bluuebunny/crossref_metadata_2025 huggingface dataset:
A Randomized, Controlled Trial of an Intensive Community Nurse–Supported Discharge Program in Preventing Hospital Readmissions of Older Patients with Chronic Lung Disease
Authors: Kwok Timothy , Lum Chor Ming , Chan Hok Shum , Ma Hon Ming , Lee Diana , Woo Jean
Published: July 2004

Objectives: To evaluate the effectiveness of an intensive community nurse (CN)‐supported discharge program in preventing hospital readmissions of older patients with chronic lung disease (CLD).

Design: Randomized, controlled trial.

Setting: Two acute hospitals in the same health region in Hong Kong.

Participants: One hundred fifty‐seven hospitalized patients aged 60 and older with a primary diagnosis of CLD and at least one hospital admission in the previous 6 months.

Intervention: CNs made home visits within 7 days of discharge, then weekly for 4 weeks and monthly until 6 months. CNs coordinated closely with a geriatric or respiratory specialist in hospital. Subjects had telephone access to CNs during normal working hours from Monday to Saturday.

Measurements: The primary outcome was the rate of unplanned readmission within 6 months. The secondary outcomes were the rate of unplanned readmission within 28 days, number of unplanned readmissions, hospital bed days, accident and emergency room attendance, functional and psychosocial status, and caregiver burden.

Results: One hundred forty hospitalized patients completed the trial. Intervention group subjects had a higher rate of unplanned readmission within 6 months than control group subjects (76% vs 62%, P=.080, χ2 test). There was no significant group difference in any of the secondary outcomes except that intervention group subjects did better on social handicap scores.

Conclusion: There was no evidence that an intensive CN‐supported discharge program can prevent hospital readmissions in older patients with CLD.
Site of Death in the Hospital Versus Nursing Home of Medicare Skilled Nursing Facility Residents Admitted Under Medicare's Part A Benefit
Authors: Levy Cari R. , Fish Ron , Kramer Andrew M.
Published: July 2004

Objectives: To determine factors that predict site of death (hospital vs nursing home (NH)), related costs, and geographic variation in site of death of NH residents admitted under the Medicare Part A Benefit.

Design: Retrospective cohort study.

Setting: NHs located in the United States (N=13,146).

Participants: All persons admitted to skilled nursing facilities (SNFs) in 2001 who died in a SNF (n=101,307) or hospital (n=51,187).

Measurements: Patient, facility, and geographic characteristics associated with death in a hospital and receipt of Medicare payment.

Results: Absence of a do‐not‐resuscitate order, non‐Caucasian ethnicity, greater functional independence, and higher cognitive status correlated with hospital as the site of death. Rural, hospital‐based, and government‐owned facilities had the lowest in‐hospital death rates. Site of death varied widely from state to state. Of those who died in a hospital, 24.2% (12,410) died within 24 hours of transfer. The average daily combined stay Medicare payment for those who died in the hospital was $969, versus $300 for those who died in a NH.

Conclusion: Patient and facility characteristics predict site of death of Medicare NH patients, but in‐hospital death rather than NH death varies geographically and is associated with higher daily Medicare payment.
The Effect of a Cognitive Task on Voluntary Step Execution in Healthy Elderly and Young Individuals
Authors: Melzer Itshak , Oddsson Lars I. E.
Published: July 2004

Objectives: To investigate voluntary step behavior of healthy elderly individuals during single‐ and dual‐task conditions and to compare it with those of young subjects.

Design: Laboratory‐based study.

Setting: Tests of healthy elderly and young individuals from senior community centers and from the university population in Boston, Massachusetts.

Participants: Sixty‐six elderly and 12 young subjects.

Measurements: Forward, sideways, and backward rapid voluntary stepping performed as a reaction time task while standing on a force platform and (1) awaiting a cutaneous cue (single task) and (2) awaiting a cutaneous cue while performing an attention‐demanding Stroop task (dual task). Step initiation phase, foot‐off time, foot contact time, and preparatory and swing phases were extracted from center‐of‐pressure and ground reaction force data.

Results: Elderly subjects were significantly slower than young in all step parameters under both conditions. For dual compared with single task, the initiation phase increased 108% in the elderly group and 34% in the young. There was a short‐term learning effect during the dual task in elderly subjects but not in the young.

Conclusion: The disproportional increase in step initiation time during the dual task in the elderly group suggests that they lacked neural processing resources required for swift multitasking during a voluntary postural task. This may be a factor contributing to balance loss and the large number of falls in elderly persons. Training may improve this skill. Clinical tests of postural function should incorporate multitask conditions to capture a more complete assessment of an individual's ability.
Prevalence and Outcomes of Low Mobility in Hospitalized Older Patients
Authors: Brown Cynthia J. , Friedkin Rebecca J. , Inouye Sharon K.
Published: July 2004

Objectives: To estimate the prevalence of different levels of mobility in a hospitalized older cohort, to measure the degree and rate of adverse outcomes associated with different mobility levels, and to examine the physician activity orders and documented reasons for bedrest in the lowest mobility group.

Design: A prospective cohort study.

Setting: An 800‐bed university teaching hospital.

Participants: Four hundred ninety‐eight hospitalized medical patients, aged 70 and older.

Measurements: Using average mobility level, scored from 0 to 12, the low‐mobility group was defined as having a score of 4 or less, intermediate as a score of higher than 4 to 8, and high as higher than 8. Outcomes were functional decline, new institutionalization, death, and death or new institutionalization.

Results: Low and intermediate levels of mobility were common, accounting for 80 (16%) and 157 (32%) study patients, respectively. Overall, any activity of daily living (ADL) decline occurred in 29%, new institutionalization in 13%, death in 7%, and death or new institutionalization in 22% of patients in this cohort. When compared with the high mobility group, the low and intermediate groups were associated with the adverse outcomes in a graded fashion, even after controlling for multiple confounders. The low‐mobility group had an adjusted odds ratio (OR) of 5.6 (95% confidence interval (CI)=2.9–11.0) for ADL decline, 6.0 (95% CI=2.5–14.8) for new institutionalization, 34.3 (95% CI=6.3–185.9) for death, and 7.2 (95% CI=3.6–14.4) for death or new institutionalization. The intermediate group had adjusted ORs of 2.5 (95% CI=1.5–4.1), 2.9 (95% CI=1.4–6.0), 10.1 (95% CI=1.9–52.9), and 3.3 (95% CI=1.8–5.9) for ADL decline, new institutionalization, death, and death or new institutionalization, respectively. Bedrest was ordered at some point during hospitalization in 165 (33%) patients. For most patients, mobility was limited involuntarily (bedrest orders), and almost 60% of bedrest episodes in the lowest mobility group had no documented medical indication.

Conclusion: Low mobility and bedrest are common in hospitalized older patients and are important predictors of adverse outcomes. This study demonstrated that the adverse outcomes associated with low mobility and bedrest may be viewed as iatrogenic events leading to complications, such as functional decline.
The Health Status of Elderly Veteran Enrollees in the Veterans Health Administration
Authors: Selim Alfredo J. , Berlowitz Dan R. , Fincke Graeme , Cong Zhongxiao , Rogers William , Haffer Samuel C. , Ren Xinhua S. , Lee Austin , Qian Shirley X. , Miller Donald R. , Spiro Avron , Selim Bernardo J. , Kazis Lewis E.
Published: July 2004

Objectives: To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations.

Design: Cross‐sectional study.

Setting: Outpatient.

Participants: A total of 1,406,049 veteran enrollees were surveyed, and 887,775 returned the questionnaire (63.1%). Of these, 663,729 (74%) were aged 65 and older.

Measurements: Patient demographics, comorbid conditions, and health status, which was assessed using the Veterans 36‐item short form (SF‐36), a reliable and valid measure of health‐related quality of life (HRQoL).

Results: Elderly veteran enrollees are a group with poor health status across all scales of the Veterans SF‐36. Significant decline in HRQoL was found in patients grouped by increasing age (65–74, 75–84, and ≥85). Of the Veterans SF‐36 scales, the role physical and role emotional scales and physical functioning presented the largest decrements by age group. The elderly veteran enrollees had poorer health status than older people enrolled in Medicare managed care, ranging from 0.5 to 1 standard deviations worse.

Conclusion: Elderly veteran enrollees have substantial disease burden, as reflected by major impairments across multiple dimensions of HRQoL. These findings bear important implications for use of services, suggesting that the Veterans Health Administration will require considerable resources to provide care for its aging population.
Ethnic Differences in the Prevalence and Pattern of Dementia‐Related Behaviors
Authors: Sink Kaycee M. , Covinsky Kenneth E. , Newcomer Robert , Yaffe Kristine
Published: July 2004

Objectives: To determine the prevalence of dementia‐related behaviors in a large, multiethnic sample of community‐dwelling patients with moderate to severe dementia and to determine whether differences in patient or caregiver characteristics could explain any differences in prevalence of these behaviors between white and nonwhite patients.

Design: Cross‐sectional study.

Setting: Community‐based.

Participants: A total of 5,776 Medicare patients (5,090 white, 469 black, 217 Latino; mean age 78.9) enrolled in the Medicare Alzheimer's Disease Demonstration and Evaluation study at eight sites across the United States between 1989 and 1991.

Measurements: Trained interviewers collected information on patient demographic characteristics, cognitive and functional status, and caregiver characteristics such as relationship to patient, functional status, depression, and burden. Ethnicity was obtained by self‐report. Caregivers were asked if the patient typically demonstrated any of eight dementia‐related behaviors. To determine the independent association between ethnicity and dementia‐related behaviors, logistic regression models were developed for each of the behaviors, adjusting for patient and caregiver characteristics.

Results: Overall, 92% of patients had one or more dementia‐related behaviors. Sixty‐one percent of black and 57% of Latino patients were reported to have four or more behaviors, compared with 46% of white patients (P<.001). The prevalence of specific behaviors ranged from 24% for combativeness to 67% for wandering. After multivariate adjustment, black patients were significantly more likely than whites to be constantly talkative (odds ratio (OR)=1.41, 95% confidence interval (CI)=1.11–1.80), to have hallucinations (OR=1.89, 95% CI=1.49–2.40) and episodes of unreasonable anger (OR=1.70, 95% CI=1.34–2.15), to wander (OR=1.40, 95% CI=1.08–1.81), and to wake their caregiver (OR=1.33, 95% CI=1.04–1.69). Latinos had a significantly higher likelihood than whites of having hallucinations (OR=1.49, 95% CI=1.10–2.01), episodes of unreasonable anger (OR=1.59, 95% CI=1.18–2.16), combativeness (OR=1.59, 95% CI=1.17–2.17), and wandering (OR=1.59, 95% CI=1.21–2.26). For most behaviors, these adjusted ORs are similar in magnitude of effect and statistical significance to the unadjusted estimates.

Conclusion: Black and Latino community‐dwelling patients with moderate to severe dementia have a higher prevalence of dementia‐related behaviors than whites. Therefore, as the aging minority population grows, it will be especially important to target caregiver education, in‐home support, and resources to minority communities.
Government Expenditures at the End of Life for Short‐ and Long‐Stay Nursing Home Residents: Differences by Hospice Enrollment Status
Authors: Miller Susan C. , Intrator Orna , Gozalo Pedro , Roy Jason , Barber Janet , Mor Vincent
Published: July 2004

Objectives: To examine end‐of‐life government expenditures for short‐ and long‐stay Medicare‐ and Medicaid‐eligible (dual‐eligible) nursing home (NH) hospice and nonhospice residents.

Design: A retrospective cohort study.

Setting: Six hundred fifty‐seven Florida NHs.

Participants: Dual‐eligible NH residents who died in Florida NHs between July and December 1999 (N=5,774).

Measurements: Nursing home stays of 90 days or less were considered short stays (n=1,739), and those over 90 days were long stays (n=4,035). Three diagnosis groups were studied: cancer without Alzheimer's disease or dementia, Alzheimer's disease or dementia, and other diagnoses. Eligibility and expenditure claims data for 1998 and 1999 were merged with vital statistics and NH resident assessment data to determine diagnoses, location of death, hospice enrollment, eligibility, and expenditures.

Results: Twenty percent of short‐stay (n=350) and 26% of long‐stay (n=958) NH decedents elected hospice; of these, 73% of short‐stay and 58% of long‐stay NH residents had hospice stays of 30 days or less. Overall, mean government expenditures in the last month of life were significantly less for hospice than nonhospice residents ($7,365; 95% confidence interval (CI)=$7,144–7586 vs $8,134; 95% CI=$7,896–8,372), but 1‐month expenditures were only significantly lower for hospice residents with short NH stays, not for those with long NH stays.

Conclusion: Overall, hospice care in NHs does not appear to increase government expenditures. Because significantly lower expenditures are observed for short‐stay NH hospice residents, policy restricting access to Medicare hospice for Medicare skilled nursing facility residents may represent a missed opportunity for savings.
Black/White Differences in Pressure Ulcer Incidence in Nursing Home Residents
Authors: Baumgarten Mona , Margolis David , Van Doorn Carol , Gruber‐Baldini Ann L. , Hebel J. Richard , Zimmerman Sheryl , Magaziner Jay
Published: July 2004

Objectives: To compare black and white nursing home residents with respect to the incidence of nursing home (NH)‐acquired pressure ulcers (PUs) and to examine the role of resident characteristics and facility characteristics in explaining differences between the racial groups.

Design: Prospective cohort study conducted between 1992 and 1995.

Setting: Fifty‐nine Maryland NHs.

Participants: A total of 1,938 residents (301 black, 1,637 white) aged 65 and older newly admitted to participating NHs.

Measurements: The outcome variable was the first occurrence of a Stage 2, 3, or 4 PU as determined based on medical record review. The predictor variable was race (black, white). Eight resident characteristics (age, sex, number of activity of daily living dependencies, bedfast, PU on admission to facility, incontinence, dementia, and whether the resident was on Medicaid) and three facility characteristics (number of beds, for‐profit ownership status, and urban/nonurban location) were considered as possible confounding variables.

Results: The incidence of PUs was 0.38 per person‐year in the NH. The rate for blacks was significantly higher than for whites (0.56 vs 0.35 per person‐year) (P<.001). In multivariate analysis, controlling for eight resident characteristics and three facility characteristics, race was significantly associated with PU incidence (hazard ratio comparing blacks with whites=1.31, 95% confidence interval=1.02–1.66).

Conclusion: Blacks have a higher incidence of NH‐acquired PUs than whites; resident characteristics appear to mediate the higher risk. Future research should aim to identify modifiable factors that explain differences between racial groups in PU risk and to develop solutions to prevent the suffering and cost associated with PUs.
Risk Factors for Deep Vein Thrombosis in Inpatients Aged 65 and Older: A Case‐Control Multicenter Study
Authors: Weill‐Engerer Sébastien , Meaume Sylvie , Lahlou Amina , Piette François , Saint‐Jean Olivier , Sachet Annick , Beinis Jean‐Yves , Gallinari Claude , Grancher Anne‐Sophie , Vincent Jean‐Pierre , Naga Henri , Belmin Joel , Salvatore Rosella , Kazes Marie , Pautas Eric , Boiffin André , Piera Jean‐Bernard , Duviquet Monique , Knafo David , Piau Andrée , Miric Dragoslav , Jean Alain , Bellamy Valérie , Tissandier Olivier , Le Blanche Alain‐Ferdinand
Published: July 2004

Objectives: To identify independent risk factors of symptomatic deep vein thrombosis (DVT) in geriatric inpatients and to define high‐risk patients likely to benefit from preventive treatment.

Design: Hospital‐based case‐control multicenter study with prospective data collection.

Settings: Geriatric university hospitals with long‐, intermediate‐, and short‐term care facilities.

Participants: All patients aged 65 and older in 19 geriatric departments were submitted to clinical surveillance over a 16‐month period.

Measurements: Twenty‐three potential risk factors of phlebitis were screened for. Comparison using logistic regression of 310 consecutive patients with symptomatic DVT versus 310 randomly selected controls was performed. The risk for symptomatic DVT in geriatrics was then scored from the clinical risk factors identified using multivariate analysis. This score is defined by the sum of the odds ratio (OR) of each risk factor present.

Results: Six factors were identified as independently related to the development of DVT: restriction of mobility (from OR=1.73, limited mobility without immobilization, to OR=5.64, bedridden during <15 days), aged 75 and older (OR=1.5/10 years), history of DVT or pulmonary embolism (OR=3.38), acute heart failure (OR=2.52), chronic edema of the lower limbs (OR=2.51), and paresis or paralysis of a lower limb (OR=2.06). The defined score of 8 or higher corresponded to an 88.7% probability of having symptomatic DVT.

Conclusion: Treatments to prevent symptomatic DVT in hospitalized elderly should be evaluated on patients with these factors.
Providing Nutrition Supplements to Institutionalized Seniors with Probable Alzheimer's Disease Is Least Beneficial to Those with Low Body Weight Status
Authors: Young Karen W. H. , Greenwood Carol E. , Van Reekum Robert , Binns Malcolm A.
Published: July 2004

Objectives: To examine whether providing a midmorning nutrition supplement increases habitual energy intake in seniors with probable Alzheimer's disease (AD) and to investigate the effects of body weight status and cognitive and behavioral function on the response to the intervention.

Design: Randomized, crossover, nonblinded clinical trial.

Setting: A fully accredited geriatric teaching facility affiliated with the University of Toronto's Medical School with a home for the aged.

Participants: Thirty‐four institutionalized seniors with probable AD who ate independently.

Intervention: Nutrition supplements were provided between breakfast and lunch for 21 consecutive days and compared with 21 consecutive days of habitual intake.

Measurements: Investigator‐weighed food intake, body weight, cognitive function (Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (Neuropsychiatric Inventory—Nursing Home Version), and behavioral function (London Psychogeriatric Rating Scale).

Results: Relative to habitual intake, group mean analyses showed increased 24‐hour energy, protein, and carbohydrate intake during the supplement phase, but five of 31 subjects who finished all study phases completely compensated for the energy provided by the supplement by reducing lunch intake, and 24‐hour energy intake was enhanced in only 21 of 31 subjects. Compensation at lunch was more likely in subjects with lower body mass indices, increased aberrant motor behavior, poorer attention, and increased mental disorganization/confusion.

Conclusion: Nutrition supplements were least likely to enhance habitual energy intake in subjects who would normally be targeted for nutrition intervention—those with low body weight status. Those likely to benefit include those with higher body mass indices, less aberrant motor problems, less mental disorganization, and increased attention.
Plasma Hypertonicity: Another Marker of Frailty?
Authors: Stookey Jodi D. , Purser Jama L. , Pieper Carl F. , Cohen Harvey J.
Published: July 2004

Objectives: To determine whether plasma hypertonicity might be a marker of early frailty, this study tested the associations between plasma hypertonicity, incident disability, and mortality in nondisabled older adults.

Design: Longitudinal, observational study.

Setting: Community‐based.

Participants: Older adults (≥70), who reported no disability and gave blood in the 1992 Duke Established Populations for Epidemiologic Studies of the Elderly survey (n=705), were re‐interviewed in 1996 for functional status (n=561) and followed for all deaths up to January 1, 2000.

Measurements: Plasma tonicity was estimated from plasma glucose, sodium, and potassium measures and used to classify subjects as normo‐ (285–294 mOsm/L) or hypertonic (≥300 mOsm/L). Disability was defined as any impairment on the Rosow‐Breslau, activity of daily living (ADL), and instrumental activity of daily living (IADL) scales. The relative risk (RR) of any new disability and relative hazard of death associated with hypertonicity were estimated using logistic regression models and Cox proportional hazards models, respectively. All models were controlled for age, sex, race, weight status, current smoking, activity level, plasma blood urea nitrogen and creatinine, cognitive impairment, depression, and chronic disease status. To determine whether observed effects were attributable to plasma glucose alone, all models were repeated on a subsample of nondiabetic, normoglycemic subjects.

Results: Plasma hypertonicity (observed in 15% of subjects) was associated with increased risk of new Rosow‐Breslau (RR=2.1, 95% confidence interval (CI)=1.2–3.6), IADL (RR=2.3, 95% CI=1.2–4.3), and ADL (RR=2.7 95% CI=1.3–5.6) disability by 1996 and mortality by 2000 (RR=1.4, 95% CI=1.0–1.9). Results were similar for the normoglycemic subgroup (ADL: RR=2.9, 95% CI=1.0–8.0; IADL: RR=2.5, 95% CI=1.0–6.3; Rosow‐Breslau: RR=1.8, 95% CI=0.8–3.9; mortality: RR=1.5, 95% CI=0.9–2.3).

Conclusion: Plasma hypertonicity may be a marker of early frailty. It was prevalent in this sample of nondisabled community‐dwelling older adults and predicted incident disability and mortality. Further research to identify its determinants and consequences may help inform interventions against frailty.
A Comparative Study of Clinical Features and Outcomes in Young and Older Adults with Severe Acute Respiratory Syndrome
Authors: Chan Tak Yeung , Miu Ka Ying , Tsui Chung Kan , Yee Kwok Sang , Chan Ming Houng
Published: July 2004

Objectives: To determine the clinical presentation, findings, and outcomes of older adults (> 60) with severe acute respiratory syndrome (SARS) and compare these with a control group of younger patients (≤60).

Design: Retrospective cohort study.

Setting: A community‐based, acute hospital in Hong Kong.

Participants: All adult inpatients with a clinical diagnosis of SARS.

Measurements: Clinical presentations, investigations, treatment, and 30‐ and 150‐day mortality.

Results: There were 52 young and 25 older patients with a mean age±standard deviation of 39.5±11.7 and 72.1±7.2, respectively. Fever, chills, and diarrhea were more common in younger patients, whereas decrease in appetite and general condition occurred only in older patients. The prevalence of positive reverse‐transcriptase polymerase chain reaction for SARS‐associated coronavirus (SARS‐CoV) in nasopharyngeal secretions and stool samples was similar in the two groups. The prevalence of positive serological tests for SARS‐CoV was significantly lower in older patients (42% vs 92%, P<.001). This was largely due to incomplete testing in elderly patients. Older patients were more likely to develop secondary nosocomial infection, be admitted to an intensive care unit, and require mechanical ventilation. The cumulative 30‐ and 150‐day mortality rates were 3.8% and 7.6%, respectively, in young patients with SARS and 56% and 60%, respectively, in older patients (P<.001).

Conclusion: Older patients with SARS more often presented with nonspecific symptoms, and the prognosis was poor. Reverse‐transcriptase polymerase chain reaction was useful in diagnosing SARS in older patients, but the role of serological tests in individual elderly is limited.
An Analysis of an Older Driver Evaluation Program
Authors: Kantor Bonnie , Mauger Linda , Richardson Virginia E. , Unroe Kathleen Tschantz
Published: July 2004

Objectives: To identify elements of an older driver evaluation program that predict driving performance in older adults.

Setting: Outpatient medical clinic in an academic medical center.

Design: A retrospective analysis.

Participants: Six hundred sixty‐four older adults who were referred to an older driver evaluation program.

Measurements: A physician trained in geriatric medicine and a clinical geriatric nurse specialist oversaw an experienced driving evaluator and an occupational therapist who conducted assessments of older persons' functional status; reaction time; driving skills; and cognitive, hearing, and vision abilities. Self‐report data along with a medical history submitted by patients' primary care physicians supplemented the clinical assessments.

Results: A multinomial logistic regression revealed that the Mini‐Mental State Examination (MMSE), cues needed with the Trail Making Test, Part B, grip strength, and an interaction effect between the MMSE and reaction time constituted the most parsimonious model for predicting on‐the‐road performance. A receiver operating characteristic analysis indicated that this index had good sensitivity but low specificity. A binomial regression comparing imperfect and perfect drivers demonstrated the significance of the Traffic Sign and Visual Perception tests.

Conclusion: Clinicians should employ a multilevel screening process that includes initial cognitive tests, such as the MMSE and the Trail Making Test, Part B, although more studies of driving evaluation programs in medical settings that include random samples of older drivers are needed.
Hospice Care in Nursing Homes: Is Site of Care Associated with Visit Volume?
Authors: Miller Susan C.
Published: July 2004

Objectives: To determine factors associated with hospice visit volume and to examine whether visit volume differs by nursing home (NH) versus non‐NH setting.

Design: Retrospective cohort study.

Setting: Twenty‐one hospices across seven states under the ownership of one parent provider.

Participants: Hospice patients from October 1998 through September 1999 in NH (n=9,460) and non‐NH (n=15,484) settings.

Measurements: Data were from the provider's centralized information system. Average daily visit volume was the number of visits divided by the number of hospice routine home care days (days not in hospice inpatient or continuous home care). Multivariate logistic regression tested the association between site of care and an individual's probability of having average daily visits above the sample median.

Results: Average daily visits±standard deviation were 1.1±1.1 for NH and 1.2±1.3 for non‐NH hospice patients. Site of care was not significantly associated with having an average daily visit volume above the sample median, but patients in NH settings had a lower probability of having a nurse average daily visit volume above the median (adjusted odds ratio (AOR)=0.59, 95% confidence interval (CI)=0.46–0.74) and a greater probability of having social worker (AOR=2.46, 95% CI=1.87–3.24), aide (AOR=1.97; 95% CI=1.11–3.48), and clergy (AOR=3.23, 95% CI=2.21–4.44) average daily visits above the median than those in non‐NH settings.

Conclusion: A different mix, not volume, of services appears to be used to address the physical, psychosocial, and spiritual needs of hospice patients/families who reside in NH settings than of those in non‐NH settings.
Outcomes and Characteristics of Patients Discharged Alive from Hospice
Authors: Kutner Jean S. , Meyer Sue A. , Beaty Brenda L. , Kassner Cordt T. , Nowels David E. , Beehler Connie
Published: July 2004

Objectives: To describe outcomes and characteristics of patients discharged alive from hospice.

Design: Prospective cohort study using a telephone survey.

Setting: Hospices (n=18) participating in the Population‐Based Palliative Care Research Network during the 1‐year study period.

Participants: English‐speaking adults (n=164) who were discharged alive from participating hospices during the 1‐year study period.

Measurements: Mortality within 6 months of hospice discharge.

Results: Thirty‐five percent (n=48) of the 139 patients with known outcomes died within 6 months of hospice discharge, 15 of whom (31%) died without hospice readmission. There were no significant associations between sex (P=.77), length of hospice service (P=.99), diagnosis (P=.73), discharge disposition (P=.54), admission evidence of prognosis of less than 6 months to live (P=.22–.95), Karnofsky score at admission or change between admission and discharge (P=.39, P=.38, respectively), or duration of hospice care after stabilization (P=.83) and mortality within 6 months after hospice discharge. Age (P=.11), discharge Karnofsky score (P=.17), and reason for discharge being improved or stabilized condition (P=.13) trended toward statistical significance. The strongest predictor of mortality after hospice discharge was a report that the patient's condition had worsened (hazard ratio=10.2, 95% confidence interval 4.5–23.4).

Conclusion: One‐third of patients who were discharged from hospice died within 6 months of hospice discharge, indicating ongoing eligibility for hospice care even under the strictest interpretation of hospice eligibility criteria. Patients who are discharged from hospice care should be evaluated frequently, especially within the first weeks to months after discharge, for changes in status, unmet needs, and potential hospice readmission.
Psychometric Comparisons of the Timed Up and Go, One‐Leg Stand, Functional Reach, and Tinetti Balance Measures in Community‐Dwelling Older People
Authors: Lin Mau‐Roung , Hwang Hei‐Fen , Hu Ming‐Hsia , Wu Hong‐Dar Isaac , Wang Yi‐Wei , Huang Fu‐Chao
Published: July 2004

Objectives: To compare the practicality, reliability, validity, and responsiveness of the timed up and go (TUG), one‐leg stand (OLS), functional reach (FR), and Tinetti balance (TB) performance measures in people aged 65 and older.

Design: A prospective study.

Setting: Shin‐Sher Township of Taichung County, west‐central Taiwan.

Participants: Twelve hundred community‐dwelling older people.

Measurements: During an initial assessment at their residences, participants were interviewed for demographics, cognition, fall history, use of a walking aid, and activities of daily living (ADLs), in addition to completing the four balance tests. Falls were ascertained by telephone every 3 months for a 1‐year follow‐up; the four balance measures and ADLs were also reassessed at the end of the follow‐up year.

Results: Of the four balance measures, the OLS had the lowest participation rate, and participation of people who were cognitively impaired had fallen in the previous year, used a walking aid, or suffered from an ADL disability was lower than for their counterparts. The time to complete the tests ranged from 58 seconds for OLS, to 160 seconds for the TB. All four balance measures exhibited excellent test‐retest reliability and discriminant validity but poor responsiveness to fall status. The TB showed better discriminant, convergent, and predictive validities and responsiveness to ADL changes than the other three tests.

Conclusion: According to psychometric properties, the most suitable performance measure for evaluating balance in community‐dwelling older people was the TB, followed by the TUG.
Risk Factors for Adverse Drug Events Among Older Adults in the Ambulatory Setting
Authors: Field Terry S. , Gurwitz Jerry H. , Harrold Leslie R. , Rothschild Jeffrey , DeBellis Kristin R. , Seger Andrew C. , Auger Jill C. , Garber Leslie A. , Cadoret Cynthia , Fish Leslie S. , Garber Lawrence D. , Kelleher Michael , Bates David W.
Published: July 2004

Objectives: To gather information on patient‐level factors associated with risk of adverse drug events (ADEs) that may allow focus of prevention efforts on patients at high risk.

Design: Nested case‐control study.

Setting: Large multispecialty group practice in New England.

Participants: All Medicare enrollees cared for by a multispecialty group practice during 1 year (N=30,397 person‐years from July 1, 1999, through June 30, 2000). For each patient with an ADE, a control was randomly selected.

Measurements: Data were abstracted from medical records on age, sex, comorbidities, and medication use at the time of the event.

Results: ADEs were identified in 1,299 older adults. Independent risk factors included being female and aged 80 and older. There were dose‐response associations with the Charlson Comorbidity Index and number of scheduled medications. Patients taking anticoagulants, antidepressants, antibiotics, cardiovascular drugs, diuretics, hormones, and corticosteroids were at increased risk. In the analysis of preventable ADEs, the dose‐response relationship with comorbidity and number of medications remained. Patients taking nonopioid analgesics (predominantly nonsteroidal antiinflammatory drugs and acetaminophen), anticoagulants, diuretics, and anti‐seizure medications were at increased risk.

Conclusion: Prevention efforts to reduce ADEs should be targeted toward older adults with multiple medical conditions or taking multiple medications, nonopioid analgesics, anticoagulants, diuretics, and antiseizure medications.
Age‐Related Changes in Treatment Strategies for Acute Myocardial Infarction: A Population‐Based Study
Authors: Barchielli Alessandro , Buiatti Eva , Balzi Daniela , Santoro Giovanni M. , Carrabba Nazario , Fabiani Plinio , Maci Marcella , Margheri Massimo , Mangani Irene , Monami Matteo , Marchionni Niccolò ,   for the AMI‐Florence Working Group
Published: July 2004

Objectives: To compare across four age groups (<65, 65–74, 75–84, ≥85) the determinants of coronary reperfusion therapy (CRT) use in ST‐segment elevation acute myocardial infarction (STE‐AMI).

Design: Population‐based, observational study.

Setting: Performed in the health district of Florence, Italy, where percutaneous coronary intervention (PCI) is the preferred CRT.

Participants: Nine hundred thirty patients with STE‐AMI prospectively enrolled in the Florence AMI registry.

Measurements: Use of CRT, clinical factors associated with CRT use.

Results: CRT use was reduced from 71% at younger than 65 to 31% at aged 85 and older (P<.001). After adjusting for chronic comorbidity, Killip class, admission hospital category, hospitalization delay, and AMI location, CRT use was 29% (P=.17) lower at age 75 to 84 and 63% (P<.001) lower at age 85 and older than at younger than 65. Within each age group, the probability of receiving CRT was three to five times greater in patients directly admitted to the hospital with PCI facilities. Acute cardiac failure and chronic comorbidity were associated with lower CRT use only in patients aged 65 and older. Patients aged less than 85 years who received reperfusive therapy had a significantly lower risk of death (−44%, P=.045) at 1 year, whereas it was less evident and nonsignificant (−27%, P=.27) in patients aged 85 and older.

Conclusion: Results confirm that, although they might substantially benefit from CRT during STE‐AMI, older patients are excluded from CRT even when eligible. This further indicates that clinicians are not yet completely prepared to manage most efficiently frail elderly with AMI, a task requiring a specific interdisciplinary training program in geriatric cardiology.
The Tumor Necrosis Factor Alpha −308G>A Polymorphism Is Associated with Dementia in the Oldest Old
Authors: Bruunsgaard Helle , Benfield Thomas L. , Andersen‐Ranberg Karen , Hjelmborg Jacob v. B. , Pedersen Agnes N. , Schroll Marianne , Pedersen Bente K. , Jeune Bernard
Published: July 2004

Objectives: To test the hypothesis that the tumor necrosis factor (TNF) −308 G>A promoter gene polymorphism is a risk factor in age‐related dementia and longevity.

Design: A cross‐sectional and a longitudinal study.

Setting: A population‐based sample of Danish centenarians.

Participants: One hundred‐year‐old Danes (n=122) from “The Longitudinal Study of Danish Centenarians.” Octogenarians (n=174) and healthy volunteers aged 18 to 30 (n=47) served as reference groups.

Methods: Whether the distribution of TNF −308 GG/GA/AA genotypes were different in centenarians than in younger age groups was investigated (Fischer exact test). Furthermore, whether the TNF −308 G>A polymorphism was associated with the prevalence of dementia (logistic regression analysis), the plasma level of TNF‐α (analysis of variance), and mortality in the following 5 years (Cox regression analysis) within the cohort of centenarians was tested.

Results: The distribution of TNF −308 genotypes was not different across the three different age groups, but the GA genotype was associated with decreased prevalence of dementia in centenarians. The few centenarians with AA carrier status had higher mortality risk and tended to show higher plasma levels of TNF‐α, but the significance was questionable due to a low number of subjects with this genotype.

Conclusion: It is possible that the TNF −308 A allele is maintained during aging because subjects who are heterozygous for this polymorphism possess the optimal inflammatory response with regard to protection against age‐related neurodegeneration.
Normal Values of Balance Tests in Women Aged 20–80
Authors: Isles Rosemary C. , Choy Nancy L. Low , Steer Marie , Nitz Jennifer C.
Published: July 2004

Objectives: To determine normal values for four commonly used clinical functional balance tests from community‐dwelling women aged 20 to 80 and to identify any significant decline due to aging.

Design: A cross‐sectional study was undertaken to provide normative values for four clinical balance tests across 6 decade cohorts.

Setting: The Betty Byrne‐Henderson Center for Women and Aging, Royal Womens' Hospital, Brisbane, Australia.

Participants: Four hundred fifty‐six community‐dwelling, independently ambulant women with no obvious neurological or musculoskeletal‐related disability, aged 20 to 80, were randomly recruited from a large metropolitan region.

Measurements: The clinical balance measures/tests were the Timed Up and Go test, step test, Functional Reach test, and lateral reach test. Multivariate analysis was used to test the effect for age, height, and activity level.

Results: Normal data were produced for each test across each decade cohort. Gradual decline in balance performance was confirmed, with significant effect for age demonstrated.

Conclusion: New normative data across the adult age decades are available for these clinical tests. Use of clinical balance tests could complement other balance tests and be used to screen women aged 40 to 60 whose performance is outside the normal values for age and to decrease later falls risk.
The Identification of Genetically Related Bacterial Isolates Using Pulsed Field Gel Electrophoresis on Nursing Home Units: A Clinical Experience
Authors: Drinka Paul J. , Stemper Mary E. , Gauerke Cathy D. , Miller Janice M. , Reed Kurt D.
Published: July 2004

Objectives: To describe a laboratory‐based technique to track nursing home infections.

Design: Retrospective data analysis.

Setting: A 721‐bed skilled care facility with 14 nursing units.

Participants: Residents in a nursing home, average age 76±10, 78% male.

Measurements: Bacterial isolates were listed for each nursing unit. Clusters of identical species and antibiotic susceptibility were identified followed by pulsed‐field gel electrophoresis (PFGE). If the genetic analysis yielded related strains, the director of nursing performed a clinical investigation. PFGE is available through reference laboratories at a cost of approximately $75/isolate.

Results: Twenty‐four clinical clusters of phenotypically identical bacteria (species, antibiotic susceptibility) were identified. Fourteen included genetically related isolates.

Conclusion: Approximately half of the phenotypically identical clusters contained genetically related isolates. The identification of genetically related bacterial isolates on nursing units by PFGE provides staff with a specific circumstance to review secretion precautions. Genetic analysis may also demonstrate that apparent clusters are unrelated.
Accuracy of Nursing Home Medical Record Information about Care‐Process Delivery: Implications for Staff Management and Improvement
Authors: Schnelle John F. , Bates‐Jensen Barbara M. , Chu Lily , Simmons Sandra F.
Published: July 2004

Arguments have been made that the culture of nursing homes (NHs) must change to improve the quality of care, and two initiatives have been designed to accomplish this goal. One initiative is to provide resident outcome information (quality indicators) to NH management and consumers via public reporting systems. This initiative is based on the assumptions that resident outcomes are related to care processes implemented by NH staff, the NH industry will respond to market forces, and there are management systems in place within NHs to change the behavior of direct care staff if outcomes are poor. A separate staffing initiative argues that NH care will not improve until there are resources available to increase the number of direct care staff and improve staff training. This initiative also assumes that systems are in place to manage staff resources. Unfortunately, these initiatives may have limited efficacy because information useful for managing the behavior of direct care providers is unavailable within NHs. Medical record documentation about daily care‐process implementation may be so erroneous that even the best‐intentioned efforts to improve the care received by residents will not be successful.

A culture of inaccurate documentation is largely created by a discrepancy between care expectations placed on NHs by regulatory guidelines and inadequate reimbursement to fulfill these expectations. Nursing home staff have little incentive to implement the technologies necessary to audit and assure data quality if accurate documentation reveals that care consistent with regulatory guidelines is not or cannot be provided. A survey process that largely focuses on chart documentation to assess quality provides further incentive for care‐process documentation as opposed to care‐process delivery. This article reviews methods to improve the accuracy of NH medical record documentation and to create data systems useful for staff training and management.
Building Academic Geriatric Capacity: An Evaluation of the John A. Hartford Foundation Centers of Excellence Initiative
Authors: Reuben David B. , Lee Ming , Katz Diane , Warshaw Gregg , Medina‐Walpole Annette , Bragg Elizabeth , Frank Janet C.
Published: July 2004

Almost 15 years ago, the John A. Hartford Foundation began its Centers of Excellence (CoE) program. In summer 2002, a quantitative and qualitative evaluation of the CoE program was conducted. The evaluation used previously collected quantitative data from surveys of program directors and graduates of fellowship programs, as well as interviews and surveys of currently funded CoEs.

Since its inception, the CoE program has supported 163 geriatrics fellows, of whom 63% entered academic geriatrics. Almost half of these graduating fellows have gone to new academic institutions. CoEs have also supported 222 faculty, including some who were in disciplines other than geriatrics. The vast majority (82%) have remained in academics, and nearly two‐thirds are currently in geriatrics. As the priorities and needs of the institutions and geriatrics programs changed, most centers shifted their CoE priorities. These changes predominantly took two forms: a refocus from one activity to another or an expansion of outreach or levels of support.

Based upon this formal evaluation, the Hartford‐supported CoE program has been successful in strengthening academic geriatrics, particularly in attracting, developing, and retaining geriatrics faculty.
Overview of genetic evaluation in dairy cattle
Authors: TOGASHI Kenji , LIN Ching Yonn , YOKOUCHI Kunio
Published: July 2004

It is costly and time‐consuming to carry out dairy cattle selection on a large experimental scale. For this reason, sire and cow evaluations are almost exclusively based on field data, which are highly affected by a large array of environmental factors. Therefore, it is crucial to adjust for those environmental effects in order to accurately estimate the genetic merits of sires and cows. Index selection is a simple extension of the ordinary least squares under the assumption that the fixed effects are assumed known without error. The mixed‐model equations (MME) of Henderson provide a simpler alternative to the generalized least squares procedure, which is computationally difficult to apply to large data sets. Solution to the MME yields the best linear unbiased estimator of the fixed effects and the best linear unbiased predictor (BLUP) of the random effects. In an animal breeding situation, the random effects such as sire or animal represent the animal's estimated breeding value, which provides a basis for selection decision. The BLUP procedure under sire model assumes random mating between sires and dams. The genetic evaluation procedure has progressed a long way from the dam‐daughter comparison method to animal model, from single trait to multiple trait analysis, and from lactational to test‐day model, to improve accuracy of evaluations. Multiple‐trait evaluation appears desirable because it takes into account the genetic and environmental variance‐covariance of all traits evaluated. For these reasons, multiple‐trait evaluation would reduce bias from selection and achieve a better accuracy of prediction as compared to single‐trait evaluation. The number of traits included in multiple‐trait evaluation should depend upon the breeding goal. Recent advances in molecular and reproductive technologies have created great potential for quantitative geneticists concerning genetic dissection of quantitative traits, and marker‐assisted genetic evaluation and selection.