bluuebunny/crossref_metadata_2025 huggingface dataset:
The Ankle Brachial Index Independently Predicts Walking Velocity and Walking Endurance in Peripheral Arterial Disease
Authors: McDermott Mary McGrae , Liu Kiang , Guralnik Jack M. , Mehta Shruti , Criqui Michael H. , Martin Gary J. , Greenland Philip
Published: April 2015

OBJECTIVES: Maintaining function among older men and women is an important public health goal as the population lives longer with chronic disease. We report the relationships between lower extremity peripheral arterial disease (PAD), PAD severity, and PAD‐related symptoms with walking velocity and endurance among men and women aged 55 and older.

DESIGN: A cross‐sectional design.

SETTING: An academic medical center.

PARTICIPANTS: Participants with PAD were men and women aged 55 and older identified from a blood flow laboratory or a general medicine practice (n = 158). Randomly selected controls without PAD were identified from the general medicine practice (n = 70).

MEASUREMENTS: PAD was diagnosed and quantified using the ankle brachial index (ABI). Subjects were categorized according to whether they had severe PAD (ABI <0.40), mild to moderate PAD (ABI 0.40 to <0.90), or no PAD (ABI 0.90 to <1.50). Walking endurance was assessed with the 6‐minute walk. Usual walking velocity and maximal walking velocity were assessed with “usual” and “maximal” paced 4‐meter walks, respectively.

RESULTS: Average distances achieved in the 6‐minute walk were 1569 ± 390 feet for subjects with ABI 0.90–1.50, 1192 ± 368 feet for subjects with ABI 0.40 to <0.90, and 942 ± 334 feet for subjects with ABI < 0.40 (trend P value < .001). Walking velocities for both the usual and maximal paced 4‐meter walks were slowest among subjects with ABI < 0.40 and fastest among subjects with ABI 0.90 to <1.50. Subjects with PAD who had pain at rest had slower walking velocity and poorer walking endurance than other subjects with PAD. In multiple linear regression analyses that included subjects with PAD only, ABI level was an independent predictor of 6‐minute walk performance (regression coefficient = 159 ft/0.40 ABI units, P = .011), usual paced 4‐meter walk (regression coefficient = .095 meters/sec/0.40 ABI units, P = .031), and maximal paced 4‐meter walk (regression coefficient = .120 meters/sec/0.40 ABI units, P = .050) adjusting for age, sex, race, leg symptoms, and comorbid diseases known to affect functioning. Pain at rest was associated independently with the maximally paced 4‐meter walk (−0.201 meters/sec, P = .024), but not with the other walks.

CONCLUSION: ABI level has a measurable and independent association with walking endurance and both usual and maximal walking velocity. These data suggest that PAD may impair lower extremity function by diminishing function of both Type I (“slow twitch”) and Type II (“fast twitch”) muscle fibers. Because walking velocity has important prognostic implications for functioning, these data also suggest that ABI may be used to identify patients at increased risk of mobility loss.
Development and Validation of a Geriatrics Attitudes Scale for Primary Care Residents
Authors: Reuben David B. , Lee Ming , Davis James W. , Eslami Michelle S. , Osterweil Daniel G. , Melchiore Susan , Weintraub Nancy T.
Published: April 2015

OBJECTIVE: To develop and validate an instrument measuring attitudes toward older persons and caring for older patients.

DESIGN: Cross‐sectional and longitudinal studies.

SETTING: An academic medical center.

PARTICIPANTS: Initial Study: 121 primary care residents (n = 96), fellows (n = 14), and faculty (n = 11) participated in instrument development in 1995. Longitudinal Study: 95 residents (n = 87) and fellows (n = 8) of the initial cohort participated in the 1996 follow‐up study, and 61 of the initial cohort (57 residents and 4 fellows) participated in the 1997 follow‐up study. Cross Validation Study: 96 first‐year residents (n = 78) and fellows (n = 18) participated in this study.

MEASUREMENTS: A 14‐item geriatrics attitudes scale was developed. The items were selected from a pool of 37 items administered to the 121 participants in the initial study.

RESULTS: The instrument demonstrated high reliability (Cronbach's α = .76) and known‐groups and construct validity. Attitudes were progressively more positive with more medical training (P < .001), and residents with greater career interest in geriatrics scored higher than those less interested (P = .007). Cross validation results supported the reliability and validity of the instrument. Longitudinal data showed significantly different trends of attitude changes among groups of residents and fellows over a 2‐year period.

CONCLUSIONS: The 14‐item geriatrics attitudes scale developed in this study shows sound reliability, validity, and sensitivity to change among primary care residents. The performance of other groups of medical trainees and the relationship of attitude changes to specific medical training warrant further investigation.
Prevalence Rates of Hearing Impairment and Comorbid Conditions in Older People: The Veneto Study
Authors: Maggi Stefania , Minicuci Nadia , Martini Alessandro , Langlois Jean , Siviero Paola , Pavan Mara , Enzi Giuliano
Published: April 2015

OBJECTIVES: To investigate the prevalence rate of hearing impairment, assessed by both the Sanders' questionnaire and the speech audiometry test, and its association with health‐related factors in the older population of the Veneto region of Italy.

DESIGN: A cross‐sectional survey.

SETTING: A community‐based population.

PARTICIPANTS: 2398 noninstitutionalized individuals aged 65 years and older residing in the Veneto region of Italy.

MEASUREMENTS: Prevalence rates of hearing impairment and odds ratios for its association with potential risk factors.

MAIN RESULTS: The prevalence of self‐reported hearing impairment at home was 8.1% in men and 7.4% in women, and in a social environment it was 11.1% and 9.3%, respectively. Women were less likely to report hearing difficulties in both environments, and increased risks were found for depression, age, and poor self‐rated health. Participants with diabetes or cognitive impairment had increased odds only at home, in contrast to people with a low education level, who had increased odds only in a social environment. The prevalence assessed by speech audiometry was 19% in both sexes. Increased age, diabetes, and poor self‐rated health were associated with impaired speech intelligibility, cognitive impairment was associated with 4‐fold increased odds among past users of alcohol, and men with a low education level were about three times as likely as others to have hearing impairment.

CONCLUSIONS: Speech audiometry testing detected a higher prevalence of hearing impairment than use of a self‐reported questionnaire and was associated with poor self‐rated health, history of diabetes, and cognitive impairment among past users of alcohol and among men with low levels of education. The association between hearing deficit and depressive symptomatology was confirmed only with self‐reported hearing impairment.
Low Prevalence of Hearing Aid Use Among Older Adults with Hearing Loss: The Epidemiology of Hearing Loss Study
Authors: Popelka Michael M. , Cruickshanks Karen J. , Wiley Terry L. , Tweed Theodore S. , Klein Barbara E. K. , Klein Ronald
Published: April 2015

OBJECTIVES: To measure the prevalence of hearing aid use among older adults with hearing loss and to identify factors associated with those currently using hearing aids.

DESIGN: Population‐based cohort study.

SETTING: The south‐central Wisconsin community of Beaver Dam.

PARTICIPANTS: A total of 1629 adults, aged 48 to 92 years, who have hearing loss and are participating in the Epidemiology of Hearing Loss Study and the Beaver Dam Eye Study.

MEASUREMENTS: A hearing‐related risk factor and medical history questionnaire, the Hearing Handicap Inventory for the Elderly (screening version), screening tympanometry, pure‐tone air‐ and bone‐conduction audiometry, and word recognition tests were administered by trained examiners using standard protocols.

RESULTS: The prevalence of current hearing aid use among those with a hearing loss (pure‐tone average > 25 decibels hearing level over 500, 1000, 2000, and 4000 Hertz, worse ear) was 14.6%. The prevalence was 55% in a subset of the most severely affected participants. In univariate analyses, current hearing aid use was associated with age, severity of loss, word recognition scores, self‐reported hearing loss, self‐perceived hearing handicap, and history of noise exposure. Factors associated with current hearing aid use in multivariate logistic regression models were age, severity of loss, education, word recognition scores, Hearing Handicap Inventory for the Elderly (screening version) score, and self‐report of a hearing loss.

CONCLUSIONS: Few older adults with hearing loss are currently utilizing hearing aids. Improved screening and intervention programs to identify older adults who would benefit from amplification are needed to improve hearing‐related quality of life for this large segment of the population.
The Effectiveness of Day Hospital Care on Home Care Patients
Authors: Pitkälä Kaisu
Published: April 2015

OBJECTIVE: To study the effectiveness of rehabilitative and medically oriented day hospital care on community‐based long‐term care patients.

DESIGN: A randomized, controlled trial.

SETTING AND PARTICIPANTS: 177 patients on home‐care in a rural area were randomized into two groups. Patients in one group were offered a 2‐month period of rehabilitation and medical care in a recently opened day hospital, and in the other group patients were offered treatment, as before, in home care. Both groups were examined at the beginning and at 2, 5 and 12 months.

INTERVENTION: Rehabilitative and medically oriented day hospital care.

OUTCOME MEASURES: Use of health services, physical functioning measured by the Katz ADL Index, subjective health, symptoms, and satisfaction with care.

RESULTS: The groups used hospitals (excluding the day hospital treatment) equally during the follow‐up year. The treatment group had significantly more specialist consultations than did the control group. There were no clinically significant differences in the changes in the Katz ADL Index although more changes were found in the treatment group. The number of symptoms was reduced significantly in the treatment group, whereas the number of symptoms remained unchanged in the control group. The patients' views of their own health improved in the treatment group.

CONCLUSION: Day hospital care affects the quality of life of older people, but it does not reduce the use of other health services, nor does it clinically significantly improve the physical functioning of older people.
Impact of Integrated Home Care Services on Hospital Use
Authors: Landi Francesco , Gambassi Giovanni , Pola Roberto , Tabaccanti Sandro , Cavinato Tullio , Carbonin PierUgo , Bernabei Roberto
Published: April 2015

OBJECTIVE: To examine the effect of a home care program based on comprehensive geriatric assessment and case management on hospital use and costs among frail older individuals.

DESIGN: Quasi‐experimental study with a 6‐month follow‐up.

SETTING: Vittorio Veneto, a town in northern Italy.

PARTICIPANTS: One hundred fifteen frail older people who applied for integrated home care services.

INTERVENTION: Each patient was assessed with the Minimum Data Set for Home Care, and, subsequently, a case manager and a multidisciplinary team delivered social and health care services as indicated.

MAIN OUTCOME MEASURES: We determined the hospital admissions and days spent in the hospital for all subjects during the first 6 months after the implementation of the home care program and compared them with the rate of hospitalization that the same patients had experienced in the 6 months preceding the implementation of the program.

RESULTS: After the implementation of the integrated home care program, there was a significant reduction in the number of hospitalizations compared with pre‐implementation (56% vs 46%, respectively; P < .001), associated with a reduction in the number of hospital days, both at the individual patient level (28 ± 23 days vs 18 ± 15 days, respectively; P < .01) and for each admission (16 ± 12 days vs 12 ± 8 days, respectively; P < .01). This resulted in a 29% cost reduction with an estimated savings of $1260 per patient.

CONCLUSIONS: The implementation of an integrated home care program based on the use of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost‐effective. J Am Geriatr Soc 47:1430–1434, 1999.
Vascular Compliance as a Measure of Biological Age
Authors: Bulpitt Christopher J. , Rajkumar Chakravarthi , Cameron James D.
Published: April 2015

OBJECTIVES: To determine the measure of vascular compliance most closely related to age.

DESIGN: A review of 22 studies relating aortic compliance to age and a discussion of other factors related to vascular compliance.

MEASUREMENTS: Aortic compliance, elastic modulus, postmortem aortic changes, pulse wave velocity in the aorta, common carotid, lower limb and upper limb.

RESULTS: 1. Aortic compliance and carotid artery compliance is closely related to age; 2. Compliance in the peripheral arteries, in 16 reports, appears less closely related to age; 3. There is evidence that aortic compliance is related to hypertension, cardiac function, and left ventricular hypertrophy and can be increased by exercise, hormonal therapy, antioxidant and antihypertensive treatment; and 4. Vascular compliance is more closely related to chronological age than other measures such as skin inelasticity, greying of hair, baldness etc.

CONCLUSIONS: Because of the close relationship between aortic and carotid compliance and chronological age, deviation from the age‐predicted norm (biological age) may prove to be a good predictor of cardiovascular pathology. J Am Geriatr Soc 47:657–663, 1999.
Who Walks? Factors Associated with Walking Behavior in Disabled Older Women With and Without Self‐Reported Walking Difficulty
Authors: Simonsick Eleanor M. , Guralnik Jack M. , Fried Linda P.
Published: April 2015

OBJECTIVES: To determine how severity of walking difficulty and sociodemographic, psychosocial, and health‐related factors influence walking behavior in disabled older women.

DESIGN: Cross‐sectional analyses of baseline data from the Women's Health and Aging Study (WHAS).

SETTING: An urban community encompassing 12 contiguous zip code areas in the eastern portion of Baltimore City and part of Baltimore County, Maryland.

PARTICIPANTS: A total of 920 moderately to severely disabled community‐resident women, aged 65 years and older, identified from an age‐stratified random sample of Medicare beneficiaries.

MEASUREMENTS: Walking behavior was defined as minutes walked for exercise and total blocks walked per week. Independent variables included self‐reported walking difficulty, sociodemographic factors, psychological status (depression, mastery, anxiety, and cognition), and health‐related factors (falls and fear of falling, fatigue, vision and balance problems, weight, smoking, and cane use).

RESULTS: Walking at least 8 blocks per week was strongly negatively related to severity of walking difficulty. Independent of difficulty level, older age, black race, fatigue, obesity, and cane use were also negatively associated with walking; living alone and high mastery had a positive association with walking.

CONCLUSIONS: Even among functionally limited women, sociocultural, psychological, and health‐related factors were independently associated with walking behavior. Thus, programs aimed at improving walking ability need to address these factors in addition to walking difficulties to maximize participation and compliance. J Am Geriatr Soc 47:672–680, 1999.
Association of Interleukin‐6 and Other Biologic Variables with Depression in Older People Living in the Community
Authors: Dentino Andrew N. , Pieper Carl F. , Rao K. Murali K. , Currie Mark S. , Harris Tamara , Blazer Dan G. , Cohen Harvey Jay
Published: April 2015

OBJECTIVES: The prevalence of depression increases with age, as does the prevalence of higher levels of the cytokine interleukin‐6 (IL‐6). This analysis was performed to determine the association between increased levels of this cytokine and depression in a population‐based sample.

DESIGN: Cross‐sectional cohort study.

SETTING: Rural and urban counties in North Carolina.

PARTICIPANTS: Community‐dwelling older people.

MEASUREMENTS: The association between IL‐6 and other biologic variables with self‐report depression was examined in 1686 persons aged 70 years and older in the third in‐person survey wave (1991) of the Duke Established Population for Epidemiologic Studies of the Elderly (EPESE). Bivariate associations were established by the Spearman correlation, adjusted for age. A stepwise linear logistic regression model was used to derive a final model to assess multivariable effects on CES‐D scores.

RESULTS: Depression was correlated with IL‐6 (P = .011), D‐Dimer (P = .017), alpha‐l‐globulin (P = .023), alphas‐2‐globulin (P = .002), and beta globulin (P = .012). After controlling for age, race, and gender, IL‐6 levels remained the only biologic variable significantly associated with depression (P = .035).

CONCLUSION: These data suggest that the inflammatory marker, IL‐6, is associated with depression in older people in this cross‐sectional study. These results are compatible with the hypothesis of cytokine (IL‐6) stimulation in geriatric depression as part of an overall immunoendocrine dysregulation.
Diagnosis of Geriatric Patients with Severe Dizziness
Authors: Lawson J. , Fitzgerald J. , Birchall J. , Aldren C.P. , Kenny R.A.
Published: April 2015

OBJECTIVE: To identify the causes of dizziness in older patients presenting to the general practitioner and the clinical characteristics at presentation that might guide the general practitioner to the likely cause of dizziness and the most appropriate specialty for subsequent referral if referral is required.

DESIGN: A prospective case control study of older patients presenting with dizziness.

SETTING: The initial assessment was made in four general practices, three urban practices and one inner city practice (Newcastle). Subsequent investigations were conducted randomly in the Neurocardiovascular Investigation Unit and the Otolaryngology (ENT) Unit at local University hospitals (Newcastle).

PARTICIPANTS: Fifty consecutive patients more than 60 years of age presented with dizziness. Twenty‐two age‐ and sex‐matched case controls were recruited from the same general practices.

MEASUREMENTS: Measurements were of diagnoses attributable to symptoms.

RESULTS: Symptoms were of long duration (median 1 year). Forty‐six percent of patients had syncope and/or falls in addition to dizziness. Twenty‐eight percent had a cardiovascular diagnosis, 18% had a peripheral vestibular disorder, 14% had a central neurological disorder, 18% had more than one diagnosis, and 22% had no attributable cause of symptoms identified.

A cardiovascular diagnosis was predicted by the presence of syncope (P < .001), dizziness described as lightheadedness (P l .001), the need to sit or lie down during symptoms (P < .001), pallor with symptoms (P < .001), symptom precipitation by prolonged standing (P < .05), and whether patients had coexisting cardiovascular disease (P < .05). The description of dizziness as “vertigo” predicted a peripheral vestibular disorder (P < .001). The predictive strength of these prognostic indicators was then validated on a separate sample of 50 additional older patients.

CONCLUSIONS: Clinical characteristics can predict an attributable cause of dizziness in most older patients and thus guide general practitioners in treatment and appropriate specialist referral. The presence of syncope, falls, or cardiovascular comorbidity increases the likelihood of a cardiovascular diagnosis. Otolaryngological investigations are rarely diagnostic, but vertiginous symptoms do predict peripheral vestibular disorders.
Cardiac Rehabilitation in Older Coronary Patients
Authors: Ades Philip A.
Published: April 2015

The majority of patients presenting with acute coronary disease or undergoing coronary revascularization procedures are older than age 65. Disability rates are very high in these patient populations, particularly in women, the older‐old, and patients with clinical manifestations of angina pectoris or chronic heart failure. The presence of mental depression is also an important determinant of poor physical functioning. Cardiac rehibilitation has been demonstrated to safely increase aerobic capacity, muscular strength, and endurance in older coronary populations.
Clinico‐Neuropathological Correlation of Alzheimer's Disease in a Community‐Based Case Series
Authors: Lim Alfredo , Tsuang Debby , Kukull Walter , Nochlin David , Leverenz James , McCormick Wayne , Bowen Jim , Teri Linda , Thompson Jill , Peskind Elaine R. , Raskind Murray , Larson Eric B.
Published: April 2015

OBJECTIVES: Most clinico‐neuropathological correlative studies of Alzheimer's Disease (AD) are based on research cohorts that are not necessarily generalizable to patients seen in the general medical community. In this study, we examine the accuracy of the criteria used in diagnosing AD in a community‐based case series of patients with memory complaints.

DESIGN AND PARTICIPANTS: Clinical and neuropathological diagnoses were obtained from 134 patients evaluated for dementia who subsequently underwent autopsy.

SETTING: Subjects who exhibited new symptoms of dementia and were enrolled in the University of Washington/Group Health Cooperative Alzheimer's Disease Patient Registry were eligible for this study.

MEASUREMENTS: Clinico‐pathological correlation was performed using NINCDS‐ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and CERAD (Consortium to Establish a Registry for Alzheimer's Disease) criteria.

RESULTS: Ninety‐five of the 134 cases studied met CERAD neuropathological criteria for AD. The sensitivity of NINCDS‐ADRDA “probable AD” was 83% (diagnosing AD correctly) and overall clinical diagnostic accuracy was 75%. However, there was a high rate of additional neuropathological findings. Only 34 of the 94 cases had pure AD on neuropathology, whereas the remainder frequently had coexisting vascular or Parkinson's disease lesions.

CONCLUSIONS: This study of a large series of community‐based incident dementia cases provides a way of judging the adequacy of currently available clinical diagnostic criteria. It also shows that co‐existing neuropathological findings are common in community‐based AD. J Am Geriatr Soc 47:564–569, 1999.
Economic Evaluation of Donepezil for the Treatment of Alzheimer's Disease in Canada
Authors: O'Brien Bernie J. , Goeree Ron , Hux Margaret , Iskedjian Michael , Blackhouse Gordon , Gagnon Michelle , Gauthier Serge
Published: April 2015

BACKGROUND: Donepezil is a new drug recently approved in the United States and Canada for the treatment of Alzheimer's disease (AD). We estimated the cost‐effectiveness of donepezil 5 mg daily as an adjunct to usual care in the management of persons with mild‐to‐moderate AD defined as a Mini‐Mental Health State Examination (MMSE) score in the range 10 to 26.

METHODS: Treatment effect data as MMSE change‐over‐baseline scores were obtained from a 30‐week placebo‐controlled trial of donepezil. MMSE scores beyond observed trial data were estimated using a Markov model with 10 cycles of 24 weeks based on the placebo MMSE progression observed in the trial. Data from AD subjects in the Canadian Study of Health and Aging were used to estimate costs of nursing home care, community services, medications, and caregiver time as a function of MMSE score. A clinic‐based cohort study from Alberta was used to estimate the distribution of AD patients by MMSE score presenting for treatment. The effectiveness measure for the economic model was expected time (over 5 years) spent with nonsevere AD (MMSE ≥ 10).

RESULTS: Over 5 years of treatment, donepezil is predicted to reduce health care costs by CA$929 per patient but increase caregiver time costs by CA$48 per patient for an overall cost saving to society of CA$882 per patient. Patients not receiving donepezil are predicted to spend 2.21 years of the 5 years in nonsevere AD compared with 2.41 years for treated patients (a gain of just over 2 months). Sensitivity analysis reveals that cost savings per patient increase if more AD patients are assumed to survive to 5 years; however, if donepezil treatment continues when patients' MMSE score falls below 10, the incremental cost is higher for treatment at CA$1554 per patient.

CONCLUSION: Based on the limited available data, our model predicts that the use of donepezil for mild‐to‐moderate AD in Canada is associated with lower 5‐year costs and less time spent with severe AD when compared with the alternative of usual care with no donepezil therapy. As more reliable long‐term data become available, these predictions should be confirmed and/or updated. J Am Geriatr Soc 47:570–578, 1999.
Orthostatic Hypotension and Cognitive Decline in Older People
Authors: Viramo Petteri , Luukinen Heikki , Koski Keijo , Laippala Pekka , Sulkava Raimo , Kivelä Sirkka‐Liisa
Published: April 2015

OBJECTIVES: To establish the role of orthostatic hypotension (OH) as a risk factor for cognitive decline among home‐dwelling and institutionalized older people and to describe other predictors of cognitive decline.

DESIGN: Follow‐up study with two clinical examinations.

SETTING: A community‐based setting in northern Finland.

PARTICIPANTS: All of the 1159 people aged 70 or more living in five rural municipalities around the town of Oulu in Northern Finland in 1991. At the time of the follow‐up examination, 2.5 years later, 884 of the original participants were alive and 651 were re‐examined.

MEASUREMENTS: In 1991, 907 people (78.3% of the total population) were tested for orthostatic hypotension, and their cognitive capacity was assessed with the Mini‐Mental State Examination (MMSE). The calculation/spelling tasks were excluded from the final version used in the statistical analysis. The re‐assessment of cognitive capacity was made on 651 subjects (73.6% of those alive) who had participated in the first examination. The data were analyzed using polychotomous and linear regression analysis models.

RESULTS: The prevalence of OH was 28.7%, with no age or sex differences. The mean sum score for the shortened MMSE in 1991 was 21.6 (±3.98) for persons with OH and 21.1 (±4.08) for non‐OH persons. During the follow‐up, the sum score declined in the OH group by .44 (±2.81) points and in the non‐OH group by .83 (±3.61) points. No type of OH (systolic or diastolic 1‐ or 3‐minute values or their combination) predicted cognitive decline; the only predictors were old age and low level of formal education.

CONCLUSIONS: Orthostatic hypotension is a common clinical condition that affects every fourth person aged 70 years or older. By temporarily inducing cerebral hypoperfusion, it may cause or exacerbate cognitive dysfunction. In an unselected population, OH was not associated with cognitive deterioration, nor did it predict cognitive decline during a 2‐year follow‐up. J Am Geriatr Soc 47:600–604, 1999.
Blood Pressure Behavior in the Nursing Home: Implications for Diagnosis and Treatment of Hypertension
Authors: Auseon Alex , Ooi Wee L. , Hossain Monir , Lipsitz Lewis A.
Published: April 2015

OBJECTIVES: To determine patterns of elevated blood pressure (BP) behavior, their clinical correlates, and the relationship to diagnosis and management of hypertension.

DESIGN: A cross‐sectional, prevalence survey.

SETTING: Forty‐five nursing homes owned or managed by a large national chain.

PARTICIPANTS: A total of 857 older residents (mean age = 84 years).

MEASUREMENTS: Supine and standing (1 and 3 minutes) BP and heart rate, taken four times in one day (before and after breakfast, and before and after lunch) by trained nurses using a random zero sphygmomanometer; medication profile; active medical diagnoses; functional status; sociodemographics.

RESULTS: The prevalence of a single, elevated, supine systolic pressure (> 160 mm Hg) was 14.3%, and of two to four elevated measures was 14.9%. The pre‐breakfast reading was consistently the highest, and mean systolic pressures decreased after breakfast. Compared with those not treated, older residents taking antihypertensive medications had higher systolic pressures at all times and showed the same pattern of decline after breakfast. Isolated diastolic hypertension was uncommon (0.9%). Cardiovascular disease, orthostatic hypotension, diabetes, and use of angiotensin converting enzyme inhibitors or calcium channel blockers were more prevalent among older residents who had elevated pressures on multiple occasions (P < .03). Successful antihypertensive treatment was associated with a lower prevalence of orthostatic hypotension. Diuretic use was more likely to be associated with blood pressure control.

CONCLUSION: The diagnosis of hypertension in frail older people would benefit from multiple, within‐day measures, including postural BP, taken before and after meals. Diuretic use alone, or in conjunction with ACE inhibitors or calcium channel blockers, was more likely to be associated with normalized blood pressures.
Identifying Patterns of Disruptive Behavior in Long‐Term Care Residents
Authors: Souder Elaine , Heithoff Kim , O'Sullivan Patricia S. , Lancaster Anne Elizabeth , Beck Cornelia
Published: April 2015

OBJECTIVES: To determine the frequency, timing, and pattern of 45 operationalized disruptive behaviors (DB) in older people in long‐term care units.

DESIGN: Nursing staff collected prospective descriptive data over 21 consecutive shifts for each patient to document prevalence, frequency, and co‐occurrences of DBs.

SETTING: All of the eight long‐term care units and one acute/admission unit of a large Veterans Administration Medical Center (VAMC). Each 40‐bed unit had patients with varying levels of cognitive impairment and skilled nursing needs.

PARTICIPANTS: The sample consisted of 240 hospitalized VA patients with a mean age of 72.8 (SD = 8.6) years and mean length of stay of 4.02 (SD = 8.6) years. Residents had dementia, a psychiatric diagnosis, or mixed dementia and psychiatric diagnoses.

MEASUREMENTS: The Disruptive Behavior Scale (DBS), an instrument designed for collecting patient‐level data on 45 separate DBs.

RESULTS: In a 24‐hour period, the average frequency was 3.6 DBs per subject. We found that 41.2% of DB occurred during the day shift, 39.2% during the evening shift, and 19.6% during the night shift. In 32% of observed occurrences, only one DB occurred within the hour. In the remaining 68% of observations, two or more DBs occurred within the same hour. We found two behaviors, Does Not Follow Directions and Excessive Motor Activity, to occur with multiple behaviors in multiple categories. Several characteristic patterns were noted; e.g., physically aggressive behaviors rarely co‐occurred with verbal DBs. Physically nonaggressive behaviors seemed to occur most frequently with other physically nonaggressive behaviors and, to a lesser extent, with verbal DBs.

CONCLUSIONS: These findings lend support to the existence of patterns of DBs in long‐term care patients, a useful step toward targeting interventions early in the behavioral sequence.
Alcohol Use and Functional Disability Among Cognitively Impaired Adults
Authors: Reid M. Carrington , Concaio John , Towle Virginia R. , Williams Christianna S. , Tinetti Mary E.
Published: April 2015

BACKGROUND: The extent to which alcohol exposure increases risk for functional disability among older adults with cognitive impairment has not previously been assessed.

OBJECTIVE: To examine the potential relationship between alcohol use and functional disability among older cognitively impaired adults.

DESIGN: Retrospective medical record review.

SETTING: Hospital‐based geriatric assessment center. PARTICIPANTS: Two hundred forty‐two consecutive participants with Mini‐Mental Status Examination scores of < 24.

MEASUREMENTS: Proxy‐reported alcohol intake was classified in categories of never, former, light (<1 drink/week), moderate (> 1 but <14 drinks/week), and heavy (> 14 drinks/ week) drinkers, and functional status was determined by proxy‐reported performance in seven basic (BADL) and seven instrumental (IADL) activities of daily living (0 = poorest function and 14 = best function).

RESULTS: Compared with never drinkers, moderate drinkers demonstrated higher mean BADL (12.2 vs 11.4, P =. 033) and IADL scores (6.6 vs 5.6, P =. 067), whereas heavy drinkers had higher BADL (12.8 vs 11.4, P =. 019) but lower IADL scores (4.8 vs 5.6, P =. 425). Former drinkers demonstrated both lower BADL (10.8 vs 11.4, P =. 107) and IADL scores (3.9 vs 5.6, P =. 011) compared with never drinkers. Evaluation of a potential dose‐response effect was limited due to low numbers of light and heavy drinkers.

CONCLUSIONS: Among cognitively impaired adults, moderate and heavy drinkers demonstrated better BADL function, whereas former drinkers had poorer IADL function, compared with never drinkers. Prospective studies that incorporate additional measures of exposure (e.g., cumulative lifetime consumption) and function (e.g., performance‐based tests) may provide a more comprehensive understanding of alcohol's effects among older cognitively impaired adults.
Development and Testing of a Five‐Item Version of the Geriatric Depression Scale
Authors: Hoyl M. Trinidad , Alessi Cathy A. , Harker Judith O. , Josephson Karen R. , Pietruszka Fern M. , Koelfgen Maryanne , Mervis J. Randy , Fitten L. Jaime , Rubenstein Laurence Z.
Published: April 2015

OBJECTIVE: To develop and test the effectiveness of a 5‐item version of the Geriatric Depression Scale (GDS) in screening for depression in a frail community‐dwelling older population.

DESIGN: A cross‐sectional study.

SETTING: A geriatric outpatient clinic at the Sepulveda VA Medical Center, Sepulveda, California. PARTICIPANTS: A total of 74 frail outpatients (98.6% male, mean age 74.6) enrolled in an ongoing trial. MEASUREMENTS: Subjects had a comprehensive geriatric assessment that included a structured clinical evaluation for depression with geropsychiatric consultation. A 5‐item version of the GDS was created from the 15‐item GDS by selecting the items with the highest Pearson x1 correlation with clinical diagnosis of depression. Sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values were calculated for the 15‐item GDS and the new 5‐item scale.

RESULTS: Subjects had a mean GDS score of 6.2 (range 0–15). Clinical evaluation found that 46% of subjects were depressed. The depressed and not depressed groups were similar with regard to demographics, mental status, educational level, and number of chronic medical conditions. Using clinical evaluation as the gold standard for depression, the 5‐item GDS (compared with the 15‐item GDS results shown in parentheses) had a sensitivity of. 97 (.94), specificity of. 85 (.83), positive predictive value of. 85 (.82), negative predictive value of. 97 (.94), and accuracy of. 90 (.88) for predicting depression. Significant agreement was found between depression diagnosis and the 5‐item GDS (kappa = 0.81). Multiple other short forms were tested, and are discussed. The mean administration times for the 5‐ and 15‐item GDS were. 9 and 2.7 minutes, respectively.

CONCLUSIONS: The 5‐item GDS was as effective as the 15‐item GDS for depression screening in this population, with a marked reduction in administration time. If validated elsewhere, it may prove to be a preferred screening test for depression.
Pharmacologic Treatment of Hypersexuality and Paraphilias in Nursing Home Residents
Authors: Levitsky Andrew M. , Owens Norma J.
Published: April 2015

PURPOSE: To discuss the pharmacologic options for treatment of hypersexuality or paraphilias in nursing home residents.

DATA SOURCES: A MEDLINE search was conducted for English‐language articles published over the past 20 years and was supplemented by a search of bibliographies of relevant articles.

STUDY SELECTION: Case reports of pharmacologic treatment of hypersexual or paraphilic behavior were selected only if the patient receiving treatment was an older person and/or cognitively impaired.

DATA EXTRACTION: Case reports were grouped according to the class of the pharmacologic agent used (antiandrogens, estrogens, GnRH analogues, or serotonergic drugs). Each case report was evaluated for pharmacologic agent administered, route of administration, duration of therapy, therapeutic response, and incidence of side effects.

CONCLUSIONS: Nursing home residents who display hypersexual or paraphilic behavior are extremely difficult to manage. Before initiating pharmacotherapy to control unwanted sexual behaviors, the current drug regimen should be evaluated carefully for drugs that may be causing or exacerbating the behavior. Case reports suggest that antiandrogens, estrogens, GnRH analogues, and serotonergic medications may be useful when other methods have failed. Controlled comparative trials of these agents are needed to establish their efficacy clearly. J Am Geriatr Soc 47:231–234, 1999.
Factors Contributing to Dehydration in Nursing Homes: Inadequate Staffing and Lack of Professional Supervision
Authors: Kayser‐Jones Jeanie , Schell Ellen S. , Porter Carol , Barbaccia Joseph C. , Shaw Heather
Published: April 2015

OBJECTIVE: To investigate the factors that influenced fluid intake among nursing home residents who were not eating well.

DESIGN: A prospective, descriptive, anthropological study.

SETTING: Two proprietary nursing homes with 105 and 138 beds, respectively.

PARTICIPANTS: Forty nursing home residents.

MEASUREMENTS: Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3‐ day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg).

RESULTS: The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration.

CONCLUSIONS: When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.
Detection of Older People at Increased Risk of Adverse Health Outcomes After an Emergency Visit: The ISAR Screening Tool
Authors: McCusker Jane , Bellavance Francois , Cardin Sylvie , Trepanier Sylvain , Verdon Josee , Ardman Orly
Published: April 2015

OBJECTIVES: To develop a self‐report screening tool to identify older people in the emergency department (ED) of a hospital at increased risk of adverse health outcomes, including: death, admission to a nursing home or long‐term hospitalization, or a clinically significant decrease in functional status.

DESIGN: Prospective (6‐month) follow‐up study of a cohort of ED patients aged 65 and older.

SETTING: The EDs of four acute‐care hospitals in Montreal, Quebec, Canada.

PARTICIPANTS: Community‐dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3‐month recruitment period. Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available.

MEASUREMENTS: Measures ascertained at the ED visit included: 27 self‐report screening questions on social, physical, and mental risk factors; medical history; use of hospital services, medications, and alcohol; and the Older American Resources and Services (OARS) activities of daily living (ADL) scale. At follow‐up, the OARS scale was readministered by telephone, and other adverse health outcomes were ascertained.

RESULTS: Among 1673 patients who completed the follow‐up measures, 488 (29.2%) had an adverse health outcome. Scale development and selection methods included logistic regression, receiver operating characteristic curves, and expert judgment. The proposed screening tool (ISAR) comprises six self‐report questions on functional dependence (premorbid and acute change), recent hospitalization, impaired memory and vision, and polymedication. The tool performed well in the total cohort aged 65 and older, and in sub‐groups defined by disposition (admitted or released from ED), language of questionnaire administration (French or English), information source (patient or other), and other characteristics.

CONCLUSIONS: The ISAR is a short self‐report questionnaire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability.
Walking Speed and Stride Length Predicts 36 Months Dependency, Mortality, and Institutionalization in Chinese Aged 70 And Older
Authors: Woo Jeanne , Ho Suzanne C. , Yu Ashley L. M.
Published: April 2015

BACKGROUND: Increasing emphasis is being placed on physical performance measures as an outcome predictor. It is uncertain whether one or two simple measurements will have predictive value compared with a battery of tests.

OBJECTIVES: To assess whether simple performance measures such as walking speed and stride length will predict dependency, mortality, and institutionalization.

DESIGN: A 3‐year longitudinal study of a random sample of subjects.

SETTING: Older people living in the community in Hong Kong, Special Administrative Region, China.

SUBJECTS: A total of 2032 Chinese subjects aged 70 years and older were recruited territory‐wide by proportional random sampling and followed for 3 years.

MEASUREMENTS: Functional status was measured using the Barthel Index at baseline and follow‐up. The time taken to walk a distance of 16 feet and the number of steps taken were measured at baseline. Stride length is estimated by dividing 16 by the average number of steps needed to complete the walk. Outcomes regarding dependency, mortality, and institutionalization at 36 months were recorded.

RESULTS: After excluding subjects lost to follow‐up and those who had died, data were available for 559 men and 612 women. Univariatc analysis showed that reduced walking speed and stride length were associated with increased risk of dependency, mortality, and institutionalization. In multivar‐iate analysis for dependency and mortality, stride length, walking speed, age, and sex were included in the best prediction model (ROC = 0.798 and 0.707, respectively), whereas only stride length was included in the prediction for institutionalization (ROC = 0.764).

CONCLUSIONS: In terms of prevention or modifying outcomes, these two simple performance measures may be used as indicators for checking for occult disease and for interventional measures such as exercise prescription.
Cost of Alzheimer's Disease and Related Dementia in Managed‐Medicare
Authors: Gutterman Elane M. , Markowitz Jeffrey S. , Lewis Barbara , Fillit Howard
Published: April 2015

BACKGROUND: Managed care organizations (MCOs) will have increased responsibility for the care of large numbers of persons with dementia. There are, however, few studies that inform about decisions of healthcare utilization and expenditures for individuals with dementia in managed care.

OBJECTIVES: To examine in a large MCO whether people diagnosed with dementia have higher healthcare utilization and costs than enrollees without dementia.

DESIGN: A retrospective study of medical and prescription claims.

SETTING: An MCO covering more than 80,000 Medicare enrollees in four geographical locales between January 1, 1996, and March 31, 1998.

SUBJECTS: There were 677 paired cases with and without dementia. Controls were selected randomly and matched to cases on age, gender, and region.

MEASUREMENTS: Summed total costs and number of claims accrued during the study period, as well as a breakdown of costs and claims with respect to place of service, were annualized and adjusted for age, gender, and comorbid conditions. Costs and claims were broken down by place of service.

RESULTS: Dementia prevalence was 0.83%. Mean total costs were 1.5 times higher for patients with dementia relative to controls ($13,487 vs $9,276, P < .001) when annualized and adjusted for level of comorbidity. Almost 75% of the higher costs among cases were linked to inpatient expenses.

CONCLUSIONS: Higher costs for individuals with dementia and disproportionate inpatient costs in this MCO parallel patterns among Medicare enrollees in fee‐for‐service. The high prevalence of dementia among the oldest old coupled with the high costs of dementia care create very significant clinical and financial incentives for managed care plans to improve the care of members suffering from dementia. J Am Geriatr Soc 47:1065–1071,1999.
ADVANCING GERIATRIC NURSING PRACTICE: Randomized Controlled Trial of Nurse Case Management of Frail Older People
Authors: Mezey Mathy , Fulmer Terry , Gagnon Anita J. , Schein Constance , McVey Lynne , Bergman Howard
Published: April 2015

OBJECTIVES: To compare the effects of nurse case management with usual care provided to community‐dwelling frail older people in regard to quality of life, satisfaction with care, functional status, admission to hospital, length of hospital stay, and readmission to emergency department.

DESIGN: Randomized controlled trial.

SETTING: University hospital and two proximal community health centers.

PARTICIPANTS: 427 frail older people (>70 years of age and at risk for repeated hospital admissions) discharged home from the emergency department.

INTERVENTIONS: Experimental: Nurse case management, which consisted of coordination and provision of healthcare services by nurses, both in and out of hospital, for a 10‐month period.

Control: Usual care, which varied by healthcare provider and community health center.

MEASUREMENTS: Outcomes were assessed 10 months post‐randomization by telephone and/or home interview and by medical record review. Questionnaires included the SF‐36®, CSQ‐8, and OARS.

RESULTS: No significant differences were found in quality of life, satisfaction with care, functional status, admission to hospital, or length of hospital stay. Nurse‐case‐managed older adults were readmitted to the emergency department significantly more often than their usual care counterparts.

CONCLUSIONS: Frail older people receiving nurse case management are more likely to use emergency health services without a concomitant increase in health benefits. J Am Geriatr Soc 47:1118–1124,1999.