: Hartert T.V. , Togias A. , Mellen B.G. , Mitchel E.F. , Snowden M.S. , Griffin M.R.
Published: April 2015

BACKGROUND: Asthma causes serious morbidity in older people, but pharmacologic therapy in older people with asthma has never been studied, at least in part because of the difficulty of defining asthma in this population.

OBJECTIVE: To determine if older persons enrolled in Medicaid and hospitalized with an exacerbation of asthma receive appropriate outpatient asthma care.

DESIGN: Descriptive pharmacoepidemiology of a group of older adults with asthma.

SETTING: The Tennessee Medicaid Program.

PARTICIPANTS: Persons aged 65 and older, enrolled in the Tennessee Medicaid program, identified through Medicaid's computerized database as having a hospital care visit for asthma in 1992 and who had their diagnosis confirmed by chart review.

MEASUREMENT: Medication utilization.

RESULTS: The source population included 93,686 persons aged 65 or older enrolled in the Tennessee Medicaid program. The group meeting study criteria included 512 patients with chronic asthma who had a hospital care visit for an asthma exacerbation. Eighty‐one percent of these 512 persons with an asthma hospitalization confirmed by chart review were classified as having moderate to severe or potentially fatal asthma. These patients had had a median of 15 outpatient visits in the previous year, and more than half of them had an outpatient visit in the 14 days before their hospitalization. However, among those with moderate to severe or near fatal asthma only 25% filled prescriptions for inhaled corticosteroids, whereas 52% were taking theophylline, the most commonly prescribed asthma medication in this group. There was also high use of antibiotics (29%) and low use of rescue corticosteroids (5%) before the hospital care visit, despite frequent medical encounters.

CONCLUSIONS: Despite widespread promulgation of the National Asthma Education Prevention Program guidelines, our study suggests that providers caring for indigent older subjects with moderate to severe or potentially fatal asthma were not following these guidelines. There was significant underutilization of inhaled anti‐inflammatory agents, beta‐agonists, and rescue corticosteroids in this population despite frequent outpatient medical care visits. J Am Geriatr Soc 48:651–657, 2000.
The C677T Mutation in the Methylenetetrahydrofolate Reductase (MTHFR) Gene and Vascular Dementia
Authors: Pollak Rivka Dresner , Pollak Arthur , Idelson Maria , Bejarano‐Achache Idit , Doron Dafna , Blumenfeld Anat
Published: April 2015

OBJECTIVE: To determine the association between the C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene and vascular dementia in Ashkenazi and non‐Ashkenazi Jews.

DESIGN: A case‐control study.

SETTING: Nursing homes in Jerusalem, Israel.

PARTICIPANTS: Two hundred fifty nine Jewish people of Ashkenazi and non‐Ashkenazi origin, older than age 70, who have vascular dementia (VD) (n = 85), Alzheimer's disease (AD) (n = 92), and who are cognitively intact (n = 82) with no clinical evidence of atherosclerotic vascular disease.

MEASUREMENTS: The frequencies of the mutant allele (T allele) and homozygotes for the C677T MTHFR mutation (T/T genotype). The total plasma homocysteine (tHCT) level in 75 subjects.

RESULTS: There were no significant differences in the frequencies of the T/T genotype or T allele among VD, AD, and cognitively intact older people of the same ethnic origin (0.15, 0.19, 0.25 T/T genotype and 0.42, 0.46, 0.47 T allele in Ashkenazi; 0.08, 0.06, 0.10 T/T genotype and 0.28, 0.32, 0.33 T allele in non‐Ashkenazi with VD and AD, and in cognitively intact older people, respectively). The relative risk of VD associated with the T/T genotype versus the C/C genotype was 0.62 (95% CI, 0.19‐1.19) in Ashkenazi and 0.65 (95% CI, 0.11‐3.7) in non‐Ashkenazi, respectively. The relative risk of AD associated with the T/T genotype was 0.85 (95% CI, 0.29‐2.45) in Ashkenazi and 0.62 (95% CI, 0.1–4.3) in non‐Ashkenazi, respectively. The frequencies of mutant homozygotes and allele were significantly higher in Ashkenazi than in non‐Ashkenazi Jews (19.9% vs 7.5% T/T genotype, X2 = 6.2, P = .01, 0.45 vs 0.31 T allele, X2 = 9.77, P = .002 in Ashkenazi vs non‐Ashkenazi, respectively). There were no differences in mean tHCT concentration among VD, AD, and cognitively intact older people.

CONCLUSIONS: The MTHFR C677T is not associated with an increased risk of vascular dementia or Alzheimer's disease. The frequency of the mutation is significantly higher in Ashkenazi compared with non‐Ashkenazi Jews. J Am. Geriatr Soc 48:664–668, 2000.
Dually Incontinent Nursing Home Residents: Clinical Characteristics and Treatment Differences
Authors: Chiang Lillian , Ouslander Joseph , Schnelle Jack , Reuben David B.
Published: April 2015

OBJECTIVE: Previous studies have described urinary and fecal incontinence in nursing homes and their separate effects on healthcare utilization. However, little is known about those who are incontinent of both.

DESIGN: Retrospective chart review.

SETTINGS: Twenty sites in three states

PARTICIPANTS: A total of 413 nursing home residents were categorized as having neither fecal nor urinary incontinence (C, n = 114), urinary incontinence only (UI, n = 53), fecal incontinence only (FI, n = 9), or were dually incontinent (DI, n = 237).

MEASUREMENTS: Charts were abstracted for sociodemographic information and health status information as well as utilization for the year before the date of abstraction. We then compared these characteristics across groups using ANOVA with pairwise comparisons and multiply adjusted regression.

RESULTS: Almost all patients with DI were cognitively and mobility impaired. However, there were no significant differences between the groups with respect to age and number of diagnoses. A diagnosis of stroke was also more common among those with DI compared with C. When examining healthcare utilization in multiply adjusted regression, dually incontinent residents received significantly fewer days of hospital care than those with UI.

CONCLUSIONS: Dual incontinence in NH residents is likely to have an important functional component. These residents seem to be treated less aggressively with respect to hospitalization compared with those with UI alone. The reasons for these differences need to be explored further. J Am Geriatr Soc 48:673–676, 2000.
Gender Differences in the Treatment of Cerebrovascular Disease
Authors: Ramani Subha , Byrne‐Logan Susan , Freund Karen M. , Ash Arlene , Yu Wei , Moskowitz Mark A.
Published: April 2015

OBJECTIVE: Previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women.

DESIGN: Secondary database analyses.

STUDY PARTICIPANTS: We examined the use of carotid endarterectomy in a nationally representative sample of Medicare enrollees aged 65 to 84, hospitalized for a principal diagnosis of stroke in 1992, the “all strokes group”. We also studied a subgroup of patients, the “carotid disease subgroup”, admitted with a principal diagnosis of precerebral arterial occlusion and stenosis or transient cerebral ischemia.

MEASUREMENTS: We determined rates of carotid endarterectomy for the all strokes group within gender and age groups and calculated corresponding female‐to‐male relative risks (RR) and 95% confidence intervals (CI). We also performed similar analyses for the carotid disease subgroup. We then used logistic regression to estimate the relative risk of use of carotid endarterectomy for women, controlling for age and comorbidity.

RESULTS: The all‐strokes group consisted of 3356 women and 2927 men, of whom 1009 women and 990 men were in the carotid disease subgroup. The overall age‐adjusted female‐to‐male relative risk of undergoing carotid endarterectomy for those aged 65 to 84 was 0.69 (95% CI, 0.64‐0.74) in the all strokes group and 0.77 (95% CI, 0.72‐0.82) in the carotid disease subgroup. In both analyses, the RR became more pronounced with increasing age. In the all strokes group, for example, the RR was 0.80 (0.70‐0.92) for those aged 65 to 69 and 0.39 (0.32‐0.48) for those aged 80 to 84. The RR for the all strokes group remained similar in magnitude even after controlling for comorbidity (RR, 0.63 and 95% CI, 0.59‐0.70).

CONCLUSION: We conclude that women hospitalized for strokes undergo fewer carotid endarterectomies than men. Further studies are needed to examine the reasons for and implications of this gender difference. J Am Geriatr Soc 48:741–745, 2000.
Effect of Aging on the Relationship Between Multiple Risk Factors and Waist Circumference
Authors: Iwao Satoshi , Iwao Nobuko , Muller Denis C. , Elahi Dariush , Shimokata Hiroshi , Andres Reubin
Published: April 2015

OBJECTIVE: To examine the relationship between various coronary risk factors and the different levels of fat distribution in younger (<65 years) and older (<65 years) men and women, using the classifications proposed by the National Heart, Lung and Blood Institute (NHLBI) and the World Health Organization (WHO).

DESIGN: Cross‐sectional study of subjects enrolled in the Baltimore Longitudinal Study of Aging.

MEASUREMENTS: Systolic blood pressure, diastolic blood pressure, fasting glucose, 2‐hour glucose, fasting insulin, homeostasis model assessment insulin resistance (HOMAIR), triglyceride, total cholesterol, high‐density lipoprotein (HDL)‐cholesterol, and low‐density lipoprotein (LDL)‐cholesterol were measured as risk factors. The proportion of subjects with abnormal risk factor levels by waist circumference classifications was determined in the age and gender subgroups.

RESULTS: There were significant adverse effects of age per se on all risk factors with the exception of fasting insulin and HOMAIR in both men and women, total cholesterol in men, and diastolic blood pressure in women. HDL‐cholesterol was higher in older subjects. There were significant correlations between waist circumference and all of the risk factors in the younger group. Waist circumference did not have a significant correlation with total cholesterol in older men, or with total cholesterol and LDL‐cholesterol in older women. The proportion of subjects with an abnormal risk factor level increased with increasing waist circumference for most risk factors in both younger and older subjects, but proportions of subjects in each individual waist group were higher in older than in younger groups for systolic blood pressure, diastolic blood pressure, fasting glucose, and 2‐hour glucose in men, and for systolic blood pressure, fasting glucose, 2‐hour glucose, total and LDL‐cholesterol, and triglyceride in women.

CONCLUSIONS: Our data indicate that the waist circumference cutpoints proposed by NHLBI and WHO standards are useful for the prediction of cardiovascular disease risk factors in older as well as in younger men and women. J Am Geriatr Soc 48:788–794, 2000.
Subcutaneous Fluid Infusion in a Long‐Term Care Setting
Authors: Dasgupta Monidipa , Binns Malcolm A. , Rochon Paula A.
Published: April 2015

OBJECTIVE: To study the use of hypodermoclysis in a long‐term care setting for chronic fluid supplementation and to compare it to intravenous (IV) fluid in the treatment of acute mild to moderate dehydration.

DESIGN: A prospective observational study.

PARTICIPANTS: Fifty‐five residents of a long‐term care facility treated with fluid therapy during a 5‐week period.

MAIN OUTCOME MEASURES: Efficacy of hydration and adverse effects were obtained from detailed chart review, interviews with healthcare providers, and investigators' observations.

RESULTS: The study subjects were frail older people. Hypodermoclysis was used for maintenance fluid needs in 24 residents; none of these residents required any additional fluid therapy for dehydration. In addition, 37 residents received fluids for acute dehydration. In these residents, hypodermoclysis was associated with clinical improvement in 57% and no clinical change in 25%. Recipients of IV fluids improved 81% of the time and the remainder were unchanged. Hypodermoclysis was associated with fewer fluid therapy‐related complications relative to IV therapy (P = .04).

CONCLUSIONS: Hypodermoclysis is an effective procedure for providing fluids for both chronic maintenance needs and acute situations associated with mild to moderate dehydration in a long‐term care setting. Hypodermoclysis appears safer and can avoid transfers to hospital for rehydration. J Am Geriatr Soc 48:795–799, 2000.
Inclusion of Older Women in Randomized Clinical Trials: Factors Associated with Taking Study Medication in the Fracture Intervention Trial
Authors: Buist Diana S.M. , LaCroix Andrea Z. , Black Dennis M. , Harris Fran , Blank Jan , Ensrud Kristine , Edgerton Donna , Rubin Susan , Fox Kathleen M.
Published: April 2015

OBJECTIVES: The purpose of this study is to describe the early study medication discontinuation (SMD) experience during the first year of follow‐up in a randomized clinical trial in older women and to determine the associations between various baseline characteristics and risk of SMD.

DESIGH, SETTING, AND PARTICIPANTS: The authors studied 6459 postmenopausal women aged 55 to 80 from 11 clinical settings during their first year of participation in the Fracture Intervention Trial (FIT). This trial was designed to test the efficacy of alendronate (Fosamax) on fracture prevention among women with low bone mass.

RESULTS: Study medication discontinuation was greatest in the first month post‐randomization (2.2%) and declined thereafter. Cumulative rates of study medication discontinuation were 4.8% (n = 311) at 3 months and 11.1% (n = 717) at 12 months. SMD was not associated with age, marital status, alcohol consumption, regular exercise, past estrogen replacement therapy use, bone mineral density, or personal or maternal fracture history. After adjusting for covariates and markers of comorbidity, the strongest predictor of SMD was fair‐to‐poor self‐rated health (relative risk (RR) 2.10; 95% confidence interval (CI) 1.47, 2.99). Having four or more depressive symptoms was also a significant predictor and had a risk associated with SMD (RR vs none 1.34; 95% CI 1.05, 1.71) similar to that seen for individuals with good self‐rated health (RR 1.49; 95% CI 1.16, 1.91).

CONCLUSIONS: Results from this cohort emphasize that clinical trials in older women with multiple concomitant conditions can achieve high levels of adherence. Thought should be given to measuring self‐rated health and depressive symptoms before randomization to help identify individuals to be targeted for special assistance programs that focus on encouraging adherence.
Insights into the Pathophysiology and Mechanisms of Constipation, Irritable Bowel Syndrome, and Diverticulosis in Older People
Authors: Camilleri Michael , Lee Joon Seong , Viramontes Blanca , Bharucha Adil E. , Tangalos Eric G.
Published: April 2015

OBJECTIVES: To review the epidemiology, pathophysiology and mechanisms of irritable bowel syndrome (IBS), constipation, and diverticulosis, for the purpose of addressing these three common conditions in older adults (>65 years of age).

DESIGN: Using a MEDLINE search, we identified original English language journal articles and reviews from 1965 to December 1998. We also selected articles published before 1965 or after 1998 that were cross‐referenced or pertinent to the topics researched.

RESULTS: The prevalence of constipation and diverticulosis is higher in older than in younger adults. Significant risk factors for constipation in older women are failure of the anorectal angle to open or excessive perineal descent, which represent disturbances of pelvic floor function and rectal evacuation. In contrast, the prevalence of IBS is no greater than in younger adults. Nevertheless, these syndromes impact on the patient's functional status and quality of life. The mechanisms resulting in these gastrointestinal syndromes are unclear. Uncoordinated colonic activity and colonic segmentation may lead to IBS and diverticulosis, respectively, and these pathophysiological findings suggest disorders of inhibitory control of neuromuscular function. The total number of neurons in the myenteric plexus is decreased, and collagen deposited in the distal colon is increased with aging in humans. Animal studies suggest that senescent colonic muscle responds less to excitatory factors in vitro, and neural injury in older animals may result from apoptosis, defects of mitochondrial metabolism, and inadequate levels or response to neurotrophins. Future investigations will reveal whether similar mechanisms underlie human disease. Currently, treatment is aimed at relief of symptoms of IBS or constipation or dealing with the complications of diverticulosis.

CONCLUSIONS: Constipation, IBS, and diverticulosis are common problems of aging. There is a need for further systematic research of the basic mechanisms in neuromuscular dysfunction with aging, including the studies of physical characteristics of the colonic wall, pelvic floor function (particularly in women with excessive perineal descent), and neurohormonal control of motility and sensation. Insights on the pathophysiology and mechanisms of neural injury may lead to more specific treatments in the future, e.g., serotonergic agents and neurotrophins. Meanwhile, collaborations between primary care physicians, geriatricians, and gastroenterologists can optimize management of these three common conditions that significantly impact the quality of life of older adults.
GERIATRICS IN MANAGED CARE
Authors: Brummel‐Smith Kenneth , Morgenstern Nora E. , Gonzales Ralph , Anderson Robert J.
Published: April 2015

OBJECTIVES: Little is known about the impact of mandatory (involuntary) disenrollment of patients from Medicare managed care organization (MCO) plans. We hypothesized that involuntary disenrollment raises significant concerns for patients, that younger enrollees (aged less than 65, “Medicare disabled”) have different concerns than older patients, and that younger patients respond to termination of their plan within the MCO differently from older patients. We also examined other factors associated independently with enrollee decisions to stay in the MCO or return to Medicare fee‐for‐service.

DESIGN: A cross‐sectional telephone questionnaire.

SETTING: A Medicare managed care plan at two outpatient clinics at an academic medical center in Denver, Colorado.

PARTICIPANTS: Four hundred fifty enrollees recently notified of termination of their clinic's contract with a Medicare managed care plan were surveyed.

MEASUREMENTS: Survey questions on demographics, patient concerns about disenrollment, and factors associated with staying at the academic medical center or switching to another clinic or plan associated with the MCO.

RESULTS: Of 371 respondents, 57% switched to another plan within the MCO, including 65% of the Medicare disabled enrollees and 57% of the Medicare nondisabled enrollees. More than 60% of both Medicare disabled and older patients who switched felt that it was a significant problem for them. By multivariate analysis, age was not associated with switching, but a distant relationship with one's physician was associated with switching (odds ratio (OR) = 10.2; confidence interval (CI), 1.13–91.09) and having received care at the academic medical center for 1 year or longer (OR = 0.35, 95% CI, 0.17–0.69), postcollege education (OR = 0.34; CI, 0.16–0.69), and black race (OR = 0.29; CI, 0.13–0.68) were independently associated with not switching. Older and younger patients cited similar concerns raised by switching, but financial issues were identified as a major concern by more younger patients than older patients (P = .001).

CONCLUSIONS: Involuntary disenrollment raised significant concerns for patients in a Medicare managed care plan.
Estrogen Replacement Therapy and MRI‐Demonstrated Cerebral Infarcts, White Matter Changes, and Brain Atrophy in Older Women: The Cardiovascular Health Study
Authors: Luoto R. , Manolio T. , Meilahn E. , Bhadelia R. , Furberg C. , Cooper L. , Kraut M.
Published: April 2015

OBJECTIVE: We studied the relationship between the use of estrogen replacement therapy (ERT) and cerebral magnetic resonance imaging (MRI) abnormalities among older women.

DESIGN: A population‐based prospective study (Cardiovascular Health Study).

SETTING: Four regions in the United States.

PARTICIPANTS: A total of 2133 (62.9% of the eligible) women aged 65 to 95 years (mean age 74.8), on whom MRI was performed in 1992–1994.

MEASUREMENTS: Presence of global brain atrophy, white matter changes, small infarct‐like lesion (ILL) (<3 mm), MRI infarcts (≥3 mm, mostly small and asymptomatic), and cognitive function as measured by Mini‐Mental State Exam (MMSE), and by ERT use (current/past/never), adjusted for a number of socioeconomic, lifestyle, and reproductive covariates.

RESULTS: Current use of ERT was reported by 15% and past use by another 23% of participants; 35% of all women had MRI infarcts. The prevalence of MRI infarcts did not differ in current or past users from those who had never used ERT (nonusers). Bifrontal distance, the largest distance between frontal horns, and the size of ventricles were larger among current ERT users compared to past users or nonusers (P (trend) = .01), adjusted for all other covariates, but no dose‐response relationship to current or past ERT use was found. Duration of estrogen use was not associated with any atrophy measure. Cortical atrophy measure, sulcal widening, or white matter disease did not differ significantly by ERT use or duration of use. Central measures of atrophy, bifrontal distance, and ventricular size were significantly associated with cognition as measured by MMSE.

CONCLUSIONS: Current ERT users had much more clinically significant central atrophy than nonusers, but the implications remained unclear. J Am Geriatr Soc 48: 467–472, 2000.
Risk Factors for Nursing Home Placement in a Population‐Based Dementia Cohort
Authors: Smith G. E. , Kokmen E. , O'Brien P. C.
Published: April 2015

OBJECTIVE:To examine risk factors for nursing home placement in a population‐based dementia cohort.

METHODS:The Mayo Clinic Medical Records linkage system was used to identify all patients with onset of dementia between 1980 and 1984. The patient group included 314 cases who met DSM‐III‐R criteria for dementia, including 220 cases who were community dwelling at onset. All dementia patients were followed until death. A control group included 323 patients who did not, at any point, meet DSM‐III‐R criterion for dementia. The groups were initially matched on age, gender, and year of initial registration. Demographic, medical, social, and functional predictors were examined as static and time‐dependent risk factors for nursing home placement in the initial community‐dwelling subgroups, using stepwise Cox regression modeling.

RESULTS:Of the 314 dementia patients, 282 took residence in licensed skilled nursing homes for at least 6 weeks, suggestive of custodial care, at some point during the course of their illness. In the control group, 162 of the 323 people required nursing home placement. Within controls, the predictor variables of time to nursing home placement included initial age, being divorced, living in a townhome, apartment or assisted living apartment, change in Charlson comorbidity score, and change in amount of daily assistance required. Within the dementia sample, seven predictors were eventually determined to be associated with time to nursing home placement. These included total number of years of education, age at onset of dementia, being single, living in a retirement or supervised apartment at onset, change in Charlson comorbidity score, and a change in the amount of daily assistance required.

CONCLUSIONS:Cumulative incidence of placement was 90% in the dementia cohort and 50% in the controls. Certain variables seem to impact time to nursing home placement in all older persons, whether they have dementia or not. Among these are age, living in assisted living settings, increasing comorbidity scores, and increasing need for functional assistance. Certain additional factors may have a specific impact in dementia. Among these is education, which seems to provide a protective effect. These predictors may be important covariates in clinical dementia studies that include time to nursing home placement as an outcome variable.J Am Geriatr Soc 48: 519–525, 2000.
Advance Directive Preferences Among Subpopulations of Asian Nursing Home Residents in the Pacific Northwest
Authors: Vaughn Gina , Kiyasu Elizabeth , McCormick Wayne C.
Published: April 2015

OBJECTIVE: To study advance directives (code status) among subgroups of Asian nursing home residents.

DESIGN: Cross‐sectional design.

PARTICIPANTS AND SETTING: A total of 423 residents of Asian descent (aged >55) from two ethnic nursing homes in Seattle, Washington.

METHODS: Chart review was conducted on 423 residents (199 discharged between 1995 and 1998 and 244 current residents) to ascertain code status, age, gender, ethnicity, comorbidity (using the Charlson Index), and religion.

RESULTS: Seventy percent of the residents were women, median age was 83 ± 9, 43% were Chinese, 40% Japanese, and 17% other Asian (Korean, Filipino, Southeast Asian). The majority of the patients in any subgroup (72% overall) were ‘no code’. In bivariate analysis, ethnicity, increased age, and comorbidity were correlated with no code status. In multivariable logistic regression, Japanese residents were more likely to be no code (OR 4.1 (95% CI, 3.1‐ 5.4)) controlling for age, comorbidity, gender, and religion. Chinese were more likely to be full code (OR 3.3 (95% CI, 2.6–4.2)).

CONCLUSIONS: Code status differs significantly among Asian subgroups in these ethnic nursing homes. Whereas the majority of residents are no code, Japanese residents are more likely than Chinese or others to be no code. Higher age and comorbidity are also correlated with no code status. J Am Geriatr Soc 48: 554–557, 2000.
Interrater Reliability of the Clinical Dementia Rating in a Multicenter Trial
Authors: Rockwood Kenneth , Strang David , MacKnight Chris , Downer Robert , Morris John C.
Published: April 2015

OBJECTIVE: To test the interrater reliability of the Clinical Dementia Rating (CDR) in a multicenter clinical trial.

DESIGN: Observational study.

SETTING: Training session for a multicenter trial of milameline, a direct muscarinic agonist, in the treatment of Alzheimer's disease.

PARTICIPANTS: Twenty‐four raters (physicians and nurses) familiar with drug trials and expert in the care of patients with Alzheimer's disease.

METHODS: Independent scoring of the CDR using four videotaped CDR interviews.

OUTCOME MEASURE: Interrater reliability, as tested by the Kappa statistic

RESULTS: The overall interrater reliability was 0.62. Within the CDR domains, the global kappas ranged from 0.33 ± 0.06 to 0.88 ± 0.06.

CONCLUSIONS: The data support moderate to high overall interrater reliability but show important difficulties in the reliable assessment of early dementia. J Am Geriatr Soc 48: 558–559, 2000.
Stair Negotiation in Older People: A Review
Authors: Startzell Jill K. , Owens D. Alfred , Mulfinger Lorraine M. , Cavanagh Peter R.
Published: April 2015

Locomotion on stairs is among the most challenging and hazardous activities of daily living for older individuals. This is evidenced by the reports that stair falls account for more than 10% of fatal fall accidents. The demands that stairs place on the musculoskeletal and cardiovascular systems are compounded by the need for input from the somatosensory, visual, and vestibular systems at various stages in the task. Many of these collaborating systems deteriorate with aging, thus increasing the difficulty and risk of failure in a task that inherently involves exposure to significant danger. The task itself varies in its degree of challenge depending on many structural and environmental factors that are outside the control of the stair user. This review explores existing literature in the area of stair negotiation by older persons in an effort to define the key factors associated with difficulty and safety on stairs and to interpret these findings in the light of possible interventions that could increase stair safety. Further research is needed to ensure that current recommendations for stair design are suitable for older stair users. A Glossary of Terms is also provided. J Am Geriatr Soc 48: 567–580, 2000.
MODELS OF GERIATRICS PRACTICE
Authors: Reuben David B. , Hughes Terry Lynn , Medina‐Walpole Annette M.
Published: April 2015

OBJECTIVE: To describe the establishment and utilization of an interdisciplinary Behavior Management Program in a Transitional Care Unit as a new model of Geriatrics Practice.

DESIGN: Descriptive Study.

SETTING: A 50‐bed Transitional Care Unit in a Veterans Affairs Medical Center in Syracuse, New York.

PARTICIPANTS: All residents admitted to the Transitional Care Unit were observed for a 6‐month period under the Behavior Management Program.

PROGRAM STRUCTURE: The Behavior Management Program involved an interdisciplinary team approach to the management of behavioral disturbances. This included development of a Behavior Team and a comprehensive Behavior Observation Record, which readily assisted caregivers in determining and monitoring target behaviors that required modification. Both nonpharmacological and pharmacological interventions were employed to assist in the modification of behavioral disturbances.

RESULTS: The Behavior Management Program enhanced the overall care of Transitional Care Unit residents with behavioral disturbances. The more appropriate use of medications for specific target behaviors led to a reduction in behavioral disturbance episodes and increased the earlier diagnosis and treatment of depression. The interdisciplinary nature of the Behavior Management Program promoted educational efforts and camaraderie among staff and created a stronger liaison between the Transitional Care Unit and the Psychiatry Service. In addition, several management improvements were identified as a result of the implementation of the Behavior Management Program.

CONCLUSIONS: An interdisciplinary Behavior Management Program can prove to be a valuable asset in the management of behaviors for people with dementia, psychiatric illness, and other medical illnesses. More effective use of nonpharmacological and psychopharmacological interventions enhances the quality of life in a frail older population. This approach has strong potential for successful use in a variety of clinical settings by providers and caregivers alike. J Am Geriatr Soc 48: 581–587, 2000.
Families' Perception of the Added Value of Hospice in the Nursing Home
Authors: Baer Wendy M. , Hanson Laura C.
Published: April 2015

OBJECTIVE: To determine if family members perceive that hospice improves the care of dying nursing home residents during the last 3 months of life.

DESIGN: Mailed survey.

PARTICIPANTS: Family members for all nursing home hospice enrollees in North Carolina during a 6‐month period.

MEASUREMENTS: After residents' deaths, family members answered questions about the quality of care for symptoms before and after hospice, the added value of hospice, the effect of hospice on hospitalization, and special services provided by nursing home staff or by hospice staff.

RESULTS: A total of 292 (73%) of 398 eligible family members completed surveys. The average age of the nursing home residents who had received hospice was 79.5 years; 50% had cancer and 76% were dependent for self‐care. In their last 3 months, 70% of decedents had severe or moderate pain, 56% had severe or moderate dyspnea, and 61% had other symptoms. Quality of care for physical symptoms was rated good or excellent by 64% of family before hospice and 93% after hospice (P < .001). Dying residents' emotional needs included care for moderate or severe depression (47%), anxiety (50%), and loneliness (35%). Quality of care for emotional needs was rated good or excellent by 64% of family before hospice and 90% after hospice (P < .001). Fifty‐three percent of respondents believed hospice prevented hospitalizations. Family estimated the median added value of hospice to be $75 per day and described distinct special services provided by hospice and by nursing home staff.

CONCLUSIONS: Family members believe that nursing home hospice improves quality of care for symptoms, reduces hospitalizations, and adds value and services for dying nursing home residents. J Am Geriatr Soc 48:879‐882, 2000.
Physical Activity, Falls, and Fractures Among Older Adults: A Review of the Epidemiologic Evidence
Authors: Gregg Edward W. , Pereira Mark A. , Caspersen Carl J.
Published: April 2015

OBJECTIVES: Assess the relationship between physical activity and risk for falls and osteoporotic fractures among older adults.

DESIGN: Review and synthesis of published literature.

MEASUREMENTS: We searched the literature using MEDLINE, Current Contents, and the bibliographies of articles identified. We included randomized controlled trials (RCT) of the effects of physical activity on the incidence of falls and case‐control and prospective cohort studies of the association of physical activity with osteoporotic fracture risk. We also summarized mechanisms whereby physical activity may influence risk for falls and fractures.

RESULTS: Observational epidemiologic studies and randomized clinical trials evaluating the effectiveness of physical activity programs to prevent falls have been inconclusive. However, many studies have lacked adequate statistical power, and recent trials suggest that exercise, particularly involving balance and lower extremity strength training, may reduce risk of falling. There is consistent evidence from prospective and case‐control studies that physical activity is associated with a 20–40% reduced risk of hip fracture relative to sedentary individuals. The few studies that have examined the association between physical activity and risk of other common osteoporotic fractures, such as vertebral and wrist fractures, have not found physical activity to be protective.

CONCLUSIONS: Epidemiologic studies suggest that higher levels of leisure time physical activity prevent hip fractures and RCTs suggest certain exercise programs may reduce risk of falls. Future research needs to evaluate the types and quantity of physical activity needed for optimal protection from falls and identify which populations will benefit most from exercise. J Am Geriatr Soc 48:883–893, 2000.
Driving Cessation in Older Men with Incident Dementia
Authors: Foley Daniel J. , Masaki Kamal H. , Ross G. Webster , MD Lon R. White
Published: April 2015

OBJECTIVE: To determine the prevalence and cessation of driving among older men with incident dementia in the Honolulu‐Asia Aging Study.

DESIGN: Retrospective cohort data from a community‐based study of incident dementia.

SETTING: The Honolulu Heart Program and the Honolulu‐Asia Aging Study.

PARTICIPANTS: A total of 643 men who were evaluated for the incidence of Alzheimer's disease or other dementia between the fourth and the fifth examination of the Honolulu Heart Program.

MEASUREMENTS: Driving history, diagnosis of dementia, grip strength, walking speed, standing balance test, interviewer's rating of vision status, and the neurologist's notes on mentions of driving behavior from informal interviews with a caregiver or family informant.

RESULTS: The prevalence of driving declined dramatically with level of cognitive functioning. Among 162 men evaluated and found to have normal cognitive functioning, 78% still drove, compared with 62% of 287 men with poor cognitive functioning but no clinical dementia, 46% of 96 men with a new diagnosis of very mild dementia (Clinical Dementia Rating = 0.5), and 22% of 98 men with a new diagnosis of mild dementia (CDR = 1). Only one of 23 men diagnosed with moderate or more severe staged incident dementia (CDR > 1) was driving. About 10% of the 59 demented persons still driving relied on co‐pilots, and only one driver was reported as involved in a crash according to a review of the neurologists' notes.

CONCLUSIONS: Incident dementia is a major cause of driving cessation. Based on these data, we estimate that approximately 4% of male drivers aged 75 years and older nationwide (about 175,000 men) have dementia. This number will increase with the projected growth of drivers aged 75 years and older. J Am Geriatr Soc 48:928–930, 2000.
Prevalence, Effectiveness, and Predictors of Planning the Place of Death Among Older Persons Followed in Community‐Based Long Term Care
Authors: Leff Bruce , Kaffenbarger Kimberly P. , Remsburg Robin
Published: April 2015

BACKGROUND: Little is known about whether patients plan for the site of their death and whether such planning is effective.

OBJECTIVE: To determine the prevalence, effectiveness, and predictors of planning the place of death among older home‐bound persons followed in a community‐based, physician‐led house call program.

DESIGN: Retrospective chart review.

SETTING: A geographically defined catchment area in southeast Baltimore, Maryland.

PATIENTS: One hundred twenty‐five patients who died between July 1995 and November 1998 who were followed in a physician‐led house call program.

MAIN OUTCOME MEASURES: Presence of a plan to die in a specific place and concordance between planned and actual place of death.

RESULTS: Eighty patients (64%) made a plan to die in a specific place, and these plans were executed successfully in 73 cases (91%). The median time between formulating a plan to die in a specific place and death was 36 days. In logistic regression analysis, making a plan to die in a specific place was positively associated with an advance directive of Do Not Resuscitate (DNR) (odds ratio (OR) 11.7, confidence interval (CI) 3.7, 32.5) and negatively associated with the lack of an identifiable main medical problem other than being homebound (OR 0.17; CI, 0.02–0.88).

CONCLUSIONS: Among a group of frail older persons living in the community, planning to die in a particular place was common and implemented successfully most of the time. Providing physician care at home may facilitate improved end‐of‐life care for older persons. J Am Geriatr Soc 48:943–948, 2000.
Fabrication of Transparent Dysprosium Aluminum Garnet (Dy3Al5O12) Ceramics via a Solid‐State Reaction Method
Authors: Hu Song , Qin Xianpeng , Lu Chunhua , Zhou Guohong , Xu Zhongzi , Wang Shiwei
Published: April 2015

Polycrystalline, transparent Dy3Al5O12 ceramics were firstly fabricated by a solid‐state reaction method using high‐purity Dy2O3 and Al2O3 powders. The fully dense Dy3Al5O12 ceramic with an average grain size of less than 10 μm was obtained by vacuum sintering at 1820°C for 6 h. The in‐line transmittance of the optimized sample reaches 80% in the visible region. Scanning electron microscopy reveals that no secondary phases and almost no pores are observed at grain boundaries or triple junctions, and the fracture mode of the ceramic is mainly transgranular. The Dy3Al5O12 ceramic is promising for magneto‐optical applications. Verdet constant of the Dy3Al5O12 transparent ceramic is as high as −0.41 min·(Oe·cm)−1.
Effects of Sintering Aids on the Transparency and Conversion Efficiency of Cr4+ Ions in Cr: YAG Transparent Ceramics
Authors: Zhou Tianyuan , Zhang Le , Yang Hao , Qiao Xuebin , Liu Peng , Tang Dingyuan , Zhang Jian
Published: April 2015

Tetravalent chromium‐doped Y3Al5O12 ceramics were fabricated by solid‐state reactive sintering method using high‐purity Y2O3, α‐ Al2O3, and Cr2O3 powders as the starting materials. CaO and MgO were co‐doped as the sintering aids. The effects of TEOS and divalent dopants (CaO and MgO) on the optical qualities, the conversion efficiency of Cr4+ ions, and the microstructure evolutions of 0.1 at.% Cr4+: YAG ceramics were investigated. Fully dense, dark brown colored Cr4+: YAG ceramics with an average grain size of 3.1 μm were achieved. The in‐line transmittance of the as‐prepared ceramic at 2000 nm was 85.3% (4 mm thick), and the absorption coefficient at 1030 nm (the characteristic absorption peak of Cr4+ ions) was as high as 3.7 cm−1, which was higher than that of corresponding single crystals fabricated by Czochralski method.
Defining, Treating, and Understanding Chronic Kidney Disease—A Complex Disorder
Authors: Campbell Dean , Weir Matthew R.
Published: April 2015

Chronic kidney disease (CKD) is prevalent in more than 20 million people in the United States. The majority of care provided to patients with this disease comes from primary care physicians, although it is often poorly understood. After an extensive literature review, it is clear that it can be difficult to classify and there are many barriers to care. Risk factors for both incident CKD and disease progression include hypertension, poor glycemic control, sociodemographic factors, acute kidney injury, metabolic acidosis, and possibly hyperuricemia and dietary factors. Treatment of patients with CKD should focus on mitigating risk factors, as well as common comorbidities such as cardiovascular disease, anemia, and bone mineral disease. Novel therapies such as pirfenidone, pentoxifylline, and endothelin‐1 antagonists are being investigated with promising results.
Cost‐Effectiveness of Therapeutic Drug Monitoring in Diagnosing Primary Aldosteronism in Patients With Resistant Hypertension
Authors: Velasco Alejandro , Chung Oliver , Raza Fayez , Pandey Ambarish , Brinker Stephanie , Arbique Debbie , Price Angela , Lotan Yair , Das Sandeep R. , Vongpatanasin Wanpen
Published: April 2015

Primary aldosteronism (PA) is present in up to 20% of patients with treatment‐resistant hypertension (TRH). Investigation for PA in patients with TRH is recommended by current guidelines after medication nonadherence is excluded. Studies using therapeutic drug monitoring (TDM) have shown that >50% of patients with TRH are nonadherent to their prescribed antihypertensive medications. However, the relationship between the prevalence of PA and medication adherence as confirmed by TDM has not been previously assessed. A retrospective analysis from a hypertension referral clinic showed that prevalence of PA in adherent patients with TRH by TDM was significantly higher than in nonadherent patients (28% vs 8%, P<.05). Furthermore, cost analysis showed that TDM‐guided PA screening was $590.69 less expensive per patient, with minimal impact on the diagnostic accuracy. These data support a TDM‐guided PA screening approach as a cost‐saving strategy compared with routine PA screening for TRH.
Single versus double flap approach in periodontal regenerative treatment
Authors: Schincaglia Gian Pietro , Hebert Eric , Farina Roberto , Simonelli Anna , Trombelli Leonardo
Published: April 2015

Aim

to compare the outcomes of a regenerative strategy based on recombinant human platelet‐derived growth factor–BB (rhPDGF‐BB, 0.3 mg/ml) and β‐tricalcium phosphate (β‐TCP) in the treatment of intraosseous defects accessed with the Single Flap Approach (SFA) versus Double Flap Approach based on papilla preservation techniques (DFA).

Materials and Methods

Fifteen and 13 defects, randomly assigned to SFA or DFA, respectively, were grafted with rhPDGF‐BB + β‐TCP. Probing parameters were assessed before and 6 months after surgery. Pain (VASpain) was self‐reported using a visual analogue scale.

Results

Twelve SFA sites and DFA 6 sites showed complete flap closure at 2 weeks post‐surgery. No significant differences in 6‐month changes in probing parameters and radiographic defect fill were found between groups. Significantly lower VASpain was observed in SFA group compared to DFA group at day +1, +2 and +6. A significantly greater number of analgesics were consumed in the DFA group compared to the SFA group at day +1.

Conclusions

When combined with rhPDGF‐BB and β‐TCP, the SFA may result in similar clinical outcomes, better quality of early wound healing, and lower pain and consumption of analgesics during the first postoperative days compared to the DFA.
Practitioner Review: Self‐injurious behaviour in children with developmental delay
Authors: Oliver Chris , Richards Caroline
Published: April 2015

Background

Self‐injurious behaviour is shown by a significant minority of children with developmental delay and has a substantial impact on child and carer wellbeing. Characteristics such as a greater degree of intellectual disability, autism spectrum disorder, some genetic syndromes and repetitive and impulsive behaviours are positively associated with self‐injury. Prevalence generally increases with age into midadulthood and the behaviour is notably persistent.

Scope

In this review, we discuss the dominant causal theory of self‐injury which draws on the principles of operant learning. We evaluate the utility of this theory to account for all empirical observations of self‐injury.

Findings

A model of self‐injury is presented that extends a previous model described by Guess and Carr. The new model integrates child characteristics and operant learning principles in a phenotype × environment paradigm to explain the variance in developmental trajectory of the severity of self‐injury.

Conclusions

Behaviour dysregulation, as evidenced by the associations between self‐injury, self‐restraint, repetitive and impulsive behaviours, is identified as potentially influencing the severity and persistence of self‐injury. Risk markers for self‐injury are identified and the extended model indicates points of intervention and highlights the possibility of risk‐related, targeted early intervention. The need for increased training of practitioners in the delivery of demonstrably effective interventions for self‐injury is identified.
Evaluation of soil‐applied insecticides with Bt maize for managing corn rootworm larval injury
Authors: Estes R. E. , Tinsley N. A. , Gray M. E.
Published: April 2015

The western corn rootworm, Diabrotica virgifera virgifera LeConte, is considered one of the most significant insect pests of maize in North America. Larvae of other secondary subterranean pests such as grape colaspis, Colaspis brunnea (F.), and Japanese beetle, Popillia japonica Newman, can also injure maize seedlings and cause yield loss. In the past decade, maize hybrids containing Bt proteins have been used to manage the western corn rootworm; additionally, seeds are commonly treated with a neonicotinoid and fungicide combination to control secondary pests. Recently, soil‐applied insecticides have been used in conjunction with rootworm Bt hybrids (and seed‐applied insecticides) in areas with perceived risk for increased rootworm larval or secondary pest damage. We conducted a series of trials from 2009 to 2011 that examined multiple rootworm Bt hybrids and their near‐isolines, along with two soil‐applied insecticides, to determine whether the Bt plus insecticide combination resulted in an increased level of efficacy or yield. We also sampled for Japanese beetle and grape colaspis larvae to determine their potential for reducing yield. Densities of secondary pests in our trials were low and likely had no effect on maize yield. The addition of a soil‐applied insecticide to rootworm Bt hybrids improved efficacy only once across 17 location‐years, when overall corn rootworm injury was highest; an improvement in yield was never observed. Our results suggest that the use of a soil‐applied insecticide with a rootworm Bt hybrid should only be considered in scenarios with potentially significant rootworm larval populations. However, potential negative consequences related to trait durability when soil insecticides are used with rootworm Bt maize should be considered.