bluuebunny/crossref_metadata_2025 huggingface dataset:
Systems to cultivate suitable patients for home dialysis
Authors: Walker Rachael C. , Blagg Christopher R. , Mendelssohn David C.
Published: April 2015

The key to developing, initiating, and maintaining a strong home dialysis program is a fundamental commitment by the entire team to identify and cultivate patients who are suitable candidates to perform home dialysis. This process must start as early as possible in the disease trajectory, and must include a passionate and daily focus by physicians, nurses, social workers, and other members of the multidisciplinary team. This effort must be constant and sustained over months, with active promotion of home dialysis for suitable patients at every opportunity. Cultivation of suitable patients must become a defining and overarching mission for the entire program. This article reviews some of the components involved in this worthwhile effort and provides practical tips and links to resources.
Off‐nest behaviour in a biparentally incubating shorebird varies with sex, time of day and weather
Authors: Bulla Martin , Stich Elias , Valcu Mihai , Kempenaers Bart
Published: April 2015

Biparental incubation is a form of cooperation between parents, but it is not conflict‐free because parents trade off incubation against other activities (e.g. self‐maintenance, mating opportunities). How parents resolve such conflict and achieve cooperation remains unknown. To understand better the potential for conflict, cooperation and the constraints on incubation behaviour, investigation of the parents' behaviour, both during incubation and when they are off incubation‐duty, is necessary. Using a combination of automated incubation‐monitoring and radiotelemetry we simultaneously investigated the behaviours of both parents in the biparentally incubating Semipalmated Sandpiper Calidris pusilla, a shorebird breeding under continuous daylight in the high Arctic. Here, we describe the off‐nest behaviour of 32 off‐duty parents from 17 nests. Off‐duty parents roamed on average 224 m from their nest, implying that direct communication with the incubating partner is unlikely. On average, off‐duty parents spent only 59% of their time feeding. Off‐nest distance and behaviour (like previously reported incubation behaviour) differed between the sexes, and varied with time and weather. Males roamed less far from the nest and spent less time feeding than did females. At night, parents stayed closer to the nest and tended to spend less time feeding than during the day. Further exploratory analyses revealed that the time spent feeding increased over the incubation period, and that at night, but not during the day, off‐duty parents spent more time feeding under relatively windy conditions. Hence, under energetically stressful conditions, parents may be forced to feed more. Our results suggest that parents are likely to conflict over the favourable feeding times, i.e. over when to incubate (within a day or incubation period). Our study also indicates that Semipalmated Sandpiper parents do not continuously keep track of each other to optimize incubation scheduling and, hence, that the off‐duty parent's decision to remain closer to the nest drives the length of incubation bouts.
Progressive development in experimental models of transungual drug delivery of anti‐fungal agents
Authors: Thatai P. , Tiwary A. K. , Sapra B.
Published: April 2015

Synopsis

Pre‐clinical development comprises of different procedures that relate drug discovery in the laboratory for commencement of human clinical trials. Pre‐clinical studies can be designed to recognize a lead candidate from a list to develop the procedure for scale‐up, to choose the unsurpassed formulation, to determine the frequency, and duration of exposure; and eventually make the foundation of the anticipated clinical trial design. The foremost aim in the pharmaceutical research and industry is the claim of drug product quality throughout a drug's life cycle. The particulars of the pre‐clinical development process for different candidates may vary; however, all have some common features. Typically in vitro, in vivo or ex vivo studies are elements of pre‐clinical studies. Human pharmacokinetic in vivo studies are often supposed to serve as the ‘gold standard’ to assess product performance. On the other hand, when this general assumption is revisited, it appears that in vitro studies are occasionally better than in vivo studies in assessing dosage forms. The present review is compendious of different such models or approaches that can be used for designing and evaluation of formulations for nail delivery with special reference to anti‐fungal agents.
THE HOME SELLING PROBLEM: THEORY AND EVIDENCE
Authors: Merlo Antonio , Ortalo‐Magné François , Rust John
Published: April 2015

We formulate and solve the problem of a homeowner who wants to sell her house for the maximum possible price net of transactions costs. We estimate this model using data on transaction histories for 780 residential properties in England. The estimated model fits list price dynamics and other key features of the data. In particular, a tiny menu cost of changing the listing price, as little as ten thousandths of 1% of the house value, is sufficient to explain the high degree of stickiness of listing prices observed in the data.
Exploring private consumers’ willingness to adopt Smart Grid technology
Authors: Broman Toft Madeleine , Thøgersen John
Published: April 2015

The goal of radically increasing the proportion of electricity generated from renewable sources puts the current electrical grid under pressure and one of the solutions is to turn the grid into a ‘Smart Grid’. One of the key elements of the Smart Grid is that electricity consumers make some of their consumption available as flexible capacity to balance the grid. Consumers’ flexible capacity is only available to the grid if the consumers adopt Smart Grid technology (SGT) that establishes the link between the electric system and the consumer. This technology is new to private consumers and using it involves behavioural changes. There is a need to get more insight into who are willing to adopt SGT and why. This study draws on innovation adoption theory as a framework for understanding consumer adoption of this new technology. We explore whether consumers who have already adopted other types of new energy technology, such as a geothermal heat pump, are more favourably disposed towards SGT than other consumers. Also, we explore how consumers who have signed up to let their heat pump be used as flexible capacity in a test trial differ from other heat pump owners, if at all. We used semi‐structured interviews with household members as well as a questionnaire to explore differences between three groups: households with (1) a heat pump with SGT (n = 11), (2) a heat pump‐only (n = 7), or (3) an oil‐fired boiler (n = 6). We find that the families in the three groups perceive the technology characteristics differently and those who have trial experience with SGT are most in favour of the technology.
Research lessons from implementing a national nursing workforce study
Authors: Brzostek T. , Brzyski P. , Kózka M. , Squires A. , Przewoźniak L. , Cisek M. , Gajda K. , Gabryś T. , Ogarek M.
Published: April 2015

Background

National nursing workforce studies are important for evidence‐based policymaking to improve nursing human resources globally. Survey instrument translation and contextual adaptation along with level of experience of the research team are key factors that will influence study implementation and results in countries new to health workforce studies.

Aim

This study's aim was to describe the pre‐data collection instrument adaptation challenges when designing the first national nursing workforce study in Poland while participating in the Nurse Forecasting: Human Resources Planning in Nursing project.

Methods

A descriptive analysis of the pre‐data collection phase of the study. Instrument adaptation was conducted through a two‐phase content validity indexing process and pilot testing from 2009 to September 2010 in preparation for primary study implementation in December 2010. Means of both content validation phases were compared with pilot study results to assess for significant patterns in the data.

Results

The initial review demonstrated that the instrument had poor level of cross‐cultural relevance and multiple translation issues. After revising the translation and re‐evaluating using the same process, instrument scores improved significantly. Pilot study results showed floor and ceiling effects on relevance score correlations in each phase of the study.

Limitations

The cross‐cultural adaptation process was developed specifically for this study and is, therefore, new. It may require additional replication to further enhance the method.

Conclusions

The approach used by the Polish team helped identify potential problems early in the study. The critical step improved the rigour of the results and improved comparability for between countries analyses, conserving both money and resources. This approach is advised for cross‐cultural adaptation of instruments to be used in national nursing workforce studies.

Implications for nursing and health policy

Countries seeking to conduct national nursing workforce surveys to improve nursing human resources policies may find the insights provided by this paper useful to guide national level nursing workforce study implementation.
Do Older Women Use Estrogen Replacement? Data from the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE)
Authors: Handa Victoria L. , Landerman Richard , Hanlon Joseph T. , Harris Tamara , Cohen Harvey Jay
Published: April 2015

OBJECTIVES: The primary purpose of this study was to determine the prevalence of current and past estrogen use among older, community‐dwelling, postmenopausal women. The secondary purpose was to describe factors associated with estrogen use in this population.

DESIGN: A survey.

SETTING: The Piedmont region of North Carolina.

PARTICIPANTS: The sample included 2602 community‐dwelling women over the age of 65 who were interviewed for the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE).

MEASUREMENTS: Current and past use of estrogen.

RESULTS: Of the women surveyed, 6.1% reported current estrogen use, and 18.5% reported past use. Approximately half of the participants reported using estrogen for more than 2 years. Multivariate analysis demonstrated that current estrogen users were younger, more affluent, had smaller families, and were more likely to be white and to live in an urban area than were never users. Current users were also more likely to drink alcohol and to take calcium supplements; and compared with past estrogen users, they were more likely to be white, have smaller families, and to drink alcohol.

CONCLUSION: Estrogen replacement therapy is used by a small minority of older women, especially blacks. Moreover, although women with some risk factors for osteoporosis are more likely to use estrogen, the chief determinants of estrogen utilization are socioeconomic. J Am Geriatr Soc 44:1–6, 1996.
The Relationship of Joint Symptoms with Exercise Performance in Older Adults
Authors: Coleman Eric A. , Buchner David M. , Cress M. Elaine , Chan Benjamin K.S. , de Lateur Barbara J.
Published: April 2015

OBJECTIVES: The objective of this study is to determine if exercise increases joint symptoms in older adults with a history of arthritis or produces symptoms in older adults without such history. In addition, we examine whether joint symptoms explain the large observed variation in strength gain in older adults undergoing vigorous strength training exercise, and report the incidence of musculoskeletal injuries upon initiation of an exercise program.

DESIGN: A population‐based, single blinded, randomized controlled trial with three exercise groups and one control group.

SETTING: A large urban health maintenance organization.

PARTICIPANTS: Older men and women (N = 105) aged 68 to 85, with leg strength below the 50th percentile for their age, sex, height, and weight and without neuromuscular disease or active cardiovascular disease.

INTERVENTIONS: Supervised exercise in 1‐hour sessions, three times each week, for 24 to 26 weeks. One exercise group did strength training (ST) using weight machines (n = 25); another group did endurance training (ET) using stationary cycles (n = 25); and the third group did combined strength training and endurance training (ST+ET) (n = 25). The control group (n = 30) received no intervention.

MEASUREMENTS: Strength was measured at the ankle, knee, hip, and elbow using an isokinetic dynamometer. Joint symptoms were rated on a 6‐point scale (0 = none, 5 = severe). Arthritis severity was based on self‐reported use of arthritis medication. Health status was measured with sub‐scales of the SF‐36 and Sickness Impact Profile (SIP).

RESULTS: Joint symptoms fluctuated over time in all exercise groups, but they did not improve or worsen significantly in any group. The physical dimension of the SIP and SF‐36 subscale scores, including Bodily Pain Scores, did not change over time in any group. Subjects with arthritis and joint symptoms gained as much strength with strength training as did subjects without joint symptoms. Adjustment for age, gender, baseline strength, adherence, and exercise group did not affect this finding. The rate of minor musculoskeletal injuries was 2.2 injuries per 1000 exercise hours.

CONCLUSIONS: Moderate intensity stationary cycle exercise and vigorous intensity strength training do not appear to produce or exacerbate joint symptoms in older adults. Joint symptoms did not explain the large variation in gains in strength in older adults participating in a standardized strength training exercise program. Musculoskeletal injuries occurred relatively infrequently, and no major injuries occurred. In evaluating joint pain that occurs in older adults in well regulated exercise programs, clinicians should consider other etiologies before attributing pain to exercise per se. J Am Geriatr Soc 44:14–21, 1996.
Reporting Mistreatment of Older Adults: The Role of Physicians
Authors: Rosenblatt Dorrie E. , Cho Kyung‐Hwan , Durance Paul W.
Published: April 2015

OBJECTIVE: To characterize elder mistreatment reporting patterns over time and by reporting source with specific focus on physician reporting. To determine whether demographic or socioeconomic factors influenced the reporting of elder abuse in Michigan between 1989 and 1993 and whether these factors affected physician reporting rates.

DESIGN: Analysis of the State of Michigan's records of reported cases of suspected adult abuse for the years 1989–1993.

MEASUREMENTS: Counties were categorized by size, urbanization, and average income. The study population was analyzed as four age groups: 18–64, 65–74, 75–84, and 85–99. Physician to population ratios were calculated for the county types and compared with physician reporting rates.

MAIN RESULTS: A total of 27,371 cases of possible abuse were reported, 17,238 in persons older than age 65. Physicians reported only 2% of cases, and physician reporting rates did not increase over the 5‐year period. Physician reporting rates were highest in small counties with low physician to population ratios. There was a high percentage of primary care physicians in these counties. Forty‐seven percent of all reported cases were substantiated. There was no difference in substantiation rate for physician‐reported cases compared with other professional reporting sources.

CONCLUSION: Physician reports average only 2% of all reports of suspected elder mistreatment. Primary care physicians in counties with low physician to population ratios appear to be more active in reporting mistreatment of older people. Increasing physician awareness of the problem of elder mistreatment and providing physicians with the tools to screen for mistreatment should increase the number of cases that are reported to the agencies responsible for assisting mistreated older people. J Am Geriatr Soc 44:65–70, 1996.
Effect of Pharmacologic Lipid Lowering on Health‐Related Quality of Life in Older Persons: Results from the Cholesterol Reduction in Seniors Program (CRISP) Pilot Study
Authors: Santanello Nancy C. , Barber Beth L. , Applegate William B. , Elam Janet , Curtis Carolyn , Hunninghake Donald B. , Gordon David J. ,   For the CRISP Collaborative Study Group
Published: April 2015

OBJECTIVE: To determine the effect of lovastatin therapy on health‐related quality of life in older persons.

DESIGN: A prospective, randomized, double blind clinical trial.

SETTING: Four university medical center research clinics.

PARTICIPANTS: There were 431 men and women, primarily 65 years of age or older, with low density lipoprotein levels greater than 159 mg/dL and less than 221 mg/dL. Exclusion criteria included a Mini‐Mental state score less than 24 or presence of recent cardiovascular events or other serious chronic disease likely to shorten survival.

INTERVENTION: All participants were administered the National Cholesterol Education Program step one diet and were then randomized to placebo, 20 mg lovastatin, or 40 mg lovastatin.

MEASUREMENTS: Areas of health‐related quality of life assessed in the Cholesterol Reduction in Seniors Program (CRISP) included: (1) physical functioning, (2) sleep behavior, (3) social support, (4) depression, (5) cognitive function, and (6) health perception. Three global change questions asked the patients to judge change in general health since starting the study diet or the study medication and change in ability to function or care for self. Although some patients were followed for a total of 12 months, all participants were followed for 6 months, and 6‐month data have been used for the primary analysis in this paper.

RESULTS: Patients treated with 20 mg of lovastatin had a 17% and 24% reduction in total cholesterol and LDL‐cholesterol, respectively. Patients treated with the 40‐mg lovastatin dose achieved reductions of 20% for total cholesterol and 28% for LDL‐cholesterol. Complaints of possible adverse events were remarkably similar in the two active treatment groups and the placebo group. At 6 months of follow‐up there were no statistically significant differences found in mean change scores from baseline between treatment groups on the health‐related quality of life measures (physical functioning, sleep, social support, depression, cognitive function scales, health perception) or global questions.

CONCLUSIONS: This study demonstrates that lovastatin was extremely well tolerated in an older cohort, both with regard to symptoms and to health‐related quality of life.
A Clinical Trial to Reduce Restraints in Nursing Homes
Authors: Evans Lois K. , Strumpf Neville E. , Allen‐Taylor S. Lynne , Capezuti Elizabeth , Maislin Greg , Jacobsen Barbara
Published: April 2015

OBJECTIVE: To investigate the relative effects of two experimental interventions on the use of physical restraints.

DESIGN: Prospective 12‐month clinical trial in which three nursing homes were randomly assigned to restraint education (RE), restraint education‐with‐consultation (REC), or control (C).

SETTING: Three voluntary nursing homes in the Philadelphia area providing both skilled and intermediate care.

PARTICIPANTS: A total of 643 nursing home residents over the age of 60 were enrolled at baseline, and 463 remained to completion (1 year).

INTERVENTIONS: Both RE and REC homes received intensive education by a masters‐prepared gerontologic nurse to increase staff awareness of restraint hazards and knowledge about assessing and managing resident behaviors likely to lead to use of restraints. In addition, the REC home received 12 hours per week of unit‐based nursing consultation to facilitate restraint reduction in residents with more complex conditions.

MEASUREMENTS: Restraint status was observed systematically at baseline, immediately after the 6‐month intervention, and again at 9 and 12 months. Staff levels, psychoactive drug use, and injuries were also determined.

RESULTS: Compared with baseline, the REC home had a statistically significant reduction in restraint prevalence, whereas RE and C homes did not. At 9 months (3 months post‐intervention), absolute decline in the percents restrained were 7% RE, 7% C, and 20% REC; at 12 months (6 months post‐intervention) declines were 4% RE, 6% C, and 18% REC. However, relative to baseline, these declines represent an average reduction in restraint use of 23% RE, 11% C, and 56% REC. The differences in changes over time were consistently significant (P = .01), whether considering survivors or those present at each time point, and also when controlling for differences between groups at baseline. Further, given any change in restraint use, REC residents were between 25% and 40% more likely than either RE or C residents to experience decreased restraint use. Results were achieved without increased staff, psychoactive drugs, or serious fall‐related injuries.

CONCLUSION: A 6‐month‐long educational program combined with unit‐based, resident‐centered consultation can reduce use of physical restraints in nursing homes effectively and safely. Whether extending the intervention will achieve greater reduction is not known from these results.
The Barthel Activities of Daily Living Index: Self‐Reporting Versus Actual Performance in the Old‐Old (≥ 75 years)
Authors: Sinoff Gary , Ore Liora
Published: April 2015

BACKGROUND AND PURPOSE: The Barthel Index for assessing activities of daily living (ADL) was developed particularly for young stroke patients, but it now has a wider application in the geriatric assessment profile. This study tests the validity of the Barthel Index by self‐report in the old‐old (≥ 75 years). If more than 10% of the studied population assessed themselves incorrectly (≥ 15‐point discrepancy), the test may have limitations. We set out to try to quantify and explain this discrepancy.

METHODS: During a 3‐month period, we tested 126 old‐old patients, both geriatric medical inpatients and subjects from the community, in a cross‐sectional study. Using the Barthel Index, their functional status was assessed by self‐report and by observation of performance. A measure of the magnitude of discrepancy between the two methods (discrepancy score) was calculated as the difference between the self‐report and performance total scores.

RESULTS: Comparing the self‐report with actual ADL performance scores, the mean score for self‐report was higher (90 vs 88). There was a low Kappa score in all areas of the scale (range 0.103–0.398). Twenty of the 126 patients (15.9%) scored 15 or more points in the discrepancy score. By running a multiple linear regression, we were able to explain only 21% of the variance in the discrepancy score (R2 = .21). Significant explanatory variables were the presence of cognitive impairment, source of patients from acute geriatric ward, and age (very old ≥ 85 years).

CONCLUSION: For the purpose of this study, use of the Barthel Index by self‐reporting was found to have its limitations in the old‐old (≥ 75 years), particularly with regard to the very old (≥ 85 years) medical geriatric inpatients. Therefore, we suggest that the older people may have to be assessed by the rehabilatation services using a performance‐based measure or a different self‐report test for documenting their activities of daily living, bearing in mind that self‐reported and performance‐based measures capture physical abilities differently.
Cross‐Validation of Anthropometric and Bioelectrical Resistance Prediction Equations for Body Composition in Older People Using the 4‐Compartment Model as a Criterion Method
Authors: Goran Michael I. , Toth Michael J. , Poehlman Eric T.
Published: April 2015

OBJECTIVE: To cross‐validate existing equations in the literature for their accuracy and precision for estimating body fat in older people from anthropometric measures and height2/resistance, using the 4‐compartment model as a criteria method, and to propose new practical equations with improved accuracy and precision.

DESIGN: Measurement of body composition in a cross‐sectional cohort of healthy men and women and comparison by cross‐validation techniques against existing prediction equations.

SETTING: The study was performed on subjects admitted to a General Clinical Research Center.

PARTICIPANTS: The subjects were 41 healthy women (68.2 ± 6.6 years; 64.1 ± 10.2 kg) and 41 healthy men (70.2 ± 7.0 years; 74.9 ±11.0 kg).

MEASUREMENTS: The criteria method for total body composition was the 4‐compartment model based on measurement of total body density by underwater weight, total body water by isotope dilution, and total bone mineral from dual energy X‐ray absorptiometry. The other techniques examined for accuracy and validity were body fat estimates derived by skinfolds using the Durnin and Womersley Equations; waist circumference and age using the Lean Equations; and bio‐electrical resistance using five published equations, including two derived in the older population.

RESULTS: When compared with data derived from the 4‐compartment model, the skinfold equation of Durnin and Womersley was cross‐validated successfully in women but not in men. The Baumgartner equation was the only bioelectrical resistance equation that met the criteria for successful cross‐validation in men and women, although in women the intercept (4.0 ±2.1 kg) was close to significantly different from zero (P = .06). Error in the estimates of body fat using the Durnin and Womersley and the Baumgartner equations was significantly and inversely related to fat mass (r = ‐.39 to r = ‐.56). In our data, the significant predictors of fat mass were hip circumference, calf skinfold, gender, body weight, height2/resistance, and biceps skinfold, explaining 84% of the variance.

CONCLUSIONS: The Durnin and Womersley equation is accurate for women and the Baumgartner equation is accurate for both men and women if a correction of +4 kg is made in women; however, for both equations the error in the estimate is inversely related to fat mass. We suggest new anthropometric equations for estimating body fat in older people, which may improve accuracy and precision. The new equations will need to be tested in independent cross‐validation studies.
Atrial Fibrillation in Older Stroke Patients: Association with Recurrence and Mortality After First Ischemic Stroke
Authors: Kaarisalo Minna M. , Immonen‐Räihä Pirjo , Marttila Reijo J. , Lehtonen Aapo , Salomaa Veikko , Sarti Cinzia , Sivenius Juhani , Torppa Jorma , Tuomilehto Jaakko
Published: April 2015

OBJECTIVES: The objective of this study was to determine the association of atrial fibrillation (AF) with stroke recurrence and mortality and with the causes of death in ischemic stroke patients aged 75 years and older.

DESIGN: A population‐based study.

SETTING: The cities of Turku and Kuopio in Finland.

PARTICIPANTS: The study cohort consisted of 2635 consecutive patients aged 75 years and older, with a first ischemic stroke, registered in the FINMONICA Stroke Register.

MEASUREMENTS: 28‐day and 1‐year stroke mortality, causes of death, and recurrence of stroke.

RESULTS: There were 767 stroke patients with AF (mean age 82.2) and 1868 patients without AF (mean age 81.4). Mortality was higher in the AF group both 28 days (33.9% vs 28.1%, P = .003) and 1 year after the attack (52.7% vs 43.0%, P < .001). The age‐and sex‐adjusted relative risk of death at 28 days was 1.25 in the AF group (95% confidence interval (CI) 1.04–1.50, P = .018), and at 1 year it was 1.41 (95% CI 1.18–1.67, P < .001). In a Cox proportional hazards model, 1‐year mortality risk comparing the AF‐group with non‐AF group was 1.24 (95% CI 1.10–1.39, P < .001). The strongest risk factor predicting 1‐year mortality was recent myocardial infarction (MI) (RR 1.90, 95% CI 1.49–2.42). Myocardial infarction was more often the underlying cause of death in the AF group during the period of 28 days, but not from 28 days up to 1 year. The 1‐year recurrence rate among those alive at day 28 was 11.5% in the AF group and 9.4% in the non‐AF group (P = .240).

CONCLUSION: Recent MI and AF are independent negative prognostic factors in older patients with stroke. Although the relative risk estimates attributable to AF are of the same magnitude in older as in middle‐aged stroke patients, the much higher prevalence of AF in the older patients emphasizes its absolute impact on the mortality and recurrence after the first ischemic stroke in the age group 75 years and older. The treatment of coexisting cardiac disease also has the potential to prevent deaths and recurrent stroke events in older persons. J Am Geriatr Soc 45:1297–1301, 1997.
What Is Wrong With End‐of‐Life Care? Opinions of Bereaved Family Members
Authors: Hanson Laura C. , Danis Marion , Garrett Joanne
Published: April 2015

OBJECTIVE: To describe family perceptions of care at the end of life.

METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision‐making, and symptom relief in the last month of life, and gave suggestions to improve care.

RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85).

Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%).

CONCLUSION: Bereaved family members are generally satisfied with life‐sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families. J Am Geriatr Soc 45:1339–1344, 1997.
Diuretic Usage and Withdrawal Patterns in a Dutch Geriatric Patient Population
Authors: van Kraaij Dave J.W. , Jansen René W.M.M. , Bruijns Elly , Gribnau Frank W.J. , Hoefnagels Willibrord H.L.
Published: April 2015

OBJECTIVES: To describe diuretic usage and withdrawal patterns in a population of very old geriatric patients and to evaluate the long‐term probability of remaining free from diuretic therapy after withdrawal.

DESIGN: Retrospective analysis of medical records and 1‐year follow‐up study.

SETTING: University Hospital Nijmegen and Rijnstate Hospital Arnhem, a non‐academic teaching hospital, The Netherlands.

PARTICIPANTS: All 1547 patients, aged 75 years or older, visiting geriatric medicine departments in the two hospitals for the first time in the years 1990 through 1993.

MEASUREMENTS: Data on medical history, physical examinations, and medication use were obtained from medical records. Diuretic withdrawal and motivation was recorded as reported. Record review indicating diuretic withdrawal prompted a 1‐year follow‐up investigation and collection of additional updated information from family care and/or nursing‐home physicians.

RESULTS: A total of 593 three patients (38.3%) were using diuretics. Use of diuretics increased with age from 33.6% in patients aged 75 to 79 years to 47.4% in patients aged 90 years or older (P < .05). Diuretics were withdrawn in 218 patients (36.8%), in 101 patients because of doubts about the initial or persistent indication for diuretic use and in 91 patients because of adverse effects. No reasons for withdrawal were reported in 26 patients. Withdrawal of diuretics was attempted more often in cases of diuretic prescriptions for unknown reasons (51.2%) or ankle edema without heart failure (45.0%) than when prescriptions were for heart failure (28.5%) or hypertension (35.4%). The overall probability of remaining free of diuretic therapy for 1 year was 0.41. Success of diuretic withdrawal was significantly less when congestive heart failure was the initial indication for prescription (probability 0.24). We did not find other clinical parameters related to the success of withdrawal.

CONCLUSIONS: Our study demonstrates that diuretic therapy can be withdrawn for at least a 1‐year period in a substantial number of very old geriatric patients receiving these medications, regardless of the initial indications for prescription. However, withdrawal is performed without application of uniform criteria. Future prospective studies should be directed at developing clear guidelines for diuretic withdrawal in order to facilitate identification of eligible patients and to further improve the success of withdrawal attempts.
Changes in Advance Care Planning in Nursing Homes Before and After the Patient Self‐Determination Act: Report of a 10‐State Survey
Authors: Teno Joan M , Branco Kenneth J. , Mor Vincent , Phillips Charles D. , Hawes Catherine , Morris John , Fries Brant E.
Published: April 2015

OBJECTIVE: The Patient Self‐Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision‐making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states.

DESIGN: Pre‐ and Post‐observational cohort study

PATIENTS: Nursing home residents, residing in 270 long‐term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six‐month follow‐up was obtained at both time periods.

MAIN OUTCOME MEASURES: Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a “Do Not Resuscitate” (DNR) order, a “Do Not Hospitalize” (DNH) order, or an order to forgo artificial nutrition or hospitalization.

RESULTS: The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990.

CONCLUSION: With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation.
CONGESTIVE HEART FAILURE IN OLDER ADULTS*: Epidemiology, Pathophysiology, and Etiology of Congestive Heart Failure in Older Adults
Authors: Rich Michael W.
Published: April 2015

OBJECTIVES: To review the epidemiology, pathophysiology, and etiology of congestive heart failure (CHF) in older adults.

METHODS: Published reports relevant to the epidemiology, pathophysiology, and etiology of CHF were systematically reviewed. Studies involving older adults and more recent studies were emphasized.

RESULTS: More than 75% of patients with CHF in the United States are older than 65 years of age, and CHF is the leading cause of hospitalization in older adults. CHF is also a major cause of chronic disability, and annual expenditures for CHF currently exceed $10 billion. In addition, both the incidence and prevalence of CHF are increasing, largely as a result of the aging of the population.

Older adults are predisposed to developing CHF as a result of age‐related changes in the cardiovascular system and the high prevalence of hypertension, coronary artery disease, and valvular heart disease in this age group. Although the fundamental pathophysiology of CHF is similar in younger and older patients, older individuals are more prone to develop CHF in the setting of preserved left ventricular systolic function. This syndrome, referred to as diastolic heart failure, accounts for up to 50% of all cases of CHF in adults more than 65 years of age.

Coronary heart disease and hypertension are the most common etiologies of CHF in older adults, and they often coexist. Valvular heart disease, especially aortic stenosis and mitral regurgitation, are also common in older adults, whereas nonischemic dilated cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy occur less frequently.

CONCLUSIONS: Congestive heart failure is a major public health problem in the United States today as a result of its high and increasing prevalence in the older population as well as its substantial impact on healthcare costs and quality of life. There is an urgent need to develop more effective strategies for the prevention and treatment of CHF in older individuals.
The Sequelae of Hospitalization for Congestive Heart Failure Among Older Adults
Authors: Wolinsky Fredric D. , Smith David M. , Stump Timothy E. , Overhage J. Marc , Lubitz Robert M.
Published: April 2015

OBJECTIVES: To estimate the independent effect of hospitalization for congestive heart failure (CHF) on subsequent mortality, readmission for CHF, hospitalization for any reason, and change in functional status.

DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data are linked to Medicare hospitalization and death records for 1984–1991 and to functional status reports at three biennial follow‐ups.

SETTING: In‐home and telephone interviews.

PARTICIPANTS: a total of 7527 noninstitutionalized older adults aged 70 years or older at baseline.

MEASUREMENTS: Hospitalization for CHF was defined as having one or more episodes with primary or secondary discharge ICD9‐CM codes of 428. Multivariable proportional hazards, logistic and linear regression, as well as multiple classification analysis, were used to estimate the independent effects of having been hospitalized for CHF.

RESULTS: The adjusted risk ratios for having a primary or secondary hospital discharge diagnosis of CHF on mortality (compared with not having any CHF hospital discharge diagnoses) were 1.58 (CI95% = 1.40 to 1.78) and 1.29 (CI95% = 1.15 to 1.45), respectively (P < .001). CHF readmission and rehospitalization rates were substantial, ranging from 16.0 to 47.5% at 1 year, depending on the criteria employed. The adjusted odds ratios for having any subsequent hospitalizations associated with having a primary or secondary hospital discharge diagnosis of CHF (compared with not having any CHF hospital discharge diagnoses) were 7.70 (CI95% = 6.20 to 9.57) and 2.99 (CI95% = 2.51 to 3.56), respectively (P < .001). The percent increases in the number of hospital episodes, total charges, and total length of stay attributable to having been hospitalized for CHF were significant (P < .001) and ranged from 15.5 to 66.7%. Having been hospitalized for CHF was also related significantly to greater increases in the mean number of functional limitations at follow‐up.

CONCLUSION: Hospitalization for CHF among older adults increases substantially the risk of subsequent mortality, readmission for CHF, rehospitalization for any reason, and greater functional decline. Therefore, greater attention to the prevention and management of CHF is needed.
Increased Coronary Heart Disease Mortality After the Hanshin‐Awaji Earthquake Among the Older Community on Awaji Island
Authors: Kario Kazuomi , Ohashi Takaharu
Published: April 2015

OBJECTIVES: To investigate the characteristics of earthquake (EQ)‐induced coronary heart disease (CHD) deaths.

SETTING AND PARTICIPANTS: On January 17, 1995, the south part of Hyogo Prefecture in Japan was struck by a major EQ (Hanshin‐Awaji EQ) measuring 7.2 on the Richter scale. We investigated the characteristics of EQ‐induced CHD deaths (myocardial infarction and sudden death) in the Tsuna region, which is a community with a large older population (31% of the total of 64,000 residents are 60 years of age or older) and includes the epicenter and one of the most heavily damaged areas.

MEASUREMENTS: EQ‐related CHD mortality on the basis of direct access to records of physicians who were able to continue services for the EQ victims without interruption by this disaster situation.

RESULTS: Coronary heart disease deaths increased for a few months after the EQ, and the total number from January 17 to April 30,1995, was 45, which was significantly (1.5 times) higher than the 31 deaths during the same period of the previous year (1994). The CHD deaths after the EQ all occurred in individuals more than 60 years of age and had a positive correlation with EQ‐induced damages. Concerning the onset time, CHD deaths occurred 1.8 times more often (P < .05) in the nighttime (11 PM to 5 AM) and 1.4 times as often during the morning (5 AM to 11 AM), whereas their occurrence did not vary during a 12‐hour period from 11 AM to 11 PM.

CONCLUSION: Deaths of older individuals from CHD persisted for a few months after the EQ and were especially prominent during the nighttime and morning. Reduction of stress and related coronary risk factors in this period may suppress CHD deaths after a major EQ.
Geropsychiatric Restraint Use
Authors: DeSantis Joe , Engberg Sandra , Rogers Joan
Published: April 2015

OBJECTIVES: To investigate predictors and reasons for restraint use with geropsychiatric patients.

DESIGN: A prospective, correlational study.

SETTING: The geriatric unit of an acute‐care psychiatric hospital.

PARTICIPANTS: Twenty‐one staff nurses and 131 patients admitted consecutively over a period of 6 months.

MEASUREMENTS: Disruptive behaviors were measured with the Nursing Home Behavior Problem Scale (NHBPS), cognitive function was measured with the Mini‐Mental State Examination (MMSE), mobility was measured with a Functional Mobility Screen (FMS), and reasons for restraint use were obtained with a questionnaire completed by nurses.

RESULTS: Patients with a diagnosis of dementia, impaired mobility, or behavioral problems were more likely to be restrained. The most frequent reasons given by staff for restraint use were an unsteady gait and a risk of falling. The incidence of restraint use was 27.1%.

CONCLUSION: The use of restraint with geropsychiatric patients may be more common than previously reported and requires further investigation. J Am Geriatr Soc 45:1515–1518, 1997.
Pain in the Oldest‐Old During Hospitalization and Up to One Year Later
Authors: Desbiens Norman A. , Mueller‐Rizner Nancy , Connors Alfred F. , Hamel Mary Beth , Wenger Neil S.
Published: April 2015

OBJECTIVE: To evaluate the pain experience of very old hospitalized patients during and up to 1 year after hospitalization. To understand the relationship of level of pain to demographic, psychological, and illness‐related variables.

DESIGN: Prospective cohort study.

SETTING: Four teaching hospitals.

PARTICIPANTS: 1266 patients at least 80 years of age in the Hospitalized Elderly Longitudinal Project (HELP).

MEASUREMENTS: Pain interviews during hospitalization and 2 and 6 months later. Ordinal logistic regression was used to study the association of variables with level of pain.

RESULTS: Interviews about symptoms were available for 806 (64.6% of survivors) patients during hospitalization, 614 (57.9% of survivors) at 2‐months, and 416 (48.0% of survivors) at 12 months; of these, 45.8, 49.8 and 53.6%, respectively, reported pain, and 12.9% of those with pain during hospitalization were dissatisfied with its control.

Multivariable analysis revealed that study hospital, admission diagnosis, depressed mood, alertness, and level of activity 2 weeks before admission were associated with pain during hospitalization, and pain reported during hospitalization, study site, patient level of activity 2 weeks before hospital admission, and patient education were associated with pain 2 months later.

CONCLUSIONS: Frequency of pain among very old hospitalized patients and at follow‐up is similar to that reported for other hospitalized patients. Further studies of strategies to better control pain during and after hospitalization in very old patients are needed. These studies will have to adjust for other variables associated with pain in the oldest‐old.
Urinary and Fecal Incontinence in a Community‐Residing Older Population in Japan
Authors: Nakanishi Noriyuki , Tatara Kozo , Naramura Hiromi , Fujiwara Hitoshi , Takashima Yoshihiro , Fukuda Hideki
Published: April 2015

OBJECTIVE: To estimate the prevalence and risk factors of urinary and fecal incontinence among a community‐residing older population in Japan.

DESIGN: Population‐based cross‐sectional study.

SUBJECTS: A randomly selected sample of 1473 people aged 65 years and older living in the City of Settsu, Osaka, in 1992.

MEASURES: Data collected via in‐home visits were used to estimate the prevalence of urinary and fecal incontinence and to provide information regarding potential risk factors of urinary and fecal incontinence.

RESULTS: Data were obtained from 1405 older adults, a response rate of 95.4%. The prevalence of any degree of urinary incontinence was 98/1000 in both sexes, and 87/1000 men and 66/1000 women admitted to some degree of fecal incontinence. Daily, 34/1000 and 20/1000 of the population were incontinent of urine and feces, respectively.

There was an increasing prevalence of urinary and fecal incontinence with age in both sexes, but the expected greater prevalence in women was not found.

By univariate analyses, age older than 75 years, poor general health as measured by Activities of Daily Living, stroke, dementia, no participation in social activities, and lack of life worth living (Ikigai) were associated significantly with both urinary and fecal incontinence. In the multivariate analyses using logistic regression, age older than 75 years, poor general health, and stroke were independent risk factors for any type of incontinence. Diabetes was an independent risk factor for isolated fecal incontinence, and dementia and no participation in social activities were independent risk factors for double incontinence.

CONCLUSIONS: Incontinence of urine and feces is a prevalent condition among very old people living in the community in Japan and is associated highly with health and psychosocial conditions.