bluuebunny/crossref_metadata_2025 huggingface dataset:
What Geriatricians Should Know About the Werner Syndrome
Authors: Martin George M. , Oshima Junko , Gray Matthew D. , Poot Martin
Published: April 2015

Geriatricians want to know the extent to which inborn genetic variations influence health span and life span in their patients. Current research on this subject is largely confined to the very basic issues of identifying, mapping, and cloning relevant genes and of investigating their modes of action. Here we summarize the status of such basic research on a gene (WRN), null mutations at which cause a striking seg‐mental propertied syndrome, the Werner syndrome (WS). The views of clinicians and basic scientists concerning the significance of WRN gene action for normal aging are polarized. Some regard it as the most important aging gene and refer to the syndrome explicitly as one of premature aging. Others regard WS as an entirely inappropriate model for aging because WS exhibits many clinical and cell biological discordances with normal aging. Moreover, WS has a major impact on reproductive fitness and, hence, does not escape the forces of natural selection. By contrast, senescent phenotypes of normal (usual) aging can be defined as those that do escape the forces of natural selection. We here give a more balanced view. Work has only just begun on the potential significance of a range of variants at the WS locus, including “leaky” mutations, heterozygosity for null mutations, and polymorphisms, some of which may indeed escape the force of natural selection and thus contribute to the burden of illness in old age. We are also at a very early stage of knowledge concerning genes coding for WRN interacting proteins, variations at which may also be of significance for gerontology and geriatric medicine. J Am Geriatr Soc 47:1136–1144,1999.
Effectiveness of Preventive In‐Home Geriatric Assessment in Well Functioning, Community‐Dwelling Older People: Secondary Analysis of a Randomized Trial
Authors: Büla Christophe J. , Bérod Annick Clerc , Stuck Andreas E. , Alessi Cathy A. , Aronow Harriet U. , Santos‐Eggimann Brigitte , Rubenstein Laurence Z. , Beck John C.
Published: April 2015

OBJECTIVES: To determine whether preventive in‐home comprehensive geriatric assessment (CGA) prevents functional decline in community‐dwelling older persons with different baseline functional status: (1) without any basic activities of daily living (BADL) dependency at baseline; and (2) without any instrumental ADL (IADL) and basic ADL dependency at baseline.

DESIGN: Subgroup analyses of a 3‐year randomized controlled trial.

SETTING: The city of Santa Monica, California.

PARTICIPANTS: Participants came from the original population (n = 414) of community‐living older persons aged 75 years and older who participated in a trial testing the effectiveness of annual preventive in‐home CGA. For the first subgroup analysis, we excluded subjects (n = 27) who were dependent in one or more BADL before randomization (final sample size, n = 387); for the second subgroup analysis, we excluded 93 additional subjects who were dependent in one or more IADL before randomization (final sample size, n = 294).

INTERVENTION: Annual preventive in‐home CGA, with quarterly home visits by gerontologic nurse practitioners, for 3 years.

MEASUREMENTS: Functional status data were collected through yearly in‐home interviews by independent observers. Subjects were classified as (1) independent in both BADL and IADL, (2) dependent in IADL but independent in BADL, or (3) dependent in both IADL and BADL.

RESULTS: In both subgroup analyses, there was no difference in survival between intervention and control subjects. In the subgroup with no BADL impairment at baseline, intervention subjects spent significantly fewer days dependent in both BADL and IADL during each year of the study (5 days vs 14 days, P = .022; 13 vs 33, P = .016; and 19 vs 44, P = .014 for years 1, 2, and 3, respectively) and over all 3 years combined (36 days vs 92 days, P = .016) in bivariate analyses. In multivariate analyses, the intervention reduced time spent in complete (BADL and IADL) dependency (P = .028). In the subgroup of subjects without any IADL or BADL impairment at baseline, no significant differences were apparent in the number of days spent in complete independence and days spent in complete dependency. Intervention group subjects spent more days in partial dependency during Year 1 (24 days vs 9 days, P = .021), but the difference was not significant during Year 2 (47 vs 29, P = .088), Year 3 (49 vs 41, P = .370), and over all 3 years combined (120 vs 79, P = .123) as well as in multivariate analysis (P = .062).

CONCLUSION: These findings support the hypothesis that in‐home preventive visits delay the onset of disability in people without initial BADL impairment. Further studies in larger samples are needed to determine optimal intervention strategies and effectiveness among well functioning older people.
Severe Disruptive Vocalizers
Authors: Sloane Philip D. , Davidson Susan , Knight Nancy , Tangen Catherine , Mitchell C. Madeline
Published: April 2015

OBJECTIVES: To describe the most severe disruptive vocalizers in nursing facilities, in regard to their clinical and behavioral characteristics, staff responses, and treatments used, and to report on their prognosis over 6 months.

DESIGN: A longitudinal cohort study.

SETTING: One hundred seven skilled nursing facilities.

PARTICIPANTS: The 203 residents who were among the two most disruptive vocalizers in their respective facilities and who vocalized at least 2 hours a day.

MEASUREMENTS: Telephone interviews of licensed nursing staff who cared for the subjects, conducted at baseline, 2, 4, and 6 months. Data gathered included subject demographics, physical function, diagnoses, medication and restraint use, behavioral problems, vocalization characteristics, treatments used, and status at follow‐up.

RESULTS: Subjects tended to have dementia, to be dependent in most activities of daily living, to have multiple medical problems, to be physically restrained (48%), and to be taking psychotropic medication (76%). Nearly all (95%) were audible at least 50 feet away, with loudness associated with more severe cognitive impairment (OR 4.90, P = .001). When subjects who primarily made nonverbal noises (“screamers”) were compared with those whose predominant expressions were words (“talkers”), hearing impairment, severe cognitive impairment, and greater dependency in activities of daily living characterized the screamers. Staff reported trying a variety of treatments with all subjects, often with little success.

Two months after enrollment, 66% of surviving subjects vocalized fewer hours than at baseline, and 45% were rated as improved. Independent predictors of improvement included greater ADL independence, hearing and vision problems, shorter length of stay, urinary incontinence, and use of a treatment other than one‐on‐one interventions. Nearly one‐quarter of subjects (23.4%) died within 6 months. Baseline factors associated independently with a higher probability of death included age, use of activity intervention, physical abusiveness, and absence of wandering.

CONCLUSION: Severe disruptive vocalization is associated with severe cognitive and physical impairment and with a high probability of mortality within 6 months. Subcategorization of severe vocalizers by vocalization type or other associated factors may be useful for prognostic and treatment purposes.
Religious Activity Improves Life Satisfaction for Some Physicians and Older Patients
Authors: Ayele Hana , Mulligan Thomas , Gheorghiu Sylvia , Reyes‐Ortiz Carlos
Published: April 2015

OBJECTIVE: To assess religious perceptions and activities of physicians and older patients and to determine whether religious activities are associated with life satisfaction.

DESIGN AND SETTING: A cross‐sectional survey of practicing Virginia internists and psychiatrists and hospitalized or institutionalized (nursing home) older adults.

PARTICIPANTS: One hundred randomly sampled practicing physicians and 55 hospitalized or institutionalized older patients.

METHODS: A mailed survey was used for the physicians and a structured interview for the patients. All subjects provided information pertaining to demographics and life satisfaction using the Life Satisfaction Index (LSI‐B). For physicians or patients who engaged in any religious activity, the Intrinsic/Extrinsic Religiosity (I/E‐R) scale was used.

RESULTS: Of the 100 physicians (49 internists and 51 psychiatrists) who answered the survey (50% response rate), 75% used religious activity as a coping resource (39% somewhat, 36% definitely). There was a positive correlation between intrinsic religious activity (e.g., prayer, Bible reading) and life satisfaction (r = .293, P =. 042). Of the 55 patients interviewed, 47 (86%) used religion as a coping resource, and intrinsic religious activity was positively associated with life satisfaction (r =. 843, P <. 001). Even after controlling for age, gender, health, and marital status, intrinsic religious activity remained a predictor of higher life satisfaction.

CONCLUSIONS: Intrinsic religious activity is associated positively with life satisfaction in physicians and ill older adults.
Medical Cost for Disability: A Longitudinal Observation of National Health Insurance Beneficiaries in Japan
Authors: Tsuji Ichiro , Kuwahara Aya , Nishino Yoshikazu , Ohkubo Takayoshi , Sasaki Atsushi , Hisamichi Shigeru
Published: April 2015

OBJECTIVES: To measure the impact of disability on the use of medical care and its costs.

DESIGN: A 1‐year prospective cohort study of National Health Insurance beneficiaries in a rural Japanese community. Their physical function was examined by the Medical Outcomes Study questionnaire at the end of 1994; medical care and its costs were then monitored for 1 year.

SETTING AND PARTICIPANTS: Participants were the 49,364 subjects, aged 40 to 79 years, who were beneficiaries of National Health Insurance and lived in the catchment area of Ohsaki Public Health Center, Miyagi, Japan. The subjects were mainly farmers, self‐employed persons, housewives, or pensioners.

MEASUREMENTS: Medical care utilization (number of outpatient visits and days of inpatient care) and the costs for each subject were obtained from National Health Insurance Claim History files. These measurements were collected from January to December 1995, and the relationship between physical functioning levels and medical costs was analyzed.

RESULTS: The medical costs per capita increased with poorer physical function. Medical costs among those with limitations in performing self‐care increased by 4 times in men and 3 times in women compared with those with no functional limitation. In this cohort, the 4.3% of the subjects who were dependent in self‐care used 15% of the total inpatient days and 10% of the total medical costs.

CONCLUSION: Treatment of patients with disability requires a huge amount of medical resources. There is an urgent need for cost‐effective intervention programs for disability prevention, which could be offset against the cost for treating the disabled.
Recruitment of Older Adults for a Randomized, Controlled Trial of Exercise Advice in a General Practice Setting
Authors: Halbert Julie A. , Silagy Christopher A. , Finucane Paul , Withers Robert T. , Hamdorf Phil A.
Published: April 2015

OBJECTIVES: The success of any clinical trial depends strongly on recruiting enough participants in a reasonable time period. This paper aims to identify the obstacles, as well as the successful aspects, of recruiting of older participants into an exercise study.

DESIGN: This describes the recruitment of 299 older adults into a randomized, controlled trial of exercise advice in a general practice setting. Letters of invitation were sent from two general practices inviting the patients to attend a 15‐ minute screening appointment. Patients considered eligible for enrollment were then scheduled for a baseline appointment and randomized into the trial.

SETTING: Two general practices in Adelaide, South Australia.

PARTICIPANTS: Healthy, sedentary, community‐dwelling patients aged 60 years or older.

RESULTS: A total of 2878 letters of invitation were sent, and 913 patients attended a screening appointment. Of these, 351 (38.4%) were initially eligible, with one‐third excluded because they were already too physically active. Two hundred ninety‐nine participants, approximately 1 of every 10 patients sent letters, were enrolled in the project at the end of a 15‐week period.

DISCUSSION: A general practice approach was effective in recruiting 299 older adults to an exercise project within an acceptable time frame. Factors promoting the success of recruitment through general practice included choosing large, well established practices, computerized age‐sex registers, and placing minimal demands on the general practitioners and practice staff. A continuing problem with recruiting participants for a project involving exercise is that the volunteer population tends to be healthy and interested in physical activity.
The Effect of Visual and Hearing Impairments on Functional Status
Authors: Keller Brenda K. , Morton Joy L. , Thomas Vince S. , Potter Jane F.
Published: April 2015

OBJECTIVES: To describe the prevalence of visual and auditory impairment in frail older persons and to evaluate the association between sensory impairment and overall functional status.

DESIGN: Prospective patient evaluation and retrospective analysis of data

SETTING: The outpatient geriatric assessment clinic of a university medical center.

PARTICIPANTS: Consecutive patients seen in the University of Nebraska Medical Center Outpatient Geriatric Assessment Clinic from 1986 to 1992 for whom both vision and hearing information were available (n = 576).

MEASUREMENTS: Visual acuity was measured by the Lighthouse Near Visual Acuity Test, and auditory acuity was evaluated with the whisper test. Functional status was determined by Lawton‐Brody activities of daily living (ADL) and instrumental activities of daily living (IADL) scales. Comoro‐bid illness was classified by the Cumulative Illness Rating Scale, and mental status was assessed by the Feldstein Mini‐Mental State Exam.

RESULTS: Eighteen percent of patients had visual impairment of 20/70 or worse. Hearing impairment was found in 64%. The mean ADL and IADL scores were 20/24 and 12/23, respectively, for patients with visual acuity better than 20/70, compared with 18/24 and 8/23 for visually impaired patients (P < .001 for both comparisons). ADL and IADL scores were also higher in hearing intact patients compared with those with hearing impairment: respectively, 21/24 vs 19/24 (P < .001) and 13/23 vs 11/23 (P < .001). The effects of visual acuity and hearing acuity on IADL score are independent of mental status and co morbid illness (P < .001). The effect of visual acuity on ADL score is independent of mental status and co morbid illness (P < .001), whereas the effect of hearing on ADL score is not. Subjects with both hearing and vision impairment had mean IADL (P < = .05) and ADL (P < = .05) scores significantly lower than those with no impairment

CONCLUSIONS: Impairments of vision and hearing are common in this frail older outpatient population. Functional status, as measured by IADL and ADL scores, is diminished for sensory impaired subjects. Combined vision and hearing impairments have a greater effect on function than single sensory impairments and influence functional status independent of mental status and comorbid illness. Overall, these results suggest that interventions to improve sensory function may improve functional independence. J Am Geriatr Soc 47:1319–1325,1999.
Longitudinal Changes in Attitudes of Offspring Concerning Life‐Sustaining Measures for Their Terminally Ill Parents
Authors: Cooper‐Kazaz Rena , Friedlander Yechiel , Steinberg Avraham , Sonnenblick Moshe
Published: April 2015

OBJECTIVES: To define longitudinal changes in the attitudes of offspring concerning life‐sustaining measures for their older, terminally ill parents and to determine whether experience of a “life event” influences such decisions.

DESIGN: An attitudinal survey of three groups.

SETTING: The geriatric department of a university‐affiliated general hospital.

PARTICIPANTS: Fifty‐one subjects who had been interviewed regarding life‐sustaining treatment for their terminally ill parents were reinterviewed 6 years later. In addition, a control group composed of 116 participants was generated from patients visiting hospital outpatient clinics. The control group had no prior experience involving hospitalization of a first‐degree relative as a result of a life‐threatening situation.

INTERVENTIONS: Each subject took part in a personal interview.

MAIN OUTCOME MEASURES: Attitudes regarding life‐sustaining measures were assessed, and the subjects' sociode‐mographic and religious characteristics were noted.

RESULTS: The attitudes of offspring in the acute phase situation and after the passage of 6 years were strikingly consistent. Twenty‐one percent had requested the initiation of resuscitation in the acute phase (“real time”), and 27.4% said the same 6 years later. The provision of nutrition and medication was requested by approximately 70% of participants both at the acute phase and 6 years later. When comparing each individual's personal views at the interviews with all others, consistency in attitude was found among answers to most questions. When comparing the acute phase group with the control group, a significantly higher percentage of the former requested the initiation of resuscitation (48.3% vs 25%), whereas a smaller percentage preferred that the decision be made by the physician (3.5% vs 21.3%). Active euthanasia was requested by 6.5% of the acute phase group and 12.9% of the control group.

CONCLUSIONS: The decisions made by offspring regarding life‐sustaining measures for their terminally ill parent at real time remain unchanged 6 years after the event. Exposure to a life event significantly affects the decision‐making of the offspring of a terminally ill parent. However, the subject's attitude toward extreme solutions‐opposing active euthanasia and requesting the administration of nutrition and medication‐was not influenced by the fact that the subject had undergone a life event. J Am Geriatr Soc 47:1337–1341, 1999.
Physician Orders for Life‐Sustaining Treatment (POLST): Outcomes in a PACE Program
Authors: Lee Melinda A. , Brummel‐Smith Kenneth , Meyer Jan , Drew Nicholas , London Marla R.
Published: April 2015

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life‐Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes.

DESIGN: Retrospective chart review.

SETTING: ElderPlace, a Program of All‐inclusive Care for the Elderly (PACE) site in Portland, Oregon.

PARTICIPANTS: All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2).

MEASUREMENTS: POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life.

RESULTS: The POLST specified “do not resuscitate” for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). “Comfort care” was the designated level of medical intervention in 13 cases, “limited interventions” in 18, “advanced interventions” in 18, and “full interventions” in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes.

CONCLUSIONS: POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life‐sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.
Prevalence, Incidence, and Risk Factors Associated with Hip Fractures in Community‐Dwelling Older Mexican Americans: Results of the Hispanic EPESE Study
Authors: Espino David V. , Palmer Raymond F. , Miles Toni P. , Mouton Charles P. , Wood Robert C. , Bayne Nora S. , Markides Kyriakos P.
Published: April 2015

OBJECTIVES: To determine the rates and risk factors associated with hip fractures in the community‐dwelling older Mexican‐American population.

DESIGN: A prospective survey of a regional probability sample of older Mexican Americans aged 65 and over.

SETTING: The 1993–1996 Hispanic Established Population for the Epidemiologic Study of the Elderly (H‐EPESE), a probability sample of noninstitutionalized Mexican Americans, aged 65 and over, living in the Southwestern states of Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS: In 1993–1994 and in 1995–1996, 2895 persons, aged 65 and over, considered Mexican American, were selected at baseline as a weighted probability sample. Sample weights were used to extrapolate to the estimated 498,176 older Mexican Americans residing in the Southwest US.

MEASUREMENTS: Self‐reported hip fracture and functional measures by in home interviews.

RESULTS: Hip fracture prevalence was 4.0% at baseline. The overall incidence of hip fractures for women was 9.1 fractures/1000 person‐years. The incidence rate for men was 4.8 fractures/1000 person‐years. Extrapolation from these data to the entire older Mexican American population indicated that approximately 5162 new fractures occurred in the population during the 2 year study period. In women, hip fractures were associated independently with advanced age, not being married/living alone, having had a stroke, limitations with activities of daily living and instrumental activities of daily living. In men, only the latter limitations were associated independently with hip fracture.

CONCLUSIONS: This study indicates that older Mexican American people may have hip fracture incidence rates that place them at highest risk among the Hispanic subgroups. In light of a sparse literature on this population, the fracture estimates derived from this work contributes to our understanding of the true fracture estimates in this population. Based on the extrapolated population rates, hip fracture in this population is a significant public health problem. Adequate preventive measures need to be implemented in this growing US population.
Expert Physician Recommendations and Current Practice Patterns for Evaluating and Treating Men with Osteoporotic Hip Fracture
Authors: Colón‐Emeric Cathleen , Yballe Liza , Sloane Richard , Pieper Carl F. , Lyles Kenneth W.
Published: April 2015

OBJECTIVES: To develop recommendations for the evaluation and the treatment of men with osteoporotic hip fracture from expert publications in the field of male osteoporosis, and to define the current practice patterns in a tertiary care VA Medical Center in Durham, North Carolina.

DESIGN: Survey research; a retrospective cohort study.

SETTING: Tertiary care VA Medical Center in Durham, North Carolina.

PARTICIPANTS: (1) US physicians who published on the subject of male osteoporosis in the peer‐reviewed literature between 1993 and 1997 identified by MEDLINE database search. (2) All 119 men admitted to the Durham VA Medical Center with ICD9 code for hip fracture between 1994 and 1998.

OUTCOME MEASURES: (1) Osteoporosis evaluation and treatment recommendations of published physicians obtained by survey instrument. (2) Actual osteoporosis evaluation completed and therapy prescribed during index hospitalization in a cohort of men with hip fractures, determined by chart and database review.

RESULTS: (1) Forty‐three physician‐researchers were surveyed with an 84% response rate. For an osteoporosis evaluation, 89% of respondents recommended measuring serum testosterone, 85% serum calcium, 75% 25‐OH vitamin D levels, 73% myeloma screen, and 61% serum thyroid‐stimulating hormone (TSH). Dual Energy X‐ray Absorptiometry would be obtained by 92%. More than 70% recommended calcium, vitamin D, and bisphosphonates for men with a normal metabolic evaluation, and 60% suggested weight‐bearing exercise. (2) In the cohort of men admitted with hip fractures, 50% had a serum calcium level and 3% had a serum TSH level measured. Vitamin D was prescribed to 25% of patients in the form of a multivitamin, and 4% received calcium. There was no bisphosphonate, testosterone, or calcitonin use.

CONCLUSIONS: Physicians who have published on osteoporosis recommended metabolic evaluation and osteoporosis therapy after hip fracture. Only minimal evaluation and treatment occurred in a cohort of men with osteoporotic hip fractures.
The Activities of Daily Vision Scale: A Useful Tool to Assess Fall Risk in Older Adults with Vision Impairment
Authors: Kamel Hosam K. , Guro‐Razuman Samerah , Shareeff Musarat
Published: April 2015

OBJECTIVE: To evaluate the validity of the Activities of Daily Vision Scale (ADVS) as a tool to assess fall risk in older adults with vision impairment.

DESIGN: Cross‐sectional assessments of visual function and retrospective collection of fall data.

SETTING: The outpatient medical clinics of an academic tertiary care community hospital.

PARTICIPANTS: Randomly selected sample (n = 143) of older (≥65 years) patients seen at the outpatient medical clinics at Nassau County Medical Center in Long Island, New York. These patients had one or more of five ocular conditions: refractive errors (n = 90), cataracts (n = 77), glaucoma (n = 29), diabetic retinopathy (n = 19), and/or macular degeneration (n = 6).

MEASUREMENTS: Visual function, assessed using the ADVS, demonstrated scores ranging from 0 (marked visual disability) to 100 (no visual difficulty). Fall history and the presence of eye disease were based on the self‐recall of patients. Fall history was assessed retrospectively over a 1‐year period from the time of the interview.

RESULTS: Thirteen percent of the subjects reported having one or more falls during the 1‐year period before the time of the interview. These subjects scored significantly lower on the ADVS compared with the scores of the group that did not report falls (74 ± 22 vs 85 ± 14, P < .01). Using a cutoff score of 90 points (10% loss of visual function on the ADVS), the ADVS had a 67% sensitivity in identifying those patients who had falls. Among the patients with glaucoma and those with diabetic retinopathy, the ADVS had a 100% sensitivity in identifying those patients who reported a history of falls. In patients with cataracts and refractive errors, the ADVS had a sensitivity of 82% and 64%, respectively, in identifying patients with a history of falls. The number of falls reported by the subjects showed no relationship with the ADVS scores.

CONCLUSION: The results from this study suggest that the ADVS may prove to be a useful tool to assess fall risk in older adults with vision impairment, especially in those persons with glaucoma, diabetic retinopathy, and/or cataracts.
Glycemic Control of Older Adults with Type 2 Diabetes: Findings from the Third National Health and Nutrition Examination Survey, 1988–1994
Authors: Shorr Ronald I. , Franse Lonneke V. , Resnick Helaine E. , Di Bari Mauro , Johnson Karen C. , Pahor Marco
Published: April 2015

BACKGROUND: Although nearly half of all people who have diabetes are aged 65 or older, glycemic control of older adults with diabetes has not been well described.

METHODS: We conducted a cross‐sectional study of 1,482 participants with self‐reported type 2 diabetes in the Third National Health and Nutrition Examination Survey, 1988–1994 (NHANES III), a nationally representative sample of the US noninstitutionalized civilian population. Variables included in this analysis included age, sociodemographic factors, drug treatment, and level of glycemic control.

RESULTS: The mean % (±SE) HbA1c was 7.78 ± 0.21, 7.64 ± 0.18, 7.71 ± 0.14, and 7.27 ± 0.14 in persons aged 20 to 54,55 to 64,65 to 74 and ≥75 years, respectively. The mean mg/dL (±SE) fasting plasma glucose (FPG) was 175.9 ± 7.6,164.5 ± 6.1,183.3 ± 5.3, and 158.5 ± 5.5 in the four age groups and older, respectively. When controlling for race, gender, education, and duration of diabetes, age was not significantly associated with levels of HbA1c [P (trend) = 0 .17] or FPG [P (trend) = 0 .19].

Among NHANES III participants aged 65 or older, ADA guidelines for glycemic control (HbA1c < 7%) were achieved by 71%, 44%, and 27% of persons using no drug therapy, oral hypoglycemic agents, and insulin, respectively.

CONCLUSIONS: Although many older adults with type 2 diabetes do not achieve targets for glucose control, there is no evidence to suggest that community‐dwelling older adults with diabetes are treated less vigorously than younger persons with diabetes. J Am Geriatr Soc 48: 264–267, 2000.
The Increasing Medical Malpractice Risk Related to Pressure Ulcers in the United States
Authors: Bennett Richard G. , O'Sullivan Joan , DeVito Eric M. , Remsburg Robin
Published: April 2015

The development of pressure ulcers is a common adverse occurrence among hospital patients and nursing home residents. In recent years, there have been media reports of older plaintiffs winning up to $65 million from healthcare providers, related to the development of pressure ulcers. The passage of sweeping nursing home reform legislation as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA‐87) may have influenced this trend. A review of identifiable federal and state legal databases was undertaken to investigate these issues. One hundred seventy‐three lawsuits related to pressure ulcers were identified between 1937 and 1997, with all but 11 (6%) recorded in the last 15 years. Although the majority of cases were related to the development of pressure ulcers among nursing home residents, hospitals were a defendant in almost one‐quarter of the cases. The median (range) number of cases identified annually increased significantly in the 5‐year epochs before and after passage of OBRA‐87 and increased again after publication of OBRA‐87 regulations in 1992 (2 (2–4) vs 9 (5–15) vs 19 (16–23) cases per year, respectively, P < .0001), evidence that this law has had a broad impact on medical malpractice risk. In addition, the median (range) age of patients for whom a suit was brought also increased significantly before compared with after 1987 (48 (2–81) vs 72 (5–96) years, respectively, P = .0009), evidence that the law facilitated the ability of older adults to become plaintiffs in medical malpractice cases. The median (range) monetary settlement or judgment did not change significantly during the three 5‐year epochs ($340,000 ($4000‐$2,000,000) vs $168,000 ($2200‐$2,000,000) vs $279,000 ($25,000‐$65,000,000), respectively, P = .44), evidence that the OBRA‐87 statutes and regulations established both a standard of care that should not be breached and a standard that can be achieved by healthcare providers. This article reviews these trends, provides examples of pressure ulcer cases, discusses the implications of these findings, and provides recommendations for minimizing this medical malpractice risk. J Am Geriatr Soc 48: 73–81, 2000.
Rethinking Fundamental Assumptions: SUPPORT'S Implications for Future Reform
Authors: Lynn Joanne , Arkes Hal R. , Stevens Marguerite , Cohn Felicia , Koenig Barbara , Fox Ellen , Dawson Neal V. , Phillips Russell S. , Hamel Mary Beth , Tsevat Joel
Published: April 2015

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision‐making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

OBJECTIVE: To explore the possibility that improved individual, patient‐level decision‐making is not the most effective strategy for improving end‐of‐life care and that improving routine practices may be more effective.

DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.

RESULTS: Many of the assumptions underlying the model of improved decision‐making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision‐making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.

CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System‐level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.
Family Satisfaction with End‐of‐Life Care in Seriously Ill Hospitalized Adults
Authors: Baker Rose , Hyg MS , Wu Albert W. , Teno Joan M. , Kreling Barbara , Damiano Ann M. , Rubin Haya R. , Roach Mary J. , Wenger Neil S. , Phillips Russell S. , Desbiens Norman A. , Connors Albert F. , Knaus William , Lynn Joanne
Published: April 2015

OBJECTIVE: To examine factors associated with family satisfaction with end‐of‐life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision‐making.

SETTING: Five teaching hospitals in the United States

PARTICIPANTS: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died.

MEASUREMENTS: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision‐making.

RESULTS: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision‐making. Factors found to be significantly associated with satisfaction with communication and decision‐making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3–3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0,1.2–3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4–1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1–0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2–0.8).

CONCLUSIONS: Satisfaction scores suggest the need for improvement in end‐of‐life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end‐of‐life care. An intervention like that used in SUPPORT may help family members.
Alternative Medicine Use in Older Americans
Authors: Foster David F. , Phillips Russell S. , Hamel Mary Beth , Eisenberg David M.
Published: April 2015

OBJECTIVES: Because there are few data describing alternative medicine use in older populations, we analyzed a nationally representative survey to quantify and characterize the use of alternative medicine in people aged 65 and older.

DESIGN: We utilized data collected in a nationally representative, random, telephone survey of adults, measuring use of conventional medical services and use of 20 alternative medicine therapies in the last 12 months.

PARTICIPANTS: A total of 2055 adults, 311 of whom were aged 65 and older and who constituted our sample of older Americans.

RESULTS: Overall, 30% of people aged 65 and older used at least one alternative medicine modality in the last year compared with 46% of those less than age 65 (P < .001), and 19% of older people saw a provider of alternative medicine within the past year compared with 26% of those less than age 65. The alternative medicine modalities used most commonly by those aged 65 and older were chiropractic (11%), herbal remedies (8%), relaxation techniques (5%), high dose or mega‐vitamins (5%), and religious or spiritual healing by others (4%). Older persons with a primary care provider used alternative medicine more frequently (34% vs 7% P < .05) than those with no primary care provider. Patients who saw their physician more frequently were more likely to use alternative medicine (0 visits 7%, 1–2 visits 22%, 3–6 visits 35%, 7 or more visits 44% P < .05). Six percent of older patients were taking both herbs and prescription drugs. Of older patients who used alternative medicine, 57% made no mention of their use of any alternative modality to their doctor.

CONCLUSIONS: Thirty percent of Americans aged 65 and older reported using alternative medicine (amounting to 10 million Americans based on extrapolations to census data) and 19% visited an alternative medicine provider (making 63 million visits based on extrapolations to census data) within the past year. The two modalities used most commonly were chiropractic and herbs, both of which may be problematic in older patients. Physicians should ask all patients, including those aged 65 and older, about their use of alternative medicine, and in those aged 65 and older, physicians should ask specific questions about the user of chiropractic and herbal medicine.
Effects of a Multicomponent Intervention on Functional Outcomes and Process of Care in Hospitalized Older Patients: A Randomized Controlled Trial of Acute Care for Elders (ACE) in a Community Hospital
Authors: Counsell Steven R. , Holder Carolyn M. , Liebenauer Laura L. , Palmer Robert M. , Fortinsky Richard H. , Kresevic Denise M. , Quinn Linda M. , Allen Kyle R. , Covinsky Kenneth E. , Landefeld C. Seth
Published: April 2015

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization.

OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients.

DESIGN: Randomized controlled trial.

SETTING: Community teaching hospital.

PATIENTS: A total of 1531 community‐dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997.

INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient‐centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness.

MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction.

RESULTS: Self‐reported measures of function did not differ at discharge between the intervention and usual care groups by intention‐to‐treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05).

CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.
Assessment of Pain in Cognitively Impaired Older Adults: A Comparison of Pain Assessment Tools and Their Use by Nonprofessional Caregivers
Authors: Krulewitch Harry , London Maria R. , Skakel Victoria J. , Lundstedt Glenda J. , Thomason Heidi , Brummel‐Smith Kenneth
Published: April 2015

OBJECTIVES:To compare self‐reporting of pain by cognitively impaired (CI) older adults living in the community with reports of their caregivers; to identify the factors associated with differences in agreement; and to identify those pain assessment tools that are most useful to nonprofessional caregivers.

DESIGN:Prospective observational cohort of patients with dementia and their caregivers.

SETTING:In‐home assessments of community‐dwelling CI older adults and family members, adult foster care providers, or aides in residential care facilities. All CI subjects were enrolled in a Program for All‐inclusive Care of the Elderly program (ElderPlace) in Portland, Oregon.

PARTICIPANTS:A total of 156 CI adults and their caregivers.

METHODS:Standardized pain assessment instruments were administered to the CI subjects and their caregivers in the subject's home by trained research assistants between June and October 1998. CI subjects were assessed with the Nonverbal Visual Analog scale (“line”), the Faces Pain Scale (“faces”), and the Philadelphia Pain Intensity Scale (PIS). Research assistants observed pain behaviors in the CI subjects using the Hospice Approach Discomfort Scale. The CI subject's caregivers completed the “line,” “faces,” PIS, and Cornell Scale for Depression in Dementia. A baseline Mini‐Mental State Exam, Functional Assessment Stage Test, and Geriatric Depression Scale were performed on all CI subjects by ElderPlace medical, nursing, or social work staff.

RESULTS:The mean age of the CI subjects was 83, and 83% were women. The mean Mini‐Mental State Exam score was 15.7. One‐third of the CI subjects were unable to complete any of the three pain assessment tools. Of the 104 subjects completing at least one tool, 13 (12.5%) reported no pain and 91 (87.5%) reported some pain. Sixteen (10%) of the subjects were depressed as measured with the GDS or Cornell instrument. In 70 of the 104 subjects (67%) able to complete any tool, the caregiver and CI subject agreed as to the level of pain experienced by the CI subject. The number of tools completed by the CI subjects decreased with increased cognitive impairment. The Pain Intensity Scale was the tool most likely to be completed by both CI subjects and caregivers. The means of test scores were not significantly different for the paired groups of CI subject and caregiver, and the nonparametric correlation of each tool was significant: “faces” (Spearman's rho (ρ) = .417); “line” (ρ = .420); and PIS (ρ = .452). The Hospice Approach Discomfort Scale did not correlate well with other tools. The Pain Intensity Scale seems to be more useful than other pain assessment tools in assessing pain in cognitively impaired patients and can be used by nonprofessional caregivers in a community‐based care setting.
Long‐Term Exercise and its Effect on Balance in Older, Osteoarthritic Adults: Results from the Fitness, Arthritis, and Seniors Trial (FAST)
Authors: Messier Stephen P. , Royer Todd D. , Craven Timothy E. , O'Toole Mary L. , Burns Robert , Ettinger Walter H.
Published: April 2015

OBJECTIVES: To examine the effects of 18‐month aerobic walking and strength training programs on static postural stability among older adults with knee osteoarthritis.

DESIGN: Randomized, single‐blind, clinical trial of therapeutic exercise.

SETTING: Both center‐based (university) and home‐based.

PARTICIPANTS: A cohort of 103 older adults (age = 60 years) with knee osteoarthritis who were participants in a large (n = 439) clinical trial and who were randomly assigned to undergo biomechanical testing.

INTERVENTION: An 18‐month center‐ (3 months) and home‐based (15 months) therapeutic exercise program. The subjects were randomized to one of three treatment arms: (1) aerobic walking; (2) health education control; or (3) weight training.

MEASUREMENTS: Force platform static balance measures of average length (Rm) of the center of pressure (COP), average velocity (Vel) of the COP, elliptical area (Ae) of the COP, and balance time (T). Measures were made under four conditions: eyes open, double‐ and single‐leg stances and eyes closed, double‐ and single‐leg stances.

RESULTS: In the eyes closed, double‐leg stance condition, both the aerobic and weight training groups demonstrated significantly better sway measures relative to the health education group. The aerobic group also demonstrated better balance in the eyes open, single‐leg stance condition.

CONCLUSIONS: Our results suggest that long‐term weight training and aerobic walking programs significantly improve postural sway in older, osteoarthritic adults, thereby decreasing the likelihood of larger postural sway disturbances relative to a control group. J Am Geriatr Soc 48: 131–138, 2000.
Appropriateness of the Decision to Transfer Nursing Facility Residents to the Hospital
Authors: Saliba Debra , Kington Raynard , Buchanan Joan , Bell Robert , Wang Mingming , Lee Martin , Herbst Michael , Lee Daniel , Sur Denise , Rubenstein Lisa
Published: April 2015

OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers.

DESIGN: A structured implicit review (SIR) of medical records.

SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals.

MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate.

RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization.

CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals. J Am Geriatr Soc 48: 154–163, 2000.