bluuebunny/crossref_metadata_2025 huggingface dataset:
Underutilization of Measurement of Serum Low‐Density Lipoprotein Cholesterol Levels and of Lipid‐Lowering Therapy in Older Patients with Manifest Atherosclerotic Disease
Authors: Mendelson Gad , Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of measurement of serum lipids and of utilizing lipid‐lowering therapy, when appropriate, in older persons without contraindications to lipid‐lowering drugs and with myocardial infarction (MI), stroke, peripheral arterial disease (PAD), and no coronary artery disease (CAD), stroke, or PAD.

DESIGN: A retrospective analysis of charts of all older patients seen from January 1, 1997, through October 15, 1997, was performed to investigate the prevalence of measurement of serum lipids and utilization of lipid‐lowering therapy, when appropriate, in older persons without contraindications to lipid‐lowering drugs and with MI, stroke, PAD, and no CAD, stroke, or PAD. Patients with life‐limiting comorbidities were not included in the study.

SETTING: An academic, hospital‐based geriatrics practice staffed by fellows in a geriatrics training program and full‐time faculty geriatricians.

PARTICIPANTS: A total of 373 men and 1119 women, mean age 80 ± 8 years (range 59 to 103 years), were included in the study.

MEASUREMENTS AND MAIN RESULTS: Serum low‐density lipoprotein (LDL) cholesterol was measured in 201 of 391 patients (51%) with MI, in 78 of 187 patients (42%) with stroke, in 58 of 115 patients (50%) with PAD, and in 396 of 926 patients (43%) with no CAD, stroke, or PAD. In patients with elevated serum LDL cholesterol levels, lipid‐lowering drug therapy was given to eight of 15 patients (53%) <70 years of age with MI, to 34 of 63 patients (54%) 70 to 80 years of age with MI, and to 38 of 81 patients (47%) > 80 years of age with MI (P not significant); to three of seven patients (43%) <70 years of age with stroke, to 12 of 26 patients (46%) 70 to 80 years of age with stroke, and to 13 of 32 patients (41 %) >80 years of age with stroke (P not significant); to two of four patients (50%) <70 years of age with PAD, to seven of 17 patients (41%) 70 to 80 years of age with PAD, and to 10 of 25 patients (40%) >80 years of age with PAD (P not significant); and to six of 15 patients (40%) <70 years of age with no CAD, stroke, or PAD, to 26 of 70 patients (37%) 70 to 80 years of age with no CAD, stroke or PAD, and to 14 of 47 patients (30%) >80 years of age with no CAD, stroke, or PAD (P not significant). None of the other patients with MI, stroke, PAD, or no CAD, stroke, or PAD was treated with diet or lipid‐lowering drugs.

CONCLUSIONS: Measurement of serum LDL cholesterol and of appropriate use of lipid‐lowering drugs and diet in older patients with MI, stroke, PAD, and no CAD, stroke, or PAD is underutilized in an academic, hospital‐based geriatrics practice.
GERIATRICS IN MANAGED CARE
Authors: Brummel‐Smith Kenneth , Joseph Abe , Boult Chad
Published: April 2015

OBJECTIVE: To measure the rates of hospital use and mortality of nursing homes residents who received their primary care from nurse practitioner‐physician teams.

DESIGN: A cohort study.

SETTING: Thirty nursing homes in Southern California.

PATIENTS: Older, long‐term residents of nursing homes enrolled in a Medicare HMO (n = 307).

INTERVENTION: Primary care by an accessible interdisciplinary team supported by clinical guidelines, continuous quality improvement techniques, and increased availability of clinical services at the nursing homes.

RESULTS: The residents (mean age 83.5 years, 69.0% women) had a high prevalence of dementia (83.5%) and functional disability (87.2% were dependent in two or more activities of daily living). About half (50.8%) expressed a preference for “no hospitalization and no resuscitation.” Compared with other nursing homes populations, this cohort experienced a lower annual rate of hospital use (518 days/1000 residents) and a similar rate of mortality (23.8%).

CONCLUSIONS: Integration of the efforts of physicians, nurse practitioners, and nursing home staff can lead to low rates of hospital use by nursing home residents. The effects on residents' quality of life and mortality require further study.
Correlates and Management of Nonmalignant Pain in the Nursing Home
Authors: Won Aida , Lapane Kate , Gambassi Giovanni , Bernabei Roberto , Mor Vince , Lipsitz Lewis A. ,   on behalf of the SAGE Study Group
Published: April 2015

OBJECTIVE

Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home.

DESIGN

A cross‐sectional study.

SETTING

Nursing Home in four US states.

PARTICIPANTS

A total of 49,971 nursing home residents from 1992 to 1995.

MEASUREMENTS

We used the SAGE database (Systematic Assessment of Geriatric drug use via Epidemiology), which linked information from the Minimum Data Set and nursing home drug utilization data. The MDS items measured included pain, activities of daily living (ADL) function, mood, and time involved in activities. The use of analgesics, anxiolytics, and antidepressants was also documented.

RESULTS

Daily pain was reported in 26% of nursing home residents. The prevalence was lower among men, persons more than age 85, and racial minorities. Persons suffering pain daily were more likely to have severe ADL impairment, odds ratio (OR) (2.47 (95% CI, 2.34–2.60)), more depressive signs and symptoms (OR 1.66 (95% CI, 1.57–1.75)), and less frequent involvement in activities (OR 1.35 (95% CI, 1.29–1.40)). Approximately 25% of persons with daily pain received no analgesics. Residents who were more than 85 years old (OR 1.15 (95% CI 1.02–1.28)), cognitively impaired, (OR 1.44 (95% CI, 1.29–1.61)), of male gender (OR 1.17 (95% CI, 1.06–1.29)), or a racial minority (OR 1.69 (95% CI, 1.40–2.05) and OR 1.56 (95% CI, 0.70–1.04) for blacks and Hispanics, respectively) were at greater risk of not receiving analgesics. Approximately 50% of those in pain used physical and occupational therapies, which was more than two times higher (OR 2.44 (95% CI, 2.34–2.54)), than use for those not in pain.

CONCLUSIONS

Daily nonmalignant pain is prevalent among nursing home residents and is often associated with impairments in ADL, mood, and decreased activity involvement. Even when pain was recognized, men, racial minorities, and cognitively impaired residents were at increased risk for undertreatment. More education and research is necessary to improve the recognition and management of pain in the nursing home, remembering that attention should be paid to populations at increased risk for underrecognition and undertreatment.
Platelet Hyperactivity in Hypertensive Older Patients Is Controlled by Lowering Blood Pressure
Authors: Riondino Silvia , Pignatelli Pasquale , Pulcinelli Fabio M. , Lenti Luisa , Veroli Claudio Di , Marigliano Vincenzo , Gazzaniga Pier Paolo
Published: April 2015

OBJECTIVE

Patients with hypertension tend to have a high prevalence of atherothrombotic accidents. Platelet hyperactivity is frequently associated with hypertension. Because the vascular disease associated with hypertension evolves over the years, we investigated platelet activity parameters in a population of older hypertensive patients with no other risk factors for cardiovascular disease.

PARTICIPANTS

We studied 34 older, nonsmoking patients (mean age 74 ± 5 years) with uncomplicated hypertension before and after the normalization of blood pressure (BP) was achieved with the angiotensin‐converting enzyme inhibitor quinapril alone or in combination with the Ca2+ antagonist nifedipine.

MEASUREMENTS

Platelet aggregation, P‐selectin (CD62) expression on the platelet surface, serum levels of Interleukin‐1β (IL‐1β) and of Interleukin‐6 (IL‐6), as well as plasma levels of soluble P‐selectin and Endothelin‐1 (ET‐1), were analyzed.

RESULTS

All platelet hyperactivity parameters were reduced significantly with the normalization of BP at the end of antihypertensive drug treatment (systolic/diastolic: 186.2 ± 2.7/103.4 ± 1.1 mm Hg vs 135.0 ± 1.3/85.9 ± 1.9 mm Hg; P < .001). Those factors more strictly associated with endothelium injury, such as ET‐1 and IL‐6, did not show variations. A significant correlation (Spearman Rank test) was observed among all platelet function parameters and blood pressure values.

CONCLUSIONS

This study demonstrated that even in a population of older hypertensive patients with no other risk factor for atherogenic disease, normalization of blood pressure induces a significant reduction of the parameters of enhanced platelet hyperactivity independent of the action exerted, at the platelet level, by the antihypertensive drugs.
Inappropriate Medication Prescribing in Homebound Older Adults
Authors: Golden Adam G. , Preston Richard A. , Barnett Scott D. , Llorente Maria , Hamdan Kamal , Silverman Michael A.
Published: April 2015

OBJECTIVES

Little is known about the prescribing of medications in the growing population of homebound older adults. We report on the prevalence and pattern of inappropriate medications in a nursing home‐eligible, homebound population.

DESIGN

A cross‐sectional design.

SETTING

A managed care plan for individuals meeting nursing home eligibility.

PARTICIPANTS

2193 homebound people older than age 60.

MEASUREMENTS

We reviewed the pharmacy profiles of all older homebound enrollees. We identified the average number of medications per patient and the most commonly prescribed classes of drugs. The medication profiles were also analyzed in the context of the 26 drugs/groups listed as inappropriate by the explicit criteria of Beers [Arch Intern Med 1997; 157:1531–1536].

RESULTS

A total of 2193 people aged 60 to 106 (mean 82.8 ± 8.8) were taking an average of 5.3 ± 2.9 drugs (range 0–22). Cardiac drugs and benzodiazepines were the medications most commonly prescribed. We found 1152 of the total 11,689 prescriptions (9.9%) to be inappropriate. Eight hundred seventy‐one (39.7%) of these 2193 residents had at least one inappropriate prescription, and 230 (10.4%) had two or more. Of particular concern were 285 people prescribed excessive doses of temazepam and zoldipem, 211 people taking first‐generation antihistamines, 115 taking doxepin or amitriptyline, 106 taking an ergoloid, 98 taking dipyridamole, and 85 prescribed a long‐acting benzodiazepine.

CONCLUSIONS

Our study revealed a high prevalence of psychotropic medications and inappropriate drug use among older homebound residents, a group that is at the highest risk for adverse drug reactions. Because this group is not subject to oversight by regulatory agencies, further interventional studies and provider education will be important.
Age‐ and Gender‐Related Use of Low‐Dose Drug Therapy: The Need to Manufacture Low‐Dose Therapy and Evaluate the Minimum Effective Dose
Authors: Rochon Paula A. , Anderson Geoffrey M. , Tu Jack V. , Gurwitz Jerry H. , Clark Jocalyn P. , Shear Neil H. , Lau Paula
Published: April 2015

OBJECTIVES

Low‐dose drug therapy is promoted as a way to maximize benefit and minimize adverse drug effects when prescribing for older adults. This population‐based study evaluates the age and sex‐related use of two common therapies: thiazide diuretics, where evidence supports the use of low‐dose therapy, and beta‐blockers, where trials have not evaluated the minimum effective dose.

DESIGN

Using linked administrative databases we identified all of the 120,613 persons dispensed a thiazide diuretic therapy and 12,908 myocardial infarction survivors dispensed beta‐blocker therapy in Canada's largest province. We used logistic regression models to study the association of age and sex with dispensing of low‐dose thiazide diuretic and beta‐blocker therapy at doses lower than evaluated in trials.

RESULTS

Of 120,613 older people dispensed a thiazide diuretic, 32,372 (26.8%) were dispensed a low dose. Patients 85 years of age or older, relative to the youngest group, were 30% more likely to be dispensed low‐dose therapy (OR=1.31; 95% CI, 1.27 to 1.36; P < .001). Women were 8% more likely than men to be dispensed a low‐dose thiazide diuretic (OR=1.08; 95% CI, 1.05 to 1.11; P < .001).

Of 10,991 myocardial infarction survivors dispensed atenolol, metoprolol, propranolol, or timolol, 9458 (86.1%) were dispensed a lower‐than‐evaluated dose. Patients 85 years of age or older, relative to those in the youngest group, were more than twice as likely to be dispensed a lower‐than‐evaluated beta‐blocker therapy dose (OR=2.28; 95% CI, 1.74 to 3.04; P < .001). No difference was noted in the use of beta‐blocker therapy dose by sex (OR=1.0; 95% CI, .89 to 1.15; P = .95).

CONCLUSIONS

Low‐dose thiazide diuretic therapy prescribed widely to older people, particularly those of advanced age and women. The vast majority of myocardial infarction survivors were dispensed beta‐blocker therapy at lower‐than‐evaluated doses. These findings highlight the need to manufacture low‐dose thiazide diuretic therapy and to evaluate the minimum effective dose of beta‐blocker therapy.
Postoperative Complications in Parkinson's Disease
Authors: Pepper Patricia Vold , Goldstein Mary Kane
Published: April 2015

BACKGROUND

Although Parkinson's disease is relatively common in America, with an average annual incidence of 20 cases per 100,000 population,1 little information exists about postoperative morbidity and mortality in those Parkinson's patients who undergo elective surgery.

METHODS

We performed a retrospective cohort study using the Veterans Affairs (VA) Austin database system (a cumulative index of admissions and discharges from all US VA Medical Centers) to identify 41,213 patients who underwent elective bowel resection, cholecystectomy, or radical prostatectomy between January 1, 1990, and December 31, 1995. We examined the study population using univariate analysis, acute length of stay with multivariate analysis, and postoperative complications with logistic regression.

RESULTS

The selected surgeries were performed on 234 patients with a diagnosis of Parkinson's disease and 40,979 with no such diagnosis. In univariate analysis, patients with Parkinson's disease had significantly longer acute hospital stays than non‐Parkinson's patients (11.4 ± 15.9 days vs 8.8 ± 9.0 days, P < .001). In addition, Parkinson's patients had a higher in‐hospital mortality than non‐Parkinson's patients (7.3% vs 3.8%, P = .006). After we adjusted for coexisting morbidity, age, admitting location, and gender, patients with Parkinson's disease had an average acute hospital stay 2.34 days longer than that of non‐Parkinson's patients (P < .001). However, the mortality difference did not reach statistical significance in multivariate analysis (P = .098). Finally, Parkinson's patients had significantly increased incidences of urinary‐tract infection (odds ratio 2.045, P < .001), aspiration pneumonia (odds ratio 3.825, P < .001), and bacterial infections (odds ratio 1.682, P < .001).

CONCLUSIONS

Patients with Parkinson's disease are at greater risk for specific complications and longer hospital stay after elective bowel resection, cholecystectomy, or radical prostatectomy. Awareness of these complications may help caregivers to reduce postoperative mortality and morbidity and to decrease the length of hospitalization.
Urge Incontinence: New Health‐Related Quality of Life Measures
Authors: Brown Jeanette S. , Posner Samuel F. , Stewart Anita L.
Published: April 2015

OBJECTIVES

To develop and evaluate the psychometric properties of two new urge incontinence‐specific instruments that measure quality of life and symptom annoyance.

DESIGN

New instruments were developed and validated in racially, ethnically, and age‐diverse community‐dwelling women with urge or mixed incontinence with a primary urge component.

MEASUREMENTS

A total of 83 women with a minimum of six urge losses per week were sequentially recruited. We began with the previously developed Incontinence Impact Questionnaire and Urogenital Distress Inventory and added information from focus groups, expert clinical opinion, and literature review. Final selection of questions was based on a combination of factor analysis, item‐scale analysis, and reliability of scales to identify the best performing questions from the preliminary instruments. Both convergent and divergent validity were evaluated using established health‐related quality of life measures, frequency of incontinence episodes, global ratings of interference with daily activities and effect on feelings, and overall severity.

RESULTS

Mean age of subjects was 63.8 years, 37% were non‐white, 23% had a high school education or less, and 24% had a household income of less than $10,000/year. Ten percent reported urge incontinence alone, with the remainder having mixed incontinence. Six domains were identified for the Urge‐IIQ and one domain for the Urge‐UDI. All domains had adequate reliability (Cronbach's alpha 0.74 ‐ 0.95) and test‐retest reliability (intraclass correlations ≥ 0.59).

CONCLUSIONS

The newly developed Urge‐Incontinence Impact Questionnaire and Urge‐Urinary Distress Inventory are reliable, and evidence of validity was found in a diverse population. These instruments are available for use in trials of new therapeutic interventions for urge incontinence.
Validity and Responsiveness of the Minimum Data Set
Authors: Snowden Mark , McCormick Wayne , Russo Joan , Srebnik Debra , Comtois Kate , Bowen Jim , Teri Linda , Larson Eric B.
Published: April 2015

OBJECTIVE

To determine the criterion validity and responsiveness to change over time of the Minimum Data Set (MDS).

DESIGN

Cross sectional analysis comparing prospectively collected research data with MDS data reported from nursing homes on identical subjects. Longitudinal follow‐up of subjects allowed for calculation of responsiveness to change over time.

PARTICIPANTS

Subjects (n = 140) participating in epidemiological research on the natural history of Alzheimer's disease in the University of Washington Group Health Cooperative Alzheimer's Disease Patient Registry (ADPR) who entered nursing homes in Washington State from January 1990 through March 1996.

MAIN OUTCOME MEASUREMENTS

Spearman's correlation coefficients to compare MDS cognitive performance scale scores with Mini‐Mental State Examinations (MMSE), MDS behavior domain scores with ADPR Physician Behavior checklist scores, and MDS activities of daily living (ADL) functioning scores with Dementia Rating Scale scores for ADLs. Partial correlations were used to control for the number of days between MDS and ADPR assessments, age, and function in the other two MDS ratings of ADL, cognition, or behavior. We determined responsiveness by using the mean change in an effect size (ES) calculation for each domain of interest.

RESULTS

MDS measures in all three domains were correlated modestly to the analogous ADPR research instruments, with correlation coefficients 0.45 for cognition, 0.50 for behavior, and 0.59 for ADL functioning. Controlling for age, time between ADPR and MDS assessments, and the MDS ratings of the other two MDS domains did not improve the correlations significantly. In a subgroup of 60 subjects followed for an average of 636 days, the Cognitive performance scale of the MDS had a slightly larger effect size (ES = 0.60) than the Folstein Mini‐Mental Status Exam (ES = 0.39) used by the ADPR. However, the Dementia Rating Scale (ES = 0.77) used by the ADPR researchers reflected more change over time than the ADL domain of the MDS (ES = 0.02). The MDS behavior domain (ES = 0.058) was comparable to the research behavior checklist (ES = 0.065).

CONCLUSIONS

These data demonstrate reasonable criterion validity of the MDS and the MMSE, ADL, and behavior rating scales and suggest that the MDS data is of adequate validity for research purposes in these areas. The MDS was less able to capture dementia‐related change in ADLs in this population of patients with dementia even though the same nursing home staff completing the MDS often supplied the information for completing the research scales. As a result, the MDS may be limited as an outcome assessment instrument.
The Relationship Between Body Composition and Physical Performance in Older Women
Authors: Zamboni Mauro , Turcato Emanuela , Santana Helena , Maggi Stefania , Harris Tamara B. , Pietrobelli Angelo , Heymsfield Steven B. , Micciolo Rocco , Bosello Ottavio
Published: April 2015

BACKGROUND: The relationship between age‐associated change in body composition and physical disability is still unknown. Skeletal muscle mass declines with age in both sexes; however, since women have less muscle mass per unit of weight than men, these changes may be more debilitating in women.

OBJECTIVE: To evaluate the relationship between body composition and physical performance.

DESIGN: A cross‐sectional study.

PARTICIPANTS: 144 women aged 68 to 75 were selected randomly from the general population of Verona.

MEASUREMENTS: Body composition was evaluated using dual energy X‐ray absorptiometry and bioimpedance. Physical performance was evaluated using a modified version of the Activities of Daily Living scale. Distance walked in 6 minutes was calculated, and isometric knee strength was tested.

RESULTS: Normal women had a significantly lower body mass index (BMI) and percent body fat. These women also had a higher ratio of body cell mass (BCM) and total fat free mass (FFM) than women with physical impairments. After adjusting for BMI, women in the lowest tertile of muscle strength had significantly lower BCM than those in the highest tertile.

CONCLUSIONS: These cross‐sectional data show that although muscle strength is related to fat‐free mass, disability in older women is associated with heavier BMI and with a higher percentage of body fat. J Am Geriatr Soc 47:1403–1408, 1999.
Urinary Catheters: What Type Do Men and Their Nurses Prefer?
Authors: Saint Sanjay , Lipsky Benjamin A. , Baker Paul D. , McDonald Linda L. , Ossenkop Kathleen
Published: April 2015

OBJECTIVES: Urinary catheters are used frequently, but the relative risks and benefits of different types of devices are not clear. We sought to determine the beliefs of both older male patients and nursing staff about the relative merits and problems of condom and indwelling catheters.

DESIGN: Patient and nurse survey using convenience sampling.

SETTING: A University‐affiliated Veterans Affairs medical center.

PARTICIPANTS: Men hospitalized on medical, rehabilitation and nursing home units using either an indwelling or a condom catheter were invited to participate as were all members of the nursing staff on these units. Of 116 eligible patients, 104 were interviewed (response rate = 90%). Of 107 eligible nursing staff members, 99 completed the questionnaires (response rate = 92%).

INTERVENTION AND MEASUREMENTS: Consenting patients were interviewed personally about their urinary catheter. The nursing staff were asked to complete a self‐administered questionnaire.

RESULTS: Patients were mostly older and predominantly hospitalized on the medical service. Compared with those using an indwelling catheter, patients using a condom catheter were more likely to believe that their catheter was comfortable (86 vs 58%, P = .04) and less likely to believe it was painful (14 vs 48%, P = .008) or to restrict their activity (24 vs 61%, P = .002). The nursing staff had a mean of 13 years nursing experience, and the majority worked in the nursing home unit. Most of the nursing staff respondents believed that condom catheters were less painful and restrictive for patients and were easier to apply, but they also believed that they fell off and leaked more often and required more nursing time.

CONCLUSIONS: Both patients and nursing staff prefer condom to indwelling catheters for patient comfort, but they recognize that dislodgment and leaking are major drawbacks of condom catheters. A more secure condom catheter would greatly improve the management of male incontinence. J Am Geriatr Soc 47:1453–1457, 1999.
Serum IL‐6 Level and the Development of Disability in Older Persons
Authors: Ferrucci Luigi , Harris Tamara B. , Guralnik Jack M. , Tracy Russell P. , Corti Maria‐Chiara , Cohen Harvey J. , Penninx Brenda , Pahor Marco , Wallace Robert , Havlik Richard J.
Published: April 2015

BACKGROUND: The serum concentration of interleukin 6 (IL‐6), a cytokine that plays a central role in inflammation, increases with age. Because inflammation is a component of many age‐associated chronic diseases, which often cause disability, high circulating levels of IL‐6 may contribute to functional decline in old age. We tested the hypothesis that high levels of IL‐6 predict future disability in older persons who are not disabled.

METHODS: Participants at the sixth annual follow‐up of the Iowa site of the Established Populations for Epidemiologic Studies of the Elderly aged 71 years or older were considered eligible for this study if they had no disability in regard to mobility or in selected activities of daily living (ADL), and they were re‐interviewed 4 years later. Incident cases of mobility‐disability and of ADL‐disability were identified based on responses at the follow‐up interview. Measures of IL‐6 were obtained from specimens collected at baseline from the 283 participants who developed any disability and from 350 participants selected randomly (46.9%) from those who continued to be non‐disabled.

FINDINGS: Participants in the highest IL‐6 tertile were 1.76 (95% CI, 1.17‐2.64) times more likely to develop at least mobility‐disability and 1.62 (95% CI, 1.02‐2.60) times more likely to develop mobility plus ADL‐disability compared with to the lowest IL‐6 tertile. The strength of this association was almost unchanged after adjusting for multiple confounders. The increased risk of mobility‐disability over the full spectrum of IL‐6 concentration was nonlinear, with the risk rising rapidly beyond plasma levels of 2.5 pg/mL.

INTERPRETATION: Higher circulating levels of IL‐6 predict disability onset in older persons. This may be attributable to a direct effect of IL‐6 on muscle atrophy and/or to the pathophysiologic role played by IL‐6 in specific diseases. J Am Geriatr Soc 47:639–646, 1999.
The Importance of Subsyndromal Depression in Older Primary Care Patients: Prevalence and Associated Functional Disability
Authors: Lyness Jeffrey M. , King Deborah A. , Cox Christopher , Yoediono Z. , Caine Eric D.
Published: April 2015

OBJECTIVE: Existing diagnostic categories for depression may not encompass the majority of older people suffering clinically significant depressive symptoms. We have described the prevalence of subsyndromal depressive symptoms and tested the hypothesis that patients with subsyndromal depression have greater functional disability and general medical burden than nondepressed subjects but less than patients with diagnosable depressions.

METHODS: Subjects were 224 patients, aged 60 years and older, recruited from private internal medicine offices or a family medicine clinic. Validated measures of psychopathology, medical burden, and functional status were used. The subsyndromal depression group was defined by a score of more than 10 on the Hamilton Rating Scale for Depression and by the absence of major or minor depressive disorder. Analyses included multiple regression techniques to determine the presence of group differences adjusted for demographic covariates.

RESULTS: Subsyndromal depression was common (estimated point prevalence of 9.9% compared with 6.5% for major depression, 5.2% for minor depression, and .9% for dysthymic disorder), associated with functional disability and medical comorbidity to a degree similar to major or minor depression, and often treated with antidepressant medications.

CONCLUSIONS: Although depressive conditions are common and are associated with considerable functional and medical morbidity in older primary care patients, many patients with clinically significant depressive symptoms are not captured by criteria‐based syndromic diagnostic categories. Future work should include intervention studies of subsyndromally depressed older persons as well as attention to the course and biopsychosocial concomitants of diagnosable and subsyndromal depressions in this population. J Am Geriatr Soc 47:647–652, 1999.
Effects of Shoe Collar Height and Sole Hardness on Balance in Older Women
Authors: Lord Stephen R. , Bashford Guy M. , Howland Amelia , Munroe Bridget J.
Published: April 2015

OBJECTIVE: To determine whether shoe collar height and sole hardness affect balance in older women.

DESIGN: A randomized order, cross‐over, controlled comparison.

SETTING: Intermediate care institution and regional hospital.

PARTICIPANTS: Forty‐two women aged 60 to 92 years (mean 76, SD = 9.03). The sample comprised 15 hostel (intermediate care) residents, 11 women who lived in a retirement village, and 16 women who lived independently in the community.

OUTCOME MEASURES: Postural sway, maximal balance range and coordinated stability.

MAIN RESULTS: The subjects underwent assessments of static balance (body sway) and dynamic balance (maximal balance range and coordinated stability) under five conditions: (1) in soft‐soled bowls shoes, (2) in hard‐soled bowls shoes, (3) in college‐style shoes, (4) in college‐style shoes with a high (boot) collar, and (5) barefoot. MANOVA analysis indicated that subjects were more stable when wearing the high collar shoes than when wearing the college shoes (P < .001) or when barefoot (P < .05). In contrast, subjects performed similarly in the balance tests in the soft and hard‐soled shoes (P = .30) and no better than when barefoot (P = .12 and P = .93, respectively).

CONCLUSIONS: The findings indicate that subjects had better balance when wearing shoes with high collars than when wearing shoes with low collars and that sole hardness was not related to balance. J Am Geriatr Soc 47:681–684, 1999.
Endogenous Levels of Dehydroepiandrosterone Sulfate, but Not Other Sex Hormones, Are Associated with Depressed Mood in Older Women: The Rancho Bernardo Study
Authors: Barrett‐Connor Elizabeth , von Mühlen Denise , Laughlin Gail A. , Kripke Adrianna
Published: April 2015

OBJECTIVE: The purpose of this study was to determine whether endogenous steroid hormone levels are associated with depressed mood in community‐dwelling older women.

DESIGN: A cross‐sectional population‐based study.

SETTING: Rancho Bernardo, California

PARTICIPANTS: A total of 699 non‐estrogen using, community‐dwelling, postmenopausal women (aged 50 to 90 years) from the Rancho Bernardo cohort who were screened for depressed mood and had plasma obtained for steroid hormone assays in 1984–1987.

MEASUREMENTS: Plasma levels of total and bioavailable (non‐SHBG‐bound) estradiol and testosterone, estrone, androstenedione, cortisol, dehydroepiandrosterone, and (DHEA) and its sulfate (DHEAS) were measured by radioimmunoassay. Mood and depression were assessed using the Beck Depression Inventory.

RESULTS: Only DHEAS levels were significantly and inversely associated with depressed mood, and the association was independent of age, physical activity, and weight change (P = .0002). Age, sedentary lifestyle, and weight loss were positively associated with depressed mood. Alcohol intake, cigarette smoking, marital status, type of menopause, and season of testing were unassociated with depressed mood. A subset of 31 women with categorically defined depression had lower DHEAS levels compared with 93 age‐matched nondepressed women (1.17 ± 1.08 vs 1.57 ± .98 μmol/L; P = .01).

CONCLUSIONS: These results add to the evidence that DHEA/S is a neuroactive steroid and point to the need for careful long‐term clinical trials of DHEA therapy in older women with depressed mood. J Am Geriatr Soc 47:685–691, 1999.
Geriatric Syndromes as Outcome Measures of Hospital Care: Can Administrative Data Be Used?
Authors: Berlowitz Dan R. , Brand Harriet K. , Perkins Cynthia
Published: April 2015

OBJECTIVE: To determine how often hospital administrative databases capture the occurrence of two common geriatric syndromes, pressure ulcers and incontinence.

DESIGN: Retrospective comparison of a nursing home and hospital database.

SETTING: Department of Veterans Affairs (VA) hospitals.

PARTICIPANTS: All patients between 1992 and 1996 discharged from VA acute medical care and admitted to a VA nursing home.

MEASUREMENTS: The presence of incontinence or a pressure ulcer (stage 2 or larger) on admission to the nursing home was determined. Hospital discharge diagnoses were then reviewed to determine whether these conditions were recorded. The effect of ulcer stage, total number of discharge diagnoses, and temporal trends on the recording of these conditions in discharge diagnoses was also noted.

RESULTS: There were 17,004 admissions to nursing homes from acute care in 1996; 12.7% had a pressure ulcer and 43.4% were incontinent. Among these patients with a pressure ulcer, the hospital discharge diagnosis listed an ulcer in 30.8% of cases, and incontinence was included correctly as a discharge diagnosis in 3.4%. While deeper pressure ulcers were more likely to be recorded than superficial ulcers (P < .01), nearly 50% of stage 4 ulcers were not listed among hospital discharge diagnoses. Patients with more discharge diagnoses were more likely to record both conditions correctly. From 1992 to 1996, small but significant (P = .001) improvements were noted in the correct recording of these geriatric syndromes as discharge diagnoses.

CONCLUSIONS: The occurrence of pressure ulcers and incontinence cannot be determined from hospital administrative databases and should not be used as outcomes when measuring quality of care among hospitalized patients. J Am Geriatr Soc 47:692–696, 1999.
Home Hospital Program: A Pilot Study
Authors: Leff Bruce , Burton Lynda , Guido Susan , Greenough William B. , Steinwachs Donald , Burton John R.
Published: April 2015

OBJECTIVE: To evaluate the basic safety and feasibility of hospital care at home (Home Hospital (HH)) for treating acutely ill older persons requiring hospitalization.

DESIGN: Prospective case series

SETTINGS AND PARTICIPANTS: Community‐dwelling persons aged 65 and older requiring acute hospital admission for community‐acquired pneumonia, chronic heart failure, chronic obstructive airways disease, or cellulitis.

RESULTS: Seventeen subjects were treated in HH. One hundred twenty‐two could not be enrolled because they presented for admission at times when HH was not operational. Six patients refused to enroll in HH. Subjects treated in HH had comparable clinical outcomes to those treated in the acute hospital and were highly satisfied with HH. Charges for HH care were 60% of those for the acute hospital care.

CONCLUSIONS: In this pilot study, HH was safe, feasible, highly satisfactory, and cost‐effective for certain acutely ill older persons who required acute hospitalization. J Am Geriatr Soc 47:697–702, 1999.
Definition of Race and Ethnicity in Older People in Medicare and Medicaid
Authors: Pan Cynthia X. , Glynn Robert J. , Mogun Helen , Choodnovskiy Igor , Avorn Jerry
Published: April 2015

BACKGROUND: Race and ethnicity are important predictors of health care access and outcomes, but quality of their documentation in the healthcare system is often problematic.

OBJECTIVES: To study the agreement between Medicare and Medicaid descriptions of race and ethnicity in older beneficiaries.

DESIGN: Quasiexperimental design in a natural practice setting.

SETTING: New Jersey.

PARTICIPANTS: 153,241 dually enrolled participants in Medicare and Medicaid.

MEASUREMENTS: Agreement rates between administrative databases on recipients' race and ethnicity.

RESULTS: Agreement between Medicare and Medicaid on the recipients' race and ethnicity was modest (kappa = .58; 95% CI, .57‐.58) for men and women alike and across different age groups. Depending on whether Medicare or Medicaid was used as the reference standard, the relative agreement rates for race and ethnic group assignments varied. For example, using Medicare as the reference, the relative agreement rate was 84% for whites, 74% for blacks, 61 % for others, 23% for Hispanics, and only 5% for Asians. Using Medicaid as the reference, a different pattern emerged. However, such gradients of agreement rates across racial groups were observed in both programs. Medicare and Medicaid reported different percentages of all race and ethnicity groups, with Medicaid reporting greater proportions of White and Black beneficiaries, and Medicare reporting greater proportions of Hispanic, Asian, and Other groups.

CONCLUSIONS: Depiction of race and ethnicity data in large government health insurance programs is approximate at best and often contradictory from one program to another. This can impede efforts to study the relationship between these important characteristics and health care utilization and outcomes. J Am Geriatr Soc 47:730–733, 1999.
Drugs and Falls in Older People: A Systematic Review and Meta‐analysis: I. Psychotropic Drugs
Authors: Leipzig Rosanne M. , Cumming Robert G. , Tinetti Mary E.
Published: April 2015

OBJECTIVES: To evaluate critically the evidence linking psychotropic drugs with falls in older people.

DESIGN: Fixed‐effects meta‐analysis.

DATA SOURCES: English‐language articles in MEDLINE (1966 – March 1996) indexed under accidents or accidental falls and aged or age factors; bibliographies of retrieved papers.

STUDY SELECTION: Systematic evaluation of sedative/hypnotic, antidepressant, or neuroleptic use with falling in people aged 60 and older.

DATA EXTRACTION: Study design, inclusion and exclusion criteria, setting, sample size, response rate, mean age, method of medication verification and fall assessment, fall definition, and the number of fallers and non‐fallers taking specific classes of psychotropic drugs.

RESULTS: Forty studies, none randomized controlled trials, met eligibility criteria. For one or more falls, the pooled odds ratio (95% confidence interval) was 1.73 (95%CI, 1.52‐1.97) for any psychotropic use; 1.50 (95%CI, 1.25‐1.79) for neuroleptic use; 1.54 (95%CI, 1.40‐1.70) for sedative/hypnotic use; 1.66 (95%CI, 1.4‐1.95) for any antidepressant use (mainly TCAs); 1.51 (95%CI, 1.14‐2.00) for only TCA use; and 1.48 (95%CI, 1.23‐1.77) for benzodiazepine use, with no difference between short and long acting benzodiazepines. For neuroleptics in psychiatric inpatients, the pooled OR was 0.41 (95%CI, 0.21‐.82); for all other patients, the pooled OR was 1.66 (95%CI, 1.38‐2.00). Comparing ≥1 with ≥ 2 falls, mean subject age >75 versus ≥ 75 years old, communities with >35% versus ≥35% fallers, or subject place of residence did not affect the pooled OR. Increased falls occurred in patients taking more than one psychotropic drug.

CONCLUSION: There is a small, but consistent, association between the use of most classes of psychotropic drugs and falls. The evidence to date, however, is based solely on observational data, with minimal adjustment for confounders, dosage, or duration of therapy. The incidence of falls and their consequences in this population necessitate that future large randomized controlled trials of any medication in older persons should measure falls prospectively as an adverse outcome event.
Mismatches Between the Home Environment and Physical Capabilities Among Community‐Living Older Persons
Authors: Gill Thomas M , Robison Julie T. , Williams Christianna S. , Tinetti Mary E.
Published: April 2015

OBJECTIVE: To determine whether environmental hazards related to transfers, balance, and gait are any less prevalent in the homes of older persons with specific deficits in physical capabilities than they are in the homes of older persons without the same deficits.

DESIGN: Cross‐sectional study of a population‐based cohort.

SETTING: The general community in New Haven, Connecticut.

PARTICIPANTS: A total of 1088 persons, aged 72 years and older, who had an environmental assessment of their homes.

MEASUREMENTS: Each participant underwent a physical performance assessment and comprehensive interview to document the presence of underlying deficits in physical capabilities. Items from the environmental assessment that were potentially hazardous for participants with specific deficits in transfers, balance, or gait were identified.

RESULTS: With the exception of no grab bars in the tub/shower, environmental hazards were as prevalent in the homes of participants with specific deficits in physical capabilities as they were in the homes of participants without the same deficits, and, in many cases, they were actually more prevalent. Among participants with and without observed difficulty standing from a chair, for example, the prevalence of a low lying chair was 24% versus 14% (x2 = 13.4; P < .001), respectively. Among participants with and without an observed deficit in turning, the prevalence of an obstructed pathway was 47% versus 37% (x2 = 8.7; P = .003), respectively; and the prevalence of loose throw rugs was 72% in both groups.

CONCLUSIONS: If the epidemiologic link between environmental hazards and adverse functional outcomes can be strengthened, then interventions designed to enhance the everyday function of frail, older persons should focus on the environment as well as the individual.
Estrogen Replacement Therapy and Cognitive Decline in Older Community Women
Authors: Matthews Karen , Cauley Jane , Yaffe Kristine , Zmuda Joseph M.
Published: April 2015

BACKGROUND: The purpose of this study was to evaluate the cross‐sectional and longitudinal association of oral estrogen replacement therapy (ERT) and cognitive function in an older, nondemented sample of women.

METHODS: In a prospective cohort of 9651 white women aged 65 years and older enrolled in the Study of Osteoporotic Fractures, a modified Mini‐Mental Status Exam (mMMSE), and digit symbol substitution and Trails B tests were administered twice, 4 to 6 years apart. History and current use of oral ERT was documented. Age, educational attainment, and activity limitations were the primary covariates in the analyses; in addition, stroke and depression scores were adjusted in subsets of women with available data.

RESULTS: Current and past users of ERT had better initial scores on the mMMSE than did never users, P < .05 and .001, respectively, with better scores for current estrogen hormone users being most apparent among the older and less educated women. The percentages of women scoring ≤23 of a possible 26 on the mMMSE were 14.3 for current users, 14.5 for past users, and 20.5 for never users, P < .001. However, only past users exhibited smaller declines upon retesting in mMMSE and Trails B performance, P < .05, than did never users. Educational attainment predicted both initial test scores and change scores and was, next to age, the most powerful predictor of cognitive function.

CONCLUSIONS: Current oral ERT does not protect against age‐related declines in cognitive function in older nondemented women, whereas formal education does protect, even though it had been completed many years earlier. The influence of education in late‐life on cognitive function should be tested. J Am Geriatr Soc 47:518–523, 1999.
Associations of Symptoms of Sleep Apnea with Cardiovascular Disease, Cognitive Impairment, and Mortality Among Older Japanese‐American Men
Authors: Foley Daniel J. , Monjan Andrew A. , Masaki Kamal H. , Enright Paul L. , Quan Stuart F. , White Lon R.
Published: April 2015

OBJECTIVES: To examine the association between symptoms of sleep apnea and prevalent cardiovascular disease, cognitive impairment, and subsequent 3‐year mortality.

DESIGN: A longitudinal study.

SETTING: Participants lived in the community on Oahu, Hawaii

PARTICIPANTS: A total of 2905 older Japanese‐American men participating in the fourth examination of the Honolulu Heart Program cohort study from 1991–1993, which is the baseline for the Honolulu‐Asia Aging Study of dementia.

MEASUREMENTS: Self‐reported snoring, daytime sleepiness, and breathing pauses; diagnosed cardiovascular disease and dementia; cognitive functioning and vital status approximately 3 years later.

RESULTS: More than 12% of the participants reported that they often or always snored loudly, and 8% reported being sleepy most of the day. Fewer than 2% reported that they stop breathing when sleeping, and this was found more frequently among habitual snorers (7%, P < .001) and those sleepy during the day (5%, P < .001). The prevalence of habitual snoring declined in the older age groups, was higher among those with greater Body Mass Index scores, and was not associated with the reporting of daytime sleepiness, diagnosis of heart disease, stroke, dementia, or cognitive impairment. Daytime sleepiness was more prevalent at older ages and was associated with a higher prevalence of heart disease and with cognitive impairment and dementia, chronic obstructive pulmonary disease, and diabetes. Self‐reported apnea was associated only with a history of pneumonia. Three‐year mortality was not associated with these symptoms after adjusting for prevalent heart disease and cognitive impairment.

CONCLUSION: Symptoms of sleep apnea are reported less frequently in older Japanese‐American men. Excessive day‐time sleepiness is associated with poor cognition and dementia, but whether it also is an indicator for sleep apnea in this age group remains unclear. Epidemiologic studies of sleep apnea in older adults will require polysomnography to determine accurately the correlates and consequences of this condition. J Am Geriatr Soc 47:524–528, 1999.
Two Nursing Home Outbreaks of Respiratory Infection with Legionella sainthelensi
Authors: Loeb Mark , Simor Andrew E. , Mandell Lionel , Krueger Paul , McArthur Margaret , James Marilyn , Walter Stephen , Richardson Elizabeth , Lingley Michael , Stout Janet , Stronach David , McGeer Allison
Published: April 2015

OBJECTIVE: To describe outbreaks of infection caused by Legionella sainthelensi occurring in older residents of two nursing homes and to determine risk factors for the development of infection.

DESIGN: Descriptive epidemiology and a case‐control study.

SETTING: Two nursing homes (140 beds and 254 beds in nursing homes A and B, respectively) located in southern Ontario, Canada, experiencing outbreaks of respiratory tract infection in July and August 1994.

SUBJECTS: Case‐residents of the two nursing homes who met clinical and laboratory criteria for Legionella infection. Control‐residents were defined as those who were in the homes during the outbreaks and were asymptomatic.

MEASUREMENTS: Active surveillance was conducted in both nursing homes to identify symptomatic residents. Residents with fever or respiratory tract symptoms had nasopharyngeal swabs taken for viral antigen detection and culture, urine for Legionella antigen detection, and acute and convalescent serology for viruses, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. Chest X‐rays were performed, and an attempt was made to obtain blood and sputum cultures. Water samples from shower heads, faucets, and air conditioning units were collected for Legionella culture and polymerase chain reaction (PCR) assay. A case‐control study was done to assess possible risk factors for legionellosis.

RESULTS: Twenty‐nine cases — 17 in nursing home A; 12 in nursing home B — were identified. Four (14%) case‐residents had documented pneumonia and four case‐residents died. Univariate analysis revealed that a history of stroke (odds ratio (OR) 2.3 (95% CI, 1.0–5.3)), eating pureed food (OR 4.6 (95% CI, 1.6–12.7)), and having fluids administered with medication (OR 2.5 (95% CI, 1.0–5.9)) were significant risk factors. Cases were less likely to wear dentures (OR .4 (95% CI, .2‐.9)) or to eat solid food (OR .3, (95% CI, .1‐.6)). Only eating pureed food remained significant in a multivariable analysis (OR 4.6 (95% CI, 1.6–13.0, P = .01)).

CONCLUSION: This report describes outbreaks of legionellosis in two nursing homes, representing the first reported outbreaks of infection caused by Legionella sainthelensi. The association with illness of dietary characteristics indicative of swallowing disorders suggests that aspiration was the most likely mode of infection. The diagnosis of legionellosis should be considered during outbreaks of respiratory infection in nursing homes. J Am Geriatr Soc 47:547–552, 1999.