bluuebunny/crossref_metadata_2025 huggingface dataset:
Nurses' and Physicians' Attitudes Toward Tube‐Feeding Decisions in Long‐Term Care
Authors: Watts David T. , Cassel Christine K. , Hickam David H.
Published: April 2015

We studied attitudes of health professionals toward life‐sustaining treatment. A patient management questionnaire sent to staff physicians and nurses in 183 Oregon nursing homes consisted of eight patient sketches which varied age, mental status, and enjoyment of life. Respondents were asked whether they would favor tube‐feeding to correct malnutrition in each case.

Nurses showed higher preferences for tube‐feeding than did physicians (P = .05). For both professions, patient happiness was the strongest and most significant (P < .0001) influence upon preferences for tube‐feeding. Both professions also showed a significant (P < .001) tendency to give younger patients higher preferences for tube‐feeding. Physicians showed a significant (P < .0001) influence of patient mental status upon preferences, while patient mental status did not affect nurses' preferences. Identifiable clinical factors appear to influence attitudes of physicians and nurses toward tube‐feeding decisions.
Nutritional Contributors to Cardiovascular Disease in the Elderly
Authors: Kannel W. B.
Published: April 2015

Cardiovascular disease, so common in the elderly, has become an urgent public health concern. Major contributing factors include hypertension, dyslipidemia, impaired glucose tolerance, physical indolence, and cigarette smoking. Diet plays a major role in atherogenesis by its influence in blood lipids, blood pressure, and glucose tolerance, although its impact in the elderly is speculative owing to a paucity of direct evidence. But a rationale exists. Most cardiovascular risk factors are more prevalent in the elderly than in the young adult. The rise in blood pressure and blood lipids with advancing age is not inevitable. Diet may contribute to hypertension through an excess of calories, saturated fat, cholesterol, or salt and a deficiency of potassium, calcium, and magnesium. Antiatherogenic diets low in saturated fat and cholesterol, rich in fiber, and with substitution of polyunsaturated fat and restricted calories tend to normalize serum lipids and to cause lesions to involute. Emphasis on vegetable protein and fiber‐rich food has merit because they provide more fiber, polyunsaturated fatty acids, magnesium, selenium, complex carbohydrate, potassium, and copper, and less cholesterol, saturated fat, and sodium. The recommended fat‐modified diets are adequate in protein, vitamins, and minerals and need not be deficient in any nutrient or economically nonfeasible. The accelerating decline in cardiovascular mortality, which has included the elderly, indicates that such disease is controllable and not inevitable, even in the elderly. The decrease has occurred concurrently with reduced consumption of saturated fat and cholesterol, increased use of vegetable oils, and improved levels of cardiovascular risk factors.
Evaluation of Older Persons in the Ambulatory Setting
Authors: Williams Mark E. , Williams T. Franklin
Published: April 2015

This report provides a comprehensive description of an established outpatient geriatric consultation service. The basic objectives of the service are to promote health and to prevent or minimize disability. The consultation service uses a multidisciplinary team with core participants from medicine, nursing, and social work and is based in a setting where a wide range of specialty consultants and ancillary services are available. A detailed description of 131 individuals who received geriatric consultations during a one‐year period is provided. Despite a substantial burden of disability, most older persons after the consultation process were able to continue living in their own preferred setting. The degree to which the geriatric consultation service contributed to these favorable outcomes is currently being evaluated through a randomized clinical trial.
Wheelchair Use by Ambulatory Nursing Home Residents
Authors: Pawlson L. Gregory , Goodwin Marsha , Keith Karla
Published: April 2015

In a survey of wheelchair use in two nursing homes, the authors found a substantial number of cognitively intact nursing home residents who walked, but who also used a wheelchair. Using chart review and interviews with the residents, it was found that multiple physical factors, including pain, strength, endurance, vision and balance, and multiple social and environmental factors, including the fear of falling, were related to the resident's decision to use a wheelchair as an alternative means of mobility. A physical examination focused on aspects of mobility was completed on each resident and was intended to characterize the physical limitations in groups studied. In the nursing home environment, use of the wheelchair is viewed by the residents as a self‐initiated choice which the residents believed significantly enhanced their sense of well‐being. Finally, there was minimal recognition of mobility as a problem on the part of the medical and nursing staff. The study raises a number of important issues concerning walking versus wheelchair use in the nursing home.
Age and the Declining Rate of Autopsy
Authors: Campion Edward W. , Reder Victoria A. , Mulley Albert G. , Thibault George E.
Published: April 2015

To better understand declining autopsy rates, data have been gathered prospectively on 1080 consecutive deaths over six years among patients admitted to a medical intensive care/coronary care unit. Overall autopsy rate was 36%. Autopsy rates declined sharply with age from 60% for those aged 16 to 34 years to 23% for those 85 and over (P < .001). The highest rates by diagnosis were aortic aneurysm (70%), hepatic failure (52%), heart rhythm disturbance (48%), pulmonary embolism (45%), and sepsis (41%). Patients receiving major procedures had a significantly higher autopsy rate (38 versus 29%, P < .05) but rates bore little relation to prognoses given at admission by house officers, suddenness of death, sex, marital status or year of admission. Even among intensively treated patients, autopsy rates decline strikingly with age, demanding honest re‐appraisal to restore the place of autopsy in medical education, clinical research, and quality of care assessment for an increasingly elderly population.
Antidepressants and the Elderly
Authors: Peabody Cecilia A. , Whiteford Harvey A. , Hollister Leo E.
Published: April 2015

The pharmacologic treatment of depression in the elderly is often complicated by cardiovascular disease and other medical illnesses. Both the tricyclic antidepressants and the monoamine oxidase (MAO) inhibitors have adverse effects that are potentially dangerous in this age group. Second generation antidepressants may have fewer cardiovascular and anticholinergic side effects, but many do not offer any real advantage over the older drugs. In practical terms, the choice of antidepressants for use in elderly patients will be based largely on their degree of tolerance for unwanted effects.
Risk Factors for Sleep Disordered Breathing in Heterogeneous Geriatric Populations
Authors: Bitwise D. L. , Feldman D. E. , Bliwise N. G. , Carskadon M. A. , Kraemer H. C. , North C. S. , Petta D. E. , Seidel W. F. , Dement W. C.
Published: April 2015

This cross‐sectional, multivariate study investigated associations between sleep disordered breathing (SDB) and putative risk factors in a heterogeneous group of 720 individuals over the age of 50 years studied during all‐night in‐lab polysomnography. Results indicated that: 1) aged men were more likely to show impaired respiration during sleep than aged women; 2) excessive daytime somnolence and parasomniac symptoms (snoring, gasping during sleep) were associated with SDB but insomnia was not; 3) obesity accounted for more variance in SDB than age per se, implying that the prevalence of SDB in some elderly persons could be related to the deposition of body fat seen as individuals grow older. All four risk factors (age, sex, obesity, and symptomatic status) were statistically significant and independent predictors of impaired respiration in sleep in the elderly.
Use of Ambulatory Care Resources by Medicare‐Age Patients in a Primary Care Group Practice
Authors: Charles Gerald , Stimson David H.
Published: April 2015

The increase in the number of persons age 65 and over—the Medicare‐age group—and the increasing cost of providing medical care to patients in this group have focused attention on enrollment of these persons in capitated plans as a means of containing costs. Although much is known about resources used for inpatient care for Medicare‐age patients, detailed information organized on a per‐patient, per‐year basis about ambulatory care of these patients is lacking. In order to address this problem and to investigate possible differences in resource use by age groups within the Medicare‐age population, a study was made of a primary care group practice in which 523 patients, including 174 patients in the Medicare‐age group, were followed for one year to determine their use of ambulatory care resources. A comparison of annual resource use by patients age 75 and over with patients age 65 through 74 showed that patients age 75 and over made more visits for primary care (8.15 vs. 6.46), made more visits to specialty and subspecialty clinics (3.41 vs. 2.33) and had higher total charges for ambulatory care ($749 vs. $623). The pattern of use of specialty and subspecialty clinics suggests that the primary care physicians functioned effectively as gatekeepers because most medical problems were handled without referrals to medical subspecialty clinics. The pattern also suggests that the projected rapid increase between now and the year 2000 in the number of persons age 75 and over may result in a greater than anticipated demand for services provided by ophthalmologists, podiatrists, and otolaryngologists.
The Safety of ECT in Geriatric Psychiatry
Authors: Burke William J. , Rubin Eugene H. , Zorumski Charles F. , Wetzel Richard D.
Published: April 2015

Electroconvulsive therapy (ECT) is often described as an effective and safe treatment of depression in the elderly. However, we have previously reported that there may be increased morbidity in this population, particularly in the very old. This paper extends this work to a second, larger sample of 136 subjects of whom 40 are over 60 years of age. We have again found that while ECT is efficacious, complications increase with age (r = .26; P ≤ .003), occurring in 35% of the elderly as opposed to 18% of the younger group. This increased rate of complications appears to be accounted for by problems in the very old; six of eight subjects over 75 years of age had some untoward event. Common complications in the elderly included severe confusion, falls, and cardiorespiratory problems. Complications in the whole sample were related to health status (r = .22; P ≤ .008) which in turn correlated with age (r = .50; P ≤ .0001). Those taking a greater total number of medications and a greater number of cardiovascular medications had significantly more complications during ECT. There was no relationship between either complications and outcome or complications and the number or laterality of treatments.

These findings confirm the effectiveness of ECT in the elderly but suggest there may be unappreciated risks of ECT in this population. At particular risk are the very old, those in poor general health, and those taking multiple medications, particularly cardiovascular agents.
BOOK REVIEWS
Authors: Barzel Uriel S. , Orr William F.
Published: April 2015

The Physical and Mental Health of Aged Women. Edited by Haug MR, Ford AB, and Sheafor M. New York, Springer Publishing Company, 1985, 303 pages, $25.95.
Urinary Incontinence in Elderly Women: Clinical Findings
Authors: Wells Thelma J. , Brink Carol A. , Diokno Ananias C.
Published: April 2015

Two‐hundred women self‐described as having urinary incontinence, aged 55 to 90 years and living in the community completed a comprehensive history and physical examination. Initial presentation of urine loss was most commonly stress incontinence symptoms (35%). Scoring of peak response to volume lost and frequency revealed urine loss necessitating a clothing change for 78% and daily loss experienced by 73%. Over half had experienced a urine loss problem for more than five years. Most (65%) had sought treatment, but a minority reported current (11%) or previous (36%) treatment. Thirty‐six percent were found to have severe atrophic vaginitis with severe urethocele (10%), cystocele (13%), rectocele (12%) less common. Pelvic floor strength by clinical scoring was weak (mean, 1.05 on a 5‐point scale). The vaginal electromyograph first contraction peak mean was 5.94 micro‐volts sustained at 50% or better for 3.92 seconds. Clinical criteria established that 66% had stress, 27% a mixture of stress and urge, only 4% pure urge incontinence, and 4% other. J Am Geriatr Soc 35:933–939, 1987
Marked Decline in Trabecular Bone Mineral Content in Healthy Men with Age: Lack of Association with Sex Steroid Levels
Authors: Meier Diane E. , Orwoll Eric S. , Keenan Edward J. , Fagerstrom Richard M.
Published: April 2015

To define the association of age‐related changes in bone mineral content to gonadal function in normal men, we measured radial (largely cortical) and vertebral (largely trabecular) bone mineral content (BMC), testosterone (total and free), estrone and estradiol‐17B levels in 62 healthy subjects, ages 30 to 92. Radial BMC fell 2 to 3.4% per decade but vertebral trabecular BMC declined more rapidly at 12% per decade. Of the sex steroids measured the only statistically significant change occurred in free testosterone levels which decreased with age (r = −.57, P < .0001). Free testosterone levels correlated significantly with trabecular vertebral BMC (r = .458, P < .0002) but not with bone mineral measures at the predominantly cortical radial sites. However, by multiple regression analysis free testosterone did not add to the effect of age on vertebral BMC. There were no associations of total testosterone, estrone, or estradiol levels to bone mineral content at any of the three sites measured in these healthy men. Age‐related declines in male gonadal function do not appear to be of primary importance in male age‐related bone loss.
A Controlled Double‐Blind Study of High‐Dose Dihydroergotoxine Mesylate (HydergineR) in Mild Dementia
Authors: Thienhaus Ole J. , Wheeler Beverly G. , Simon Sandra , Zemlan Frank P. , Hartford James T.
Published: April 2015

In a double‐blind study of 41 outpatients aged 55 to 80 years with mild memory impairment, the efficacy of dihydroergotoxine mesylate (DEM, HydergineR) at 6 mg per day, administered orally, was tested during a twelve‐week period. Specific etiologies for the amnesic syndrome were ruled out by history, physical examination, and laboratory tests. Subjects with a Hamilton Depression Scale rating above 18, ie, possible pseudodementia, were excluded. Physician rating of memory, employing the Inventory of Psychic and Somatic Complaints in the Elderly (IPSC‐E), indicated statistically significant improvement of memory function in DEM treated subjects (N = 22) v those on placebo (N = 19), (F = 3.34; df = 1,39; P < .04). In contrast, structured testing of recent memory using digit symbol substitution and Zahlenverbindungs test (ZVT) showed improvement in both groups (P < .001) with no significant intergroup differences (P < .10). Out results indicate that in cases of mild, though subjectively distressing impairment, DEM at higher dosages may help to enhance short‐term memory function.
The Aging Thyroid: I. A Description of Lesions and an Analysis of Their Age and Sex Distribution
Authors: Blumenthal Herman T. , Perlstein Irving B.
Published: April 2015

Two types of follicular change in the thyroid are described. The first represents an involutional change in which colloid cysts (macrofollicles) are often found. The second represents a hyperplastic‐dysplastic (microfollicular) lesion. Two types of change in calcitonin (C) cells are also described, one of which may represent an involutional process, although this is not certain. The second is a hyperplastic (micronodular) lesion, but without evidence of dysplasia. An infiltration of lymphocytes is also commonly encountered.

Only about 15% of cases after age 60 are free of the follicular and lymphoid lesions. Both the macro‐ and microfollicular lesions show a statistically significant increase with age, as do the lymphoid lesion and its derivative Hashimoto's thyroiditis. C cell micronodules also appear to increase with age, but there are too few such cases for a reliable statistical analysis.

An analysis of combinations of the follicular and lymphoid lesions show a particularly frequent association of the microfollicular and lymphoid lesions. Evidence is presented suggesting that many microfollicular lesions may represent clones of mutated cells, and that the lymphocytes may be targeted to these microfollicles. Lymphocytes were rarely found in association with C cell micronodules.

Within individual thyroids there is considerable variation in the proportion of each lesion when combinations are present. Thus with advancing age there is. an increasing heterogeneity of thyroid structure that may confound attempts to correlate structural and physiological changes with age. J Am Geriatr Soc 35:843–854, 1987
Characterization of the Immune Response to Trivalent Influenza Vaccine in Elderly Men
Authors: Levine Marc , Beattie B. Lynn , McLean Donald M. , Corman David
Published: April 2015

This study characterizes the time course of the immune response to influenza vaccine in elderly men. Sixty‐two men aged 58 to 91 years (mean, 74.3 years) were vaccinated with trivalent inactivated influenza vaccine in the fall of 1983. Serum hemagglutinin‐inhibiting (HAI) antibody titers were measured at various times up to 24 weeks postvaccination. Seroconversion frequencies determined at single times after vaccination were 28 to 46% of subjects, whereas cumulative seroconversion frequencies were greater than or equal to 70%. Eighteen to 28% of seroconversions occurred later than four weeks, and greater than or equal to 68% of those who seroconverted experienced greater than four‐fold declines in peak HAI antibody titers by 24 weeks after vaccination. Consequently, 31 to 73% of subjects had HAI antibody titers greater than 40 throughout the study period. Measurement of HAI antibody titers at only one time after vaccination may not adequately reflect the immune response of this population or the degree of protection maintained through the influenza season.
Brophy v New England Sinai Hospital, Inc.
Authors:   D. PeterSociety for the Right to Die Inc.
Published: April 2015

On September 11, 1986, the Supreme Judicial Court of Massachusetts, in a 4–3 decision, authorized removal of the artificial feeding tube. It held that the “substituted judgment” of an incompetent person in a persistent vegetative state to refuse artificially administered sustenance must be honored. The Court also refused to compel the hospital in this case to terminate the treatment, but permitted other hospitals to comply with the patient's wishes.

We are publishing the amicus curiae brief filed by the Society for the Right to Die, Inc. in the Brophy case. Our purpose in doing this is to stimulate further discussion of the issue of the role of the patients who become incompetent, a matter of major concern to geriatric specialists. This brief has been well‐prepared. It contains a legal and ethical history of considerable merit.

It has not, however, been endorsed by the American Geriatrics Society (AGS). Some of the principles the AGS has endorsed can be found on its own brief filed in the Conroy case (published in the December 1984 issue of the Journal).

Physicians and medical ethicists in particular may wish to consider the caveats noted by David Thomasma, PhD. in his editorial in this issue of the Journal. We invite further discussion.
Dopamine and Serotonin Systems in Human and Rodent Brain: Effects of Age and Neurodegenerative Disease
Authors: Morgan David G. , May Patrick C. , Finch Caleb E.
Published: April 2015

The nonpathological age‐related changes in the dopamine‐and serotonin‐containing neurotransmitter systems in human and rodent brain are reviewed. The dopamine system exhibits age‐related declines both presynaptically and postsynaptically. Presynaptically, both the levels of dopamine and the number of midbrain dopamine‐containing neurons decline by up to 50% at advanced ages in the absence of neurological disease. Postsynaptically, the density of D‐2 dopamine receptors decreases by 40%, while D‐1 dopamine receptors either increase (man) or remain stable (rodents). Additional reductions of dopamine levels and D‐2 receptors have been reported in Alzheimer's disease (AD), but these changes are relatively small, and not consistently observed.

The levels of serotonin appear stable during normal aging, and presynaptic markers such as (3H)imipramine binding may actually increase. In human brain, the two major classes of serotonin receptor (S‐1 and S‐2) decrease by 30 to 50% over the lifespan. In AD, both presynaptic and postsynaptic markers of the serotonin system are reduced, including a loss of the serotonin‐containing raphe neurons. The additional loss of serotonin receptors in AD approaches 80% when compared with young normals.

A hypothesis is presented to explain the typically young age at onset of schizophrenia (usually before 30 years of age) and the older age at onset of parkinsonism (rarely before 50 years of age) within the context of normal age‐related declines in the dopamine system occurring in the absence of neurological disorders. The possibility that chronic cocaine abuse might accelerate the development of parkinsonism is discussed.
AIDS and the Geriatrician
Authors: Moss Robert J. , Miles Steven H.
Published: April 2015

Ten percent of acquired immune deficiency syndrome (AIDS) cases are in persons over 50 years of age with 25% of these cases in persons over 60, and 4% in persons over 70 years of age. If the present age distribution holds, there will be 27,000 AIDS cases in persons over 50, and 1100 cases in persons over 70 years of age, by 1991. Older persons are more likely to acquire AIDS through blood transfusions than to homosexual exposure or drug abuse. Changes in the management of blood products will benefit older persons. The nearly 1 million elderly homosexual men, who have been sheltered from the virus by their pattern of sexual activity, will face greater risks as the prevalence of the virus and the age of the carriers increases. The underappreciated neurological consequences of human T‐cell lymphotrophic virus type III (HTLV‐III) infection, subacute encephalitis, vacuolar myelopathy, and psychiatric disorders will be of particular interest to geriatricians who are often consulted to evaluate neurological dysfunction. Geriatricians will need to become familiar with the spectrum of HTLV‐III infection and prepared to counsel patients and extended‐care facilities.
Impact of Intracardiac Electrophysiologic Testing on the Management of Elderly Patients With Recurrent Syncope or Near Syncope
Authors: Sugrue Declan D. , Holmes David R. , Gersh Bernard J. , Wood Douglas L. , Osborn Michael J. , Hammill Stephen C.
Published: April 2015

Seventy‐five patients, 75 years of age and over, experienced recurrent syncope, with the etiology remaining unclear but presumably cardiogenic, after cardiac and neurologic examinations and noninvasive laboratory testing (including an electrocardiogram and ambulatory electrocardiographic monitoring). The mean number of previous syncopal spells was 14 (range, 1 to 64) over a mean of 36 months (range, 1 to 480 months). These patients underwent invasive electrophysiologic testing and a potential cause for syncope was identified in 68%. Abnormal findings at electrophysiologic testing included: sinus node dysfunction (55%); abnormal His‐bundle conduction (39%); and ventricular tachycardia (14%), with some patients having more than one abnormality. No major complications were associated with the electrophysiologic testing. Patients were subsequently treated with permanent cardiac pacing or antiarrhythmic drugs or both, depending upon results of the electrophysiologic study. Follow‐up examinations (mean of 26 months; range, 1 to 70) were possible in 90% of patients. No further syncope occurred in 84% of patients with an abnormal electrophysiologic study who received subsequent therapy to prevent the identified abnormality. Thus, in this difficult group of patients with recurrent syncope of uncertain etiology, electrophysiologic testing was safe and indicated abnormalities of conduction or rhythm in 68% of patients; treatment to correct these abnormalities prevented recurrent syncope in 84%.
Prognostic Factors in the Diabetic Hyperosmolar State
Authors: Wachtel Tom J. , Silliman Rebecca A. , Lamberton Preston
Published: April 2015

To evaluate the current outcome of patients hospitalized with diabetic hyperosmolar state (DHS), we retrospectively studied 135 patients admitted to two general hospitals over an 11‐year period. Mortality was 17%. Patients who died had a mean age of 77 years, compared to 68 years for the survivors (P = 0.008). They were also more likely to be nursing home residents (48 versus 23%, P = 0.01). Additionally, mean serum osmolality was significantly higher among those who died (383 versus 358 mosm/L, P < 0.0001) as was blood urea nitrogen (81.3 versus 62.3 mg/dl, P = 0.006) and sodium (148 versus 137.4 mEq/L, P < 0.001). However, mean glucose level and anion gap were similar among patients who died and patients who survived (1068 versus 1092 mg%; 23 versus 24 mEq/L, respectively). The presence of a chronic disease or an acute comorbid illness was not associated with mortality. Diminished physiologic reserve, attendant comorbidity, or functional disability may explain the effect of age and nursing home residence. High osmolality may indicate a greater water deficit and a more advanced stage of DHS at the time of diagnosis.
Nursing Homes as Acute Care Providers A Pilot Study of Incentives to Reduce Hospitalizations
Authors: Zimmer James G. , Eggert Gerald M. , Treat Anne , Brodows Belinda
Published: April 2015

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNF's when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.
Are Alzheimer Patients Healthier?
Authors: Wolf‐Klein Gisele P. , Silverstone Felix A. , Brod Meryl S. , Levy Arnold , Foley Conn J. , Termotto Val , Breuer Joseph
Published: April 2015

At an active outpatient geriatric program the gerontological team observed that Alzheimer patients appear to have fewer physical ailments than other elderly patients. To test this hypothesis, we reviewed a sample of 348 clinic patients. One hundred forty‐three had a normal mental status; 75 had Alzheimer's disease as defined by DSM‐III criteria; 139 had an abnormal mental status attributed to other etilogies. The number of diagnoses was compiled in each of the three groups. The average number of diagnoses in the nondemented group was 5.0 in males, 5.4 in females. In the non‐Alzheimer abnormal mental status group, the average number was 5.5 in males, 4.6 in females. In contrast, the number of diagnoses in the Alzheimer group was 2.9 in males and 2.8 in females (P < 0.0001). Cardiovascular diseases, hypertension, and cerebrovascular accidents were less frequent in the Alzheimer population. This study suggests that Alzheimer patients are physically healthier than non‐Alzheimer elderly patients.
Beyond Caring: The Challenge to Geriatrics
Authors: Kane Robert L.
Published: April 2015

Geriatrics has established itself in the past decade as a recognized part of health care, but several issues remain unsolved about its place in the system. It has been addressed as both an approach to primary care of the elderly and a specialty in its own right. It relies excessively on the technology of assessment. Although geriatrics responds to a pervasive need for coordinating clinical and social care for a subset of the elderly, its potential contributions to this challenge have not yet been well modeled. As it comes of age, there is a need for greater conceptual clarity and a series of demonstrations that its abilities fit the needs identified.
Continued Treatment of the Fatally Ill for the Benefit of Others
Authors: Yarborough Mark
Published: April 2015

This paper examines the moral and professional issues present in cases involving continued treatment of fatally ill patients in order to benefit a third party. It is argued that such treatment can be justified in some cases from a moral point of view. Practical considerations make such cases difficult to identify at times. It is also argued on the other hand that professional concerns should rule out the permissibility of continuing such treatment. Thus, even though it may be morally permissible at times to continue treatment, it is not good medical practice to do so.
Myocardial Infarction in Old People
Authors: Day J.J. , Bayer A. J. , Chadha J. S. , Pathy M. S. J.
Published: April 2015

The clinical features and outcome were determined for 100 consecutive patients aged 65 years or older with a history of diabetes mellitus who presented to hospital with acute myocardial infarction. Each case was compared with an age‐ and sex‐matched nondiabetic control also admitted to hospital with acute myocardial infarction. Chest pain was equally common in both groups and was the main presenting symptom. Cardiac failure was a more frequent accompaniment in the diabetics, despite the lack of evidence for greater infarct size in this group. The outcome was worst for female diabetics, of whom 46% died. Contrary to popular teaching, painless myocardial infarction is not a specific feature of elderly diabetics.
Performance‐Based Measurements Among Elderly Drivers and Nondrivers
Authors: Retchin Sheldon M. , Cox Jennifer , Irwin Linda
Published: April 2015

Although driving is an important ability for maintaining independence in the later years, clinical factors that determine driving status are unknown. Aged male veterans (mean age, 70 years) were recruited from an outpatient clinic (N = 143), including 77 frequent drivers, 41 infrequent drivers, and 25 who drove rarely or not at all. There were 116 (84%) who completed a comprehensive performance‐based assessment. There were no significant differences between the three groups in age, formal cognitive testing, or prevalence of stroke history. However, there were significant differences in grip strength, reaction time, static visual acuity, dynamic visual acuity, and peripheral vision. Using stepwise ordinal logistic regression, dynamic visual acuity, nondominant hand grip strength, and total horizontal peripheral visual field were significantly associated with driving frequency (P < .05), and together explained approximately 45% of the variance. Subtle motor and visual deficits that can be detected by a performance‐based assessment may play an important role in determining driving frequency in the elderly.
Public Financing of Medicare
Authors: Gerety Meghan B. , Winograd Carol Hutner
Published: April 2015

The following paper is an independent and unofficial commentary on the American Geriatric Society's Public Policy Committee Position Statement “Medicare” which appears in this issue
Drug‐Associated Hospital Admissions in Older Medical Patients
Authors: Grymonpre Ruby E. , Mitenko Paul A. , Sitar Daniel S. , Aoki Fred Y. , Montgomery Patrick R.
Published: April 2015

A survey of drug‐related admissions of patients aged 50 years and older was conducted at the Health Sciences Centre, Winnipeg to determine the interrelationship of risk factors, and isolate the effect of age. All nonelective medical admissions were prospectively assessed to determine the role of drug therapy as a contributory factor. Of the 863 eligible admissions, 162 exhibited at least one drug‐related adverse patient event (DRAPE) at the time of hospitalization. This accounted for 19% of the admissions (23% of 718 admissions that involved prescription drugs). Although adverse drug reactions were responsible for many DRAPEs (48%), intentional noncompliance (27%), treatment failure (19%), alcohol (14%), and medication error (10%) were also frequent contributing causes. Drugs commonly implicated in DRAPEs were systemic steroids, digoxin, nonsteroidal anti‐inflammatory agents, α‐methyldopa, calcium channel blockers, β‐blockers, theophylline, furosemide, sympathomimetics, thiazides, and benzodiazepines. The risk of a DRAPE was related to the number of diseases prior to admission (r = 0.81; P < .026) and the number of drugs used (r = 0.77; P < .001). Age was not correlated with the risk of a DRAPE. Females had significantly more adverse drug reactions, although sex was not a predictor for overall DRAPE risk.
Targeting the Hospitalized Elderly for Geriatric Consultation
Authors: Winograd Carol Hutner , Gerety Meghan B. , Brown Elizabeth , Kolodny Vita
Published: April 2015

This empirical study reports the proportion of hospitalized elderly patients who were identified as frail. As a part of a randomized controlled trial, standardized criteria were developed to target the frail hospitalized elderly for geriatric consultation. Twelve‐hundred patients aged 65 years and older admitted to the medical and surgical services at the Palo Alto Veterans Administration Medical Center were screened. Because of administrative exclusions of the randomized controlled trial (eg, short stay, lived too far away), 749 (62%) were excluded from the clinical screening process. The remaining 451 patients received clinical screening. Of these patients, almost two thirds (64%) were considered “too independent” to benefit from geriatric consultation (ie, independent in activities of daily living with short term illness), while 12% were judged “too impaired” to benefit (ie, had severe dementia or terminal cancer). Only 24% of those clinically screened (9% of the entire sample) were considered appropriate for geriatric consultation. Strikingly, over 42% of those patients aged 76 or older, were judged “too independent.”

These data suggest that a large majority of the hospitalized elderly may be too well to benefit from geriatric consultation, thus making targeting by age alone inefficient. A realistic estimate of the percentage of hospitalized patients appropriate for geriatric intervention lies somewhere between 18% (the combined percentage of those found appropriate and those already enrolled in geriatric programs) and 24% (the proportion of the clinically evaluated group found appropriate). Targeting of subjects may be accomplished inexpensively using the authors' explicit criteria. Such targeting may help focus the use of interdisciplinary geriatric expertise on those most in need.
Open Heart Surgery in Patients in the Eighth and Ninth Decades of Life
Authors: Silvay George , Bodner Neal , Koffsky Barbara , Mindich Bruce P. , Litwak Robert S. , Kaplan Joel A.
Published: April 2015

One hundred fifty‐one patients aged 70–89 years underwent a variety of open heart surgical procedures during a period of 1 year. We divided these patients into two groups: Group A was comprised of 127 patients between 70 and 79 years of age. In group B, 24 patients were between 80 and 89 years of age. These patients underwent elective open heart surgery. Information was retrieved retrospectively from the computerized data pool of the cardiothoracic registry in our institution. Statistical analysis in these two groups revealed no significant differences in any of the evaluated factors. We concluded that age should not be a contraindication for cardiac operations.
Decisions to Leave Home What Will the Neighbors Say?
Authors: Loewy Erich H.
Published: April 2015

This paper discusses two of the problems encountered when a decision not to institutionalize patients is made. When patient, physician, and family jointly decide to forego institutionalization, the family often subconsciously fears communal censure if it fails to call for help when the end is near. This may, at the last moment, prompt some families to call emergency teams and thwart the original purpose of the decision.

Instances in which a previous decision not to institutionalize is justifiably interrupted, are discussed. Such an interruption does not necessarily foil the original plan if it is transient and one to provide comfort.

An interactive model in which patients, health‐care workers, families, and the community share is used. It is suggested that when a decision not to institutionalize is well‐discussed, compassiontely made, and carefully implemented, it may itself tend to reshape the communal ethos. As a result, communities, rather than expecting reflex action, are more prone to examine the appropriateness of institutionalization or emergency measures in particular cases and under particular circumstances.
Lung, Breast, and Colorectal Cancer: The Relationship Between Extent of Disease and Age at Diagnosis
Authors: Mor Vincent , Guadagnoli Edward , Masterson‐Allen Susan , Silliman Rebecca , Glicksman Arvin S. , Cummings Frank J. , Goldberg Richard J. , Fretwell Marsha D.
Published: April 2015

We examined the relationship between age and extent of disease at initial diagnosis as part of a population‐based, prospective study documenting the patterns of care received by over 1500 newly diagnosed lung, breast, and colorectal cancer patients identified in nine Rhode Island hospitals. For each cancer site examined, no age by extent of disease relationship was observed; however, analysis by sex among lung cancer patients indicated an inverse age relationship for men. The absence of an age effect for breast cancer patients is in contrast to earlier research findings that identify a positive association between extent of disease and age at diagnosis. Past results may reflect age‐related differences in patient and physician screening behavior characteristic of earlier time periods.
Effects of Iodinated Glycerol on Thyroid Function Studies in Elderly Nursing Home Residents
Authors: Drinka Paul J. , Nolten Wolfram E.
Published: April 2015

Iodinated glycerol is used as a mucolytic expectorant in the treatment of respiratory disorders. Iodine can inhibit the biosynthesis of thyroid hormone and induce hypothyroidism, particularly in patients with a history of thyroid disease. Such effects have not been reported in individuals without known thyroid disease who are being treated with organically bound iodine in the form of iodinated glycerol. In the course of a thyroid screening program for nursing home residents, eight subjects were identified who were being treated with iodinated glycerol.

Five of these were found to have thyrotropin elevations; one showed a low serum thyroxine level and a decreased free thyroxine index. None of these residents had a history of thyroid disease. Abnormalities of thyroid function improved or resolved after discontinuation of therapy. Elderly nursing home residents without known thyroid disease are at risk of thyroid suppression when given iodinated glycerol.
Colorectal Cancer Detection With the 60 cm Flexible Sigmoidoscope in a Solo General Internist's Office
Authors: Yao Yulin
Published: April 2015

Emphasis is placed on the importance of early detection of colorectal cancer by the primary care physician using the 60 cm flexible sigmoidoscope. A training format for this procedure is proposed. The author, trained according to this format, found 49 polyps and three carcinomas among his first 365 randomly chosen patients. Of these 317 (87%) were asymptomatic, having no risk factors. The average distance of insertion was 53 cm and the average examination time was 20 minutes. The calculated cost for these 365 patients was approximately $60,000, and the estimated average cost for a potentially curable colorectal cancer detection was approximately $20,000. Although a relatively long examination time may be necessary for the beginner, the author concludes that the primary care physician can be readily trained to handle the 60 cm flexible sigmoidoscope safely and cost effectively.
Urinary Incontinence in a Community‐residing Elderly Population
Authors: Teasdale Thomas A. , Taffet George E. , Luchi Robert J. , Adam Erwin
Published: April 2015

A self‐administered postal questionnaire was presented to all attending members (843) of local summer meetings of a national association for retired persons. A 71% response rate (599) revealed that 33% of the total sample population experienced some form of urinary incontinence. Twenty‐three and seven‐tenths percent (142) experienced occasional urine dribbling, 2.3% (14) were unable to prevent involuntary emptying of their bladder, and 7.3% (44) suffered both problems. Eighty‐three percent of the respondents were between the ages of 65 and 85 years. Females accounted for 75% of all respondents. Respondents 75 years of age or older had a higher occurrence of all forms of urinary incontinence (P = .057), and a strong association existed with the same age‐group and uncontrolled emptying of the bladder (P = .02). Thirty‐seven percent of the females and 22% of the males reported having had an incontinent episode (P = .002). High parity (four or more births) was significantly associated with incontinence in females (P = .04). These survey findings provide prevalence estimates of urinary incontinence that are greater than those previously reported and show statistical differences by age and gender. The study population is not representative of all the noninstitutionalized elderly, but consists primarily of individuals who are active, ambulatory, generally healthy and may underestimate the magnitude of the problem. Urinary incontinence is substantiated as a major health problem in even the most functional community‐residing elderly citizens.
Self‐Rated Depression Scales and Screening for Major Depression in the Older Hospitalized Patient with Medical Illness
Authors: Koenig Harold G. , Meador Keith G. , Cohen Harvey J. , Blazer Dan G.
Published: April 2015

Until now, no self‐rated depression scale had been validated as a screening measure for major depression in the older patient hospitalized with medical illness. The present report establishes the validity of two brief, easily administered depression screening tests, the Geriatric Depression Scale (GDS) and the Brief Carroll Depression Rating Scale (BCDRS), in this population. Structured psychiatric interviews were performed and self‐rated depression measures administered to 128 men, aged 70 and over, consecutively admitted to medical and neurological services of a VA hospital. The GDS and BCDRS were both shown to have high sensitivity and specificity for detecting major depression in this setting. Optimal cut‐off scores determined by the receiver operating curve characteristics of these tests were 11 for the GDS and 6 for the BCDRS. At a cutoff score of 11, the GDS had a sensitivity of 92%, a specificity of 89%, and a negative predictive value of 99%; lowering the break point to 8 did not increase sensitivity. At a cutoff score of 6, the BCDRS achieved a 100% sensitivity, 93% specificity, and 100% negative predictive value. Whether clinicians decide to implement either of these depression screens in their practice will depend to a large degree on the importance ascribed to the detection of these disorders and on attitudes toward the benefits of treatment.
The Incidence of Perioperative Myocardial Infarction with Transurethral Resection of the Prostate
Authors: Ashton Carol M. , Lahart Christopher J. , Wray Nelda P.
Published: April 2015

We performed a prospective study of 250 men undergoing transurethral resection of the prostate to determine the incidence of perioperative myocardial infarction. The prevalence of coronary artery disease in the study group was 27%. Patients had measurement of total creatine kinase and its MB isoenzyme and electrocardiography preoperatively and on the first three postoperative days. Only one myocardial infarction was diagnosed, an incidence rate of 0.4%. The overall rate of serious postoperative complications was 3.6%. No deaths occurred during the operative hospitalization. We conclude that with transurethral resection perioperative myocardial infarction is a rare event despite the high prevalence of coronary artery disease in this surgical population. Routine postoperative surveillance with electrocardiograms and creatine kinase determinations in asymptomatic patients is not warranted.
Clinical Funding for Geriatric Fellowship Programs
Authors: Pawlson L. Gregory
Published: April 2015

The Medicare program provides the largest single source of funding for the clinical portion of housestaff training programs. Despite the fact that the clinical training in geriatric fellowship programs focuses heavily on the care of Medicare recipients, the proportion of funds supporting geriatric fellowships that is derived from Medicare is actually smaller than that of most other fellowship programs. Legislation passed by Congress in 1986, and just recently implemented, creates an opportunity to increase Medicare funding for geriatrics. Those concerned with geriatric fellowship training must have a clear understanding of how Medicare funding for graduate medical education will occur under the new legislation if the opportunity is to be used effectively. Finally, other barriers created by general pressures on housestaff budgets that may interfere with capitalizing on the opportunity are discussed.
The Yield of a Home Visit in the Assessment of Geriatric Patients
Authors: Ramsdell Joe W. , Swart Jo Anne , Jackson J. Edward , Renvall Marian
Published: April 2015

Elderly patients often have problems not easily detected during an office visit. We investigated the yield of a home visit by a geriatric nurse specialist as part of an interdisciplinary assessment process. Compared with the findings of an office‐based assessment by a general internist, the home visit resulted in up to four new problems (median = 2, mean = 1.7, 95% confidence interval = 1.5–1.8) and one to eight new recommendations (median = 4, mean = 3.6, 95% confidence interval = 3.4–3.9.) Twenty‐three percent of the problems could have resulted in death or significant morbidity. The most frequent problems related to psychobehavioral difficulties (23.1% of problems involving 38.3% of patients), safety (21.6% of problems involving 35.7% of patients), and caregiver related problems (20.4% of problems involving 33.8% of patients). The most common recommendations related to safety (30.7% of recommendations involving 81.8% of patients), caregiver well‐being (19.8% of recommendations involving 52.6% of patients), and social issues (12.7% involving 33.8% of patients). Baseline clinical information did not predict the yield of the home visit in this sample. We conclude that an in‐home assessment contributes unique and meaningful information to the geriatric assessment process.
Do Not Resuscitate Discussions in a Hospital‐Based Home Care Program
Authors: Havlir Diane , Brown Louise , Rousseau G. Kay
Published: April 2015

Discussion of code status of a patient is usually raised in the inpatient setting, when patients are unable to participate because of their critical condition. In order to increase patient participation, code status was discussed in the homes of 37 chronically ill patients enrolled in a hospital‐based home care program. Twenty patients or conservators did not want resuscitation performed in case of cardiac arrest. In this small, select group, outpatient code discussions benefited the patients, families, and health care providers.