bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of Formal Home Health Care Use in Elderly Patients after Hospitalization
Authors: Solomon Daniel H. , Wagner D. Raye , Marenberg Marjorie E. , Acampora Denise , Cooney Leo M. , Inouye Sharon K.
Published: April 2015

Objective: To prospectively study the incidence of and risk factors for home health care (HHC) use in a cohort of elderly medical and surgical patients discharged from acute care. Although HHC is commonly received by patients in this group, its predictors have not been well studied.

Design: Prospective cohort study.

Setting: Medical and surgical wards at a university teaching hospital, followed by 23 Medicare‐certified HHC agencies in the study catchment area.

Patients: 226 medical and surgical patients aged 70 years and older immediately after discharge from acute care.

Measurements: HHC initiated within 14 days after hospital discharge, measured by direct review of HHC agency records.

Results: The incidence of HHC initiated within 2 weeks post‐discharge was 75/226 (34%). The median duration of service was 30 days (range 3–483) with a median of 3 visits per week. Four independent predictors of HHC were identified through multivariate analysis: educational level ≤12 years (relative risk (RR) 3.3; 95% confidence interval (CI) 1.6 to 6.6); less accessible social support (RR, 1.7; CI 0.9 to 3.1); impairment in at least one instrumental activity of daily living (RR, 1.9; CI, 1.0, 3.4); and prior HHC use (RR, 2.1; CI, 1.2 to 3.6). Risk strata were created by adding one point for each risk factor present: with 0–1 risk factors, 8% used HHC; with two risk factors, 28%; with three risk factors, 45%, with four risk factors, 76%. This trend was statistically significant (P< 0.001).

Conclusions: HHC use is common among elderly patients after discharge from acute care. A simple predictive model based on four risk factors can be used on admission to predict HHC use. This model may be useful for discharge planning and health care utilization planning for the elderly population.
Early Experience with Dobutamine Stress Testing and Cardiac Cine‐tomographic Imaging in the Elderly: Antianginal Effects of Nifedipine‐GITS
Authors: Schwartz Janice B. , Caputo Gary , Abbott Joseph
Published: April 2015

Objective: To determine the effects of nifedipine‐GITS (GITS = gastrointestinal transport system) on angina and cardiovascular responses to stress‐dobutamine infusion, we used ultrafast cine‐computed tomography (CT) to assess regional wall motion, myocardial perfusion, and indices of ventricular filling and emptying.

Design: Randomized, double‐blind placebo‐controlled efficacy study after an open‐label dose titration phase.

Setting: University of California, San Francisco.

Patients: Elderly patients (>60 years; n = 9:8 male, 1 female) with coronary artery disease by history and diagnostic treadmill or coronary angiography.

Intervention: After a 3‐week open‐label dose‐titration phase, eight subjects were randomized to receive either placebo or nifedipine‐GITS at the highest tolerated dose for 2 weeks, followed by a crossover to the alternate therapy for 2 weeks. One declined because of singulus in the open‐label period.

Main Outcome Measures: Symptomatic angina relief (frequency and nitroglycerin consumption), dobutamine stress responses (time to ischemia during dobutamine infusions, cardiac output, cardiac ejection fraction, ventricular segmental wall motion, and perfusion as measured by ultrafast cine‐CT), and reported adverse effects.

Results: When compared with placebo, nifedipine‐GITS administration was associated with less frequent angina and nitroglycerin consumption (NS) and significantly decreased systolic blood pressure. Nifedipine‐GITS administration also increased resting supine heart rates. Dobutamine infusions increased heart rate, cardiac output, cardiac ejection fraction, and stroke volume and induced angina symptoms. Neither double product at angina nor systolic indices of cardiac function in response to dobutamine differed between nifedipine‐GITS and placebo, although heart rate responses were greater during nifedipine. A trend toward increased peak filling rates was seen during dobutamine stress in the nifedipine‐administration period. In most subjects (6/8), perfusion and regional wall motion abnormalities were not visualized on either rest or stress cine‐CT studies. Edema without congestive heart failure occurred frequently during nifedipine‐GITS administration.

Conclusions: These data suggest that (1) dobutamine stress can be used to induce cardiac ischemia in elderly patients with coronary artery disease, (2) nifedipine‐GITS provides symptomatic angina relief in elderly patients, (3) peripheral edema is frequent in elderly patients on nifedipine‐GITS, and (4) ultrafast computed cine‐tomography testing can be used to assess ventricular performance, but current methodology may not detect perfusion or wall motion abnormalities during angina.
Sensory Impairment and Quality of Life in a Community Elderly Population
Authors: Carabellese Corrado , Appollonio Ildebrando , Rozzini Renzo , Bianchetti Angela , Frisoni Giovanni B. , Frattola Lodovico , Trabucchi Marco
Published: April 2015

Objective: To determine the association between quality of life measures and sensory impairment in aged individuals living at home.

Design: Survey

Setting: A community survey, carried out in the historical center of a town in Northern Italy.

Patients: 1191 non‐institutionalized elders (age 70–75 years).

Measurements: Comprehensive QOL questionnaire, free‐field voice testing, and Snellen eye chart.

Results: Single sensory impairments (either visual or auditory) were significantly and independently associated with increased risk for depression (odds ratio: 2.3, 95% confidence interval: 1.5–3.4; OR:1.8, CI:1.1–2.7, respectively) and decreased self‐sufficiency in daily living activities (OR: 1.7, CI:1.1–2.6; OR:2.1, CI:1.4–3.2, respectively). Visual dysfunction, but not hearing dysfunction, was independently associated with lower social relationships (OR:2.0, CI:1.3–3.1).

Conclusion: The quality of life of community‐dwelling elderly people is significantly linked to sensory impairment, which can be detected through simple physical examination. Mood level and social relationships are particularly affected by visual impairment, whereas self‐sufficiency in daily living is more strongly related to hearing impairment.
Profile of Depressive Symptoms in Younger and Older Medical Inpatients with Major Depression
Authors: Koenig Harold G. , Cohen Harvey J. , Blazer Dan G. , Krishnan K. Ranga Rama , Sibert Thomas E.
Published: April 2015

Objective: To examine and compare the profile of cognitive symptoms, somatic symptoms, and somatic complaints in younger and older medical inpatients diagnosed with major depressive disorder (MDD)

Design: Cross‐sectional cohort.

Patients and Setting: Male patients aged 20–39 years (n = 116) and aged 70–102 years (n = 332), consecutively admitted to the medical and neurological services of a VA medical center, underwent psychiatric evaluations for depression.

Measurements: Depressive symptoms were measured using the observer‐rated Hamilton Depression Scale and the self‐rated Geriatric Depression Scale using an “inclusive” approach (symptoms rated regardless of etiology). Data on 12 common somatic complaints were also collected. Clinical diagnoses of MDD were made by a psychiatrist based on the Diagnostic Interview Schedule and other psychiatric and physical health data.

Results: After controlling for severity of medical illness, functional status, and alcohol use, symptoms that discriminated MDD best among younger men were loss of interest, feelings of guilt or of being a burden, suicidal thoughts, and depressed mood (primarily cognitive and affective symptoms). Among older men, loss of interest, insomnia, suicidal thoughts, and hypochondriasis most strongly differentiated depressed from non‐depressed patients (mixture of cognitive and somatic symptoms); fatigue, weight loss, genital symptoms, and somatic anxiety were weakly related or unrelated to MDD. Number of somatic complaints (headache, dizziness, palpitations, etc.) helped differentiate patients with MDD; although equally common among depressed young and older patients, a distinct pattern of complaints emerged in each age group.

Conclusions: Cognitive symptoms of depression can help to distinguish medical inpatients with and without MDD. In older adults, however, somatic symptoms cannot be ignored and may be more important for diagnosing MDD than previously realized. These findings will help clinicians identify patients with MDD and differentiate them from non‐depressed patients with medical illness.
Total Quality Management: Administrative and Clinical Applications in Nursing Homes
Authors: Schnelle John F. , Ouslander Joseph G. , Osterweil Dan , Blumenihal Sheldon
Published: April 2015

Objective: Describe the application of the Total Quality Management (TQM) model to the unique work force, resident population, and regulatory issues that characterize long term care settings.

Design: The key differences between TQM and current management and training practices in nursing homes are described. A specific data‐based example is provided of a successful TQM application to health care involving clinical work processes related to incontinence care.

Conclusion: Significant organizational and clinical obstacles must be overcome if TQM is to improve the quality of life and satisfaction of nursing home residents and their families as it has improved the efficiency and product quality in hospital and non‐health‐care settings.
Alterations in Glucose Metabolism in Patients with Alzheimer's Disease
Authors: Meneilly Graydon S. , Hill Amanda
Published: April 2015

Objective: To determine the alterations in glucose metabolism that occur in patients with Alzheimer's Disease (AD).

Design: Cross‐sectional comparison of AD and healthy controls.

Setting: A University teaching hospital.

Patients: Healthy controls (n = 14, BMI: 24.9 ± 0.5 kg/M2, age 73 ± 1 years) and patients with AD (n = 12, BMI: 23.9 ± 1.0 kg/M2, age 72 ± 1 years). All controls and patients with AD had a normal history and physical examination, a negative family history of diabetes, and took no medications.

Measurements: All patients and controls underwent an assessment of their dietary intake and physical activity, a 3‐hour oral glucose tolerance test (OGTT), and a 2‐hour hyperglycemic glucose clamp study.

Results: Total caloric intake (AD: 27.1 ± 1.3 kcal/kg/day; Control: 23.6 ± 1.6 kcal/kg/day; P = ns) and intake of complex carbohydrates (AD: 5.9 ± 0.4 kcal/kg/day; Control: 6.5 ± 0.3 kcal/kg/day; P = ns) were not different between groups. Leisure time physical activity was greater in controls (AD: 2970 ± 411 kcal/week; Control: 5229 ± 864 kcal/week; P < 0.05). Patients with AD had higher fasting glucose (AD: 5.9 ± 0.2 mmol/L; Control: 5.1 ± 0.1 mmol/L; P < 0.01) and insulin (AD: 144 ± 20 pmol/L; Control: 100 ± 6 pmol/L; P < 0.05) values. In response to the OGTT, the area under the curve for glucose and insulin was similar in both groups. During the hyperglycemic clamp, steady‐state glucose values were higher in the Alzheimer's patients (AD: 11.5 ± 0.2 mmol/L; Control: 10.9 ± 0.1 mmol/L, P < 0.01). First‐ and second‐phase insulin responses were similar in each group. The insulin sensitivity index (units: mL/kg.min per pmol/L × 100), a measure of tissue sensitivity to insulin, was reduced in the patients with AD (AD: 0.59 ± 0.06; Control: 0.79 ± 0.07; P < 0.05).

Conclusions: We conclude that early AD is characterized by alterations in peripheral glucose metabolism, which may relate, in part, to alterations in physical activity.
Measured versus Estimated Creatinine Clearance in a High‐Functioning Elderly Sample: MacArthur Foundation Study of Successful Aging
Authors: Malmrose Lynda C. , Gray Shelly L. , Pieper Carl F. , Blazer Dan G. , Rowe John W. , Seeman Teresa E. , Albert Marilyn S.
Published: April 2015

Objective: To assess the validity of several equations for estimating creatinine clearance in a large sample of high‐functioning, community‐dwelling elderly.

Design: Serum and 12‐hour urine samples were collected and assayed for creatinine using the Jaffe total chromagen method. Fifteen clearance‐estimating equations were evaluated for bias, accuracy, correlation with measured clearance values, and frequency of erroneous placement into renal function categories. Stepwise regression modeling and reliability testing were performed on a split sample to construct and assess a novel creatinine‐clearance‐estimating equation.

Setting: New Haven, Connecticut, East Boston, Massachusetts, and a five‐county region in and around Durham, North Carolina.

Participants: A subsample of community‐dwelling men and women (age range 70–79 years) from the Established Populations for Epidemiological Studies of the Elderly was screened for physical and cognitive functioning and placed into high‐, medium‐, and low‐functioning groups (n = 1354). High‐functioning respondents who provided blood and complete urine samples (n = 762) were included in the present study.

Results: In general, estimated creatinine clearance was more closely correlated to measured values in males than in females. Most equations underestimated creatinine clearance, with average bias ranging from—33.1 mL/min to +19.6 mL/min. Predictive accuracy ranged from 18.2 mL/min to 38.0 mL/min. Equations were variable in their erroneous placement of individuals into renal function categories. Regression modeling yielded an equation which contained novel components but failed to provide better estimates of creatinine clearance than those already available.

Conclusions: The equations evaluated here provide unacceptable predictions of creatinine clearance in normally aging individuals. We advocate the use of serum drug concentration measurements when available and encourage investigation into timed urine collections of short duration as alternatives to clearance‐estimating equations in the elderly.
Relationship between Cognitive Status and Behavioral Symptoms in Alzheimer's Disease and Mixed Dementia
Authors: Kurita Akira , Blass John P. , Nolan Karen A. , Black Ronald S. , Thaler Howard T.
Published: April 2015

Objective: To investigate the relationship between cognitive and behavioral impairments in Alzheimer's disease (AD) and to examine whether the addition of cerebrovascular disease modifies that relationship.

Design: Correlational analysis.

Setting: An outpatient dementia clinic.

Patients: An autopsy‐confirmed series of 28 patients with AD and 16 patients with mixed Alzheimer and vascular dementia (MIX).

Measurements: Neuropsychological and behavioral tests during life: Mini‐Mental State (MMS), Blessed Dementia Scale (BDS), Haycox Dementia Behavior Scale (HDBS), and two non‐cognitive functional scales derived from the BDS and HDBS.

Results: In the AD group, MMS scores correlated significantly with scores on the BDS, HDBS, and two non‐cognitive functional scales. In the MIX group, however, no significant relationship was observed between MMS scores and scores on any of the behavioral measures.

Conclusions: These observations suggest that in AD, cognitive and behavioral impairments progress simultaneously. However, with the addition of a vascular component to the dementing process, cognitive and behavioral impairments may progress more independently.
Changes in Orders Limiting Care and the Use of Less Aggressive Care in a Nursing Home Population
Authors: Holtzman Jeremy , Pheley Alfred M. , Lurie Nicole
Published: April 2015

Objective

To examine changes in the aggressiveness of care of the nursing home population and to determine the factors that predict whether care is limited.

Design

Retrospective chart review.

Setting

All nursing homes in Hennepin County, Minnesota that care for Medicaid patients.

Patients

A random sample of 1605 residents of Hennepin County, MN nursing homes from 1984 and 1988 who were also Medicaid beneficiaries. The sample was stratified by year and by whether the resident died in that year. The residents were sampled disproportionately to allow approximately 400 individuals in each stratum. A total of 1405 charts (87%) was reviewed; the remainder had either been lost or destroyed.

Main Outcome Measure

Orders limiting care (do not resuscitate, supportive care only, etc.), care that was less aggressive than care usually given to a person of that age (eg, not using antibiotics for a clear infection or not sending a resident to the hospital for an illness for which someone would “usually” be sent to the hospital), determined implicitly through chart review.

Results

The demographic characteristics of the nursing home population did not change between 1984 and 1988, but the population had significantly greater severity of illness in 1988. The percentage of residents with 'sdo not resuscitate's orders (DNR) increased from 12% to 37% (P < 0.0001), and the use of other orders to limit care (do not hospitalize, supportive care only, etc.) increased from 12% to 17% (P < 0.05). The use of CPR did not change between the two years but the percentage of residents who were found to receive less aggressive care through implicit chart review increased from 31% to 40% (P < 0.01). The year the resident was in the nursing home, the severity of illness, functional status, and dementia were significant predictors of DNR status. Factors that predict receipt of less aggressive care were similar except that age was also a significant predictor.

Conclusions

The nursing home population received less aggressive care in 1988 than in 1984. Further, there was a discrepancy between what was ordered and what was delivered in the nursing home in that residents with DNR orders had care limited beyond the withholding of CPR.
Relationship of Age with Eligibility for Thrombolytic Therapy and Mortality Among Patients with Suspected Acute Myocardial Infarction
Authors: Krumholz Harlan M. , Friesinger Gottlieb C. , Cook E. Francis , Lee Thomas H. , Rouan Gregory W. , Goldman Lee
Published: April 2015

Objective: To determine the relationship of age and the percentage of patients presenting to the emergency department with myocardial infarction who meet conventional electrocardiographic and time‐to‐presentation criteria for thrombolytic therapy.

Design: Prospective cohort study.

Setting: Emergency departments of three university hospitals and four community hospitals.

Patients: Patients enrolled in the Multicenter Chest Pain Study, an investigation of patients aged 30 years or older presenting to the emergency department with the chief complaint of anterior, precordial, or left lateral chest pain unexplained by obvious local trauma or abnormalities on the chest radiograph.

Interventions: None.

Measurements: The frequency of patients who presented with conventional electrocardiographic and time‐to‐presentation criteria for thrombolysis.

Main Results: Of a total of 12,140 patients who were enrolled in the Multicenter Chest Pain Study, 10,850 had information about their electrocardiogram and their time‐to‐presentation. Acute myocardial infarction occurred in 1,584 patients, 746 of whom were over age 65. Among patients presenting to the emergency department with acute myocardial infarction, the proportion who arrived within 6 hours of the onset of pain and had ST‐segment elevation or pathologic Q‐waves not known to be old decreased significantly with increasing age, from 34% in patients under 65 years to 18% for those 75 years and older. In addition, comorbidities that would have contraindicated thrombolytic therapy were present in an additional 12% of myocardial infarction patients who were older than 65 years.

Conclusion: Although other analyses have shown that thrombolytic therapy is cost‐effective for eligible elderly patients with acute myocardial infarction, only a small percentage of very elderly patients who present to the emergency department with acute myocardial infarctions meet current eligibility criteria to receive it, so thrombolysis is unlikely to narrow the difference in mortality rates for young as compared with elderly patients with acute infarctions.
A Prospective Community‐Based Pilot Study of Risk Factors for the Investigation of Elder Mistreatment
Authors: Lachs Mark S. , Berkman Lisa , Fulmer Terry , Horwitz Ralph I.
Published: April 2015

Purpose: To identify risk factors for the investigation of elder abuse, neglect, self‐neglect, exploitation, and abandonment in a population‐based observational cohort of community living elders.

Study Population: Population‐based sample of 2,812 community‐living men and women in New Haven, Connecticut who were over age 65 in 1982.

Methods: Matching process whereby cohort members who were investigated by Connecticut's State Ombudsman on Aging in 1985 or 1986 were identified.

Analysis: Relative risks for ombudsman investigation in 1985 or 1986 were calculated based on risk factors status at baseline interview in 1982.

Results: Sixty‐eight (2.4%) members of the cohort received investigation. Features at cohort entry significantly associated with investigation in multiple logistic regression included: requiring assistance with feeding (Adjusted OR 3.5, 95% CI 1.2, 11.7), being a minority elder (Adj. OR 2.3, 95% CI 1.4, 2.8), over age 75 at cohort inception (Adj. OR 1.9, 95% CI 1.1, 3.1), and having a poor social network as defined by a social network index (Adj. OR 1.7, 95% CI 1.0, 2.7). When stratified by race, requiring assistance with feeding was associated with ombudsman investigation in minority elders (Adj. OR 10.8, 95% CI 2.8, 40.5) but not non‐minority elders (Adj. OR 1.1, 95% CI 0.5, 7.5).

Conclusion: Functional disability, minority status, older age, and poor social networks were associated with investigation for elder mistreatment in this prospective, community‐based population of men and women over the age of 65.
A Medical Unit for the Acute Care of the Elderly
Authors: Palmer Robert M. , Landefeld C. Seth , Kresevic Denise , Kowal Jerome
Published: April 2015

Older patients often experience a loss of independent physical functioning during the course of an acute illness requiring hospitalization. This functional decline is associated with serious sequelae including prolonged hospital stay, nursing home placement, and mortality. Elements of hospitalization may contribute to the progression or persistence of functional decline. The Unit for Acute Care of the Elderly (ACE Unit) at University Hospitals of Cleveland is an acute care general medical service that is designed to foster the independent functioning of patients. The Prehab Program of Patient Centered Care on the ACE Unit is a multifaceted intervention that integrates geriatric assessment into the optimal medical and nursing care of patients in an interdisciplinary environment. The Prehab Program has several key elements tailored to each individual patient's needs: a prepared environment, patient‐centered care, multidimensional assessment and non‐pharmacologic prescriptions, medical care review, and home planning. Standards of care serve to reduce the risk of iatrogenic illness resulting from polypharmacy, use of physical restraints, and diagnostic procedures. Nurse‐initiated guidelines contribute to prevention of functional decline and to restoration of independent patient functioning. The effectiveness of the ACE Unit is being evaluated in a randomized clinical trial.
Challenges for Acute Care Geriatric Inpatient Units Under the Present Medicare Prospective Payment System
Authors: Fillit Howard
Published: April 2015

The Mount Sinai Medical Center's Geriatric Evaluation and Treatment Unit (GETU) is a 16‐bed acute care geriatric unit that operates under the Medicare Prospective Payment System (PPS) in an academic medical center environment. The Medicare PPS and the needs of our local health care system have played a considerable role in the development and operation of our inpatient acute care geriatric unit. The GETU provides acute geriatric care and geriatric assessment and is a site for education and clinical research. The GETU serves a targeted group of acutely ill, hospitalized frail elderly with complex, interdisciplinary needs. The multidisciplinary GETU team was financed from generally available and justifiable hospital resources. Geriatric assessment is conducted under the Medicare PPS during the process of acute care without prolonging hospital length of stay. In fact, during the past 6 years, the introduction of geriatric care and assessment programs has been associated with a significant reduction in hospital length of stay and hospital costs for this complex and difficult population. It is our experience that an acute care geriatric unit functioning under traditional Medical Prospective Payment can have the dual effect of enhancing care and reducing hospital costs for the hospitalized frail elderly.
The Epidemiology of Adverse and Unexpected Events in the Long‐Term Care Setting
Authors: Gurwitz Jerry H. , Sanchez‐Cross Maria T. , Eckler Marie A. , Matulis John
Published: April 2015

Objective: To describe the adverse and unexpected events reported by staff over a 1‐year period in a large, long‐term care institution.

Design: A retrospective review of resident incident reports.

Setting: A 703‐bed, academically oriented, long‐term care facility.

Patients: Residents of the facility have a mean age of 88.5 years, are 76% female, and have an average length of stay of 4.3 years.

Measurements and Main Results: Of the 3,390 adverse and unexpected events reports over the 1‐year study period, falls (with and without associated injury) were the most frequently reported incidents, followed by non‐fall‐related injuries, medication‐related events, and wandering episodes. While a large proportion of falls occurred in ambulating residents (47%), the majority occurred under different circumstances including falls from bed, wheelchair, and commode/toilet. Bruises and skin tears were the most frequently reported fall‐and non‐fall‐related injuries. The annual incidence rates for falls, fall‐related injuries, and non‐fall‐related injuries varied according to resident care unit level, with semi‐dependent residents experiencing the highest rates of falls and dependent residents experiencing the highest rates of non‐fall‐related injuries. Circadian patterns in the incidence of these events varied according to resident care level.

Conclusions: Information regarding adverse and unexpected events in the long‐term care setting can be organized into databases that allow analysis of patterns and trends. The results of these analyses may be helpful in targeting limited resources to areas of greatest need within an individual institution and for comparing quality of care across different long‐term care facilities. J Am Geriatr Soc 42:33–38, 1994
Self‐Reported Causes of Physical Disability in Older People: The Cardiovascular Health Study
Authors: Ettinger Walter H. , Fried Linda P. , Harris Tamara , Shemanski Lynn , Schulz Richard , Robbins John , Group CHS Collaborative Research
Published: April 2015

OBJECTIVE: To determine the major conditions and symptoms reported to cause difficulty in 17 physical tasks of daily life and the criterion validity of self‐report of diseases given as the causes of the difficulty in functioning, in community‐dwelling older people.

DESIGN: Cross sectional analyses of data obtained in an observational cohort study.

SETTING: Research clinics in four US communities: Winston‐Salem, NC, Hagerstown, MD, Pittsburgh, PA, and Sacramento, CA.

PARTICIPANTS: 5201 community‐dwelling people ≥ 65 years old.

RESULTS: Arthritis and other musculoskeletal diseases were given as the primary causes of difficulty in performing physical tasks by 49.0% of the participants reporting difficulty in any task, followed by heart disease (13.7%), injury (12.0%), old age (11.7%), lung disease (6.0%), and stroke (2.9%). The self‐reports of diseases that caused disability varied by task. Whereas arthritis was given as a cause of difficulty in most of the 17 different tasks, heart and lung disease were more likely to be reported as causing difficulty with activities requiring high aerobic work capacity such as walking one‐half mile or doing heavy housework. Stroke was more likely to be reported as causing difficulty with use of the upper extremities and in performing basic activities of daily living.

There was a high degree of consistency (91%) between the diseases and symptoms reported to cause disabilities. The percentage of people who reported a disease as the cause of their difficulty performing a task and had independent confirmation of the diagnosis was 85% in men and 71% in women, and varied according to type of disease and the individual's cognitive status and health status.

CONCLUSION: These data suggest that age‐related chronic diseases are important causes of disability in older people but that the type of disability is dependent on the underlying disease that causes the disability. Also, self‐report of the cause of disability appears to be generally accurate but is influenced by gender, health status, and type of disease.
Pharmacokinetics of Methylprednisolone in Elderly and Young Healthy Males
Authors: Tornatore Kathleen M. , Logue Gerald , Venuto Rocco C. , Davis Paul J.
Published: April 2015

OBJECTIVE: To characterize and compare the pharmacokinetics of a single intravenous dose of methylprednisolone in elderly and young healthy males.

DESIGN: A randomized, parallel pharmacokinetic trial.

SETTING: A public university‐affiliated hospital.

SUBJECTS: Seven healthy, elderly white males (aged 69 to 82 years) and five healthy, young white males (aged 24 to 37 years) who gave informed consent and fulfilled all screening criteria.

MEASUREMENTS: Serial blood samples were obtained over a 24‐hour study period after intravenous administration of a 10‐mg dose of methylprednisolone. Serum methylprednisolone concentrations were determined by high performance liquid chromatography and utilized to determine the pharmacokinetic parameters.

RESULTS: Methylprednisolone serum concentrations declined in a linear manner in both groups. However, 4 hours after the dose, the mean serum concentration of methylprednisolone was 50.9 ± 15.1 ng/mL in the elderly group and 37.6 ± 7.5 (P = 0.07) ng/mL in the young group. The clearance of methylprednisolone was 237 ± 62 mL/h/kg, with a volume of distribution of 1.10 ± 0.07 L/kg, for the elderly group, whereas the young males had a mean drug clearance of 359 ± 90 mL/h/kg (P < 0.05) and a mean volume of distribution of 1.28 ± 0.34 L/kg. The half‐life of methylprednisolone ranged from 1.90 to 5.40 hours in the elderly group; the range was 1.99 to 3.31 hour (P = 0.16) in the young group.

CONCLUSION: A slower methylprednisolone clearance was noted in the elderly group compared with the young counterparts. This pharmacokinetic alteration seen in healthy elderly subjects may contribute to the increased incidence of adverse effects from chronic glucocorticoid therapy that has been observed among elderly patients.
Risk Factors for Non‐Insulin‐Dependent Diabetes Mellitus Requiring Treatment in the Elderly
Authors: Gurwitz Jerry H. , Field Terry S. , Glynn Robert J. , Manson JoAnn E. , Avorn Jerry , Taylor James O. , Hennekens Charles H.
Published: April 2015

OBJECTIVE: To examine the relationship of possible modifiable risk factors, including obesity, physical activity level, alcohol consumption, blood pressure, and thiazide diuretic use with the development of non‐insulin‐dependent diabetes mellitus (NIDDM) requiring treatment among a large cohort of community‐dwelling elderly.

SETTING: The East Boston Senior Health Project, one of four components of the National Institute on Aging‐sponsored Established Populations for the Epidemiologic Study of the Elderly (EPESE).

PARTICIPANTS: Residents of East Boston who were 65 years of age or older.

MEASUREMENTS: We performed a prospective cohort study with follow‐up over two consecutive 3‐year time periods beginning in 1982–1983. The main outcome measure was the occurrence of NIDDM, defined as new treatment with a hypoglycemic agent. A total of 2737 study participants contributed 4682 3‐year intervals for analysis.

MAIN RESULTS: NIDDM requiring hypoglycemic therapy occurred in 185 participants over the duration of the study. High body mass index (>26 kg/m22) (adjusted odds ratio 2.4, 95% confidence interval 1.3–4.4) and low physical activity level (adjusted odds ratio 1.5, 95% confidence interval 1.0–2.1) were significant predictors of NIDDM in a multiple logistic regression model adjusting for age, sex, blood pressure, and self‐report of “high blood sugar”; moderate alcohol consumption (0.5‐< l ounce per day) had an inverse relation to NIDDM of borderline significance (adjusted odds ratio 0.4, 95% confidence interval 0.2–1.0). Those receiving one or more non‐thiazide antihypertensive agents had a higher risk of developing NIDDM in a model including age, sex, body mass index, various antihypertensive regimens, physical activity level, alcohol consumption, blood pressure, and self‐report of “high blood sugar.” Thiazide diuretic therapy alone or in combination with another antihypertensive was not associated with NIDDM.

CONCLUSIONS: Our findings suggest a positive relationship of obesity and low physical activity level with the development of NIDDM requiring treatment in elderly persons. The inverse association of borderline significance between moderate alcohol use and NIDDM deserves further study. Thiazide diuretic therapy conferred no excess risk for developing NIDDM in this older population although selection factors in the choice of antihypertensive therapy may partially explain the absence of a thiazide effect.
Appropriateness of Medication Prescribing in Ambulatory Elderly Patients
Authors: MD Kenneth Schmader , Hanlon Joseph T. , Weinberger Morris , Landsman Pamela B. , Samsa Gregory P. , Lewis Ingrid , Uttech Kay , Cohen Harvey J. , Feussner John R.
Published: April 2015

OBJECTIVE: To assess the quality of medication prescribing in ambulatory elderly patients on multiple medications using the Medication Appropriateness Index (MAI).

DESIGN: Cross‐sectional study.

SETTING: General Medical Clinic of the Durham VA Medical Center.

PATIENTS: 208 elderly outpatients on five or more regularly scheduled medications.

MEASUREMENTS: Medication prescribing appropriateness was measured with the MAI, a reliable method that employs 10 implicit criteria. A weighted MAI score (range 0–18 per drug) served as a summary measure of appropriateness.

RESULTS: There were 1644 medications evaluated; 26% received no inappropriate ratings, 37% had one, 19% had two, and 18% had three or more. Of 16,440 ratings, 2295 (14%) were evaluated as inappropriate. The percentage of inappropriate ratings varied across prescribing dimensions: drug‐drug interactions, 0%; drug‐disease interactions, 1.4%; medication effectiveness, 4.7%; therapeutic duplication, 5.7%; indication, 11.5%; duration of treatment, 16.5%; dosage, 17.3%; practical directions, 20.3%; cost, 29.7%; and correct directions, 32.4%. The mean MAI score for all medications was 2.2 ± 2.1 (range 0–10) and varied by therapeutic class. MAI scores were significantly lower for medications with a high potential for adverse effects compared with those with a low potential (MAI score of 1.8 vs 2.9, P < 0.001). Regression analysis revealed that no patient characteristics were associated with a higher likelihood of inappropriate prescribing.

CONCLUSIONS: Medication prescribing for elderly outpatients taking multiple medications was substantially appropriate. Prescribing dimensions with the most room for improvement were more exact directions, less expensive drugs, and practical directions. Drugs at high risk for adverse effects were prescribed more appropriately than those at low risk.
Characteristics of Nonresponders in A Community Survey of the Elderly
Authors: Norton Maria C. , Breitner John C. S. , Welsh Kathleen A. , Wyse Bonita W.
Published: April 2015

OBJECTIVE: To identify predictors of nonresponse in a community survey of cognitive status in the elderly.

DESIGN: Cross‐sectional community survey with two stages of recruitment: an initial, less‐intensive method, followed by a more aggressive approach that included face‐to‐face contact. Characteristics of initial nonresponders and responders were compared.

SETTING: A close‐knit rural community with higher than usual proportions of elderly, especially the very old. Subjects were interviewed in their homes. Collateral informants were subsequently interviewed by telephone.

PARTICIPANTS: Utah heads of household aged 75 and older who resided in a noninstitutionalized setting.

MEASUREMENTS: Mini‐Mental State Examination (MMSE), Dementia Questionnaire, and an autobiographical risk factor and family history questionnaire provided measures for all independent variables. The dependent variable was status as initial responders or initial nonresponders.

RESULTS: An initial participation rate of 63% was achieved, but a final rate of 93% was achieved when initial nonresponders were contacted later face‐to‐face. MMSE score was significantly related to responder status when analyzed alone (p = ‐.19, P = 0.02) and remained a significant predictor after adjusting for education and whether born in Cache County (P = ‐.16, P = 0.041) or current drinking, diabetes, or “other” health problems (P = ‐.18, P = 0.028). After controlling for the informant report of subject's problems with activities of daily living, MMSE score fell just below statistical significance (P = ‐.16, P = 0.079).

CONCLUSIONS: Nonresponders in community surveys of the elderly appear to be disproportionately cognitively impaired. The increase in participation rates achieved after more persistent recruitment suggests that many initial nonresponders can still be recruited if intensive methods are used.
Personality Disorder Correlates of Late and Early Onset Depression
Authors: Abrams Robert C. , Rosendahl Eileen , Card Cheryl , Alexopoulos George S.
Published: April 2015

OBJECTIVE: To compare the lifetime personality dysfunction of geriatric patients having late and early onset of major depression.

DESIGN: Group comparisons.

SETTING: Inpatient geriatric psychiatry unit and hospital‐based geriatric psychiatry outpatient clinic.

PATIENTS: Volunteer sample of recovered elderly depressives with history of early onset of major depression (age < 60) (n = 16) and history of late onset of major depression (age > 60) (n = 14).

MAJOR OUTCOME MEASURE: Personality Disorder Examination, containing diagnostic and dimensional scores for DSM‐III‐R personality disorders.

RESULTS: The two groups had similar demographic profiles and levels of depression after treatment. Early onset subjects had significantly higher mean dimensional scores in the avoidant, dependent, and not otherwise specified NOS personality disorders, and higher dimensional scores with a trend toward significance in 6 additional personality disorders.

CONCLUSIONS: Early onset geriatric depressives may have more lifetime personality dysfunction than late onset subjects. Greater personality dysfunction in early onset subjects may reflect postdepressive changes, predisposition, or a low grade depressive subtype.
Silent Exertional Myocardial Ischemia in the Elderly: A Quantitative Analysis of Anginal Perceptual Threshold and the Influence of Autonomic Function
Authors: Ambepitiya Gamini , Roberts Mark , Ranjadayalan Kulasegaram , Tallis Raymond
Published: April 2015

OBJECTIVE: To assess the perception of angina in the elderly and its relationship to autonomic function.

DESIGN: Prospective cohort study of patients with exertional ischemia.

SETTING: Medical, geriatric and cardiac outpatient clinics in two centers.

PARTICIPANTS: All subjects had ischemic heart disease as evidenced by positive treadmill stress tests and, in some, diagnostic angiography and/or documented Q wave infarction. In the first study (I), 37 older patients (range 70–82 years) and 39 younger patients (range 42–59 years) were studied. In a subsequent study (II), a further 49 patients were divided into 2 groups: those with good perception of angina (Anginal Perception Threshold < 15 seconds, group A, 26 patients) and those with no angina despite ischemia (group B, 23 patients).

MEASUREMENTS: Anginal perceptual threshold (APT), age, cardiovascular autonomic function, and blood pressure were measured. APT was defined as the time between onset of 1 mm ST depression to the onset of angina during treadmill stress testing. Autonomic function was studied using heart rate ratios before and after the valsalva maneuver, heart rate responses to deep breathing, and heart rate and blood pressure responses to standing.

RESULTS: In study I, APT in the older patients was delayed by a median value of 49 seconds [79 (range 15–188) versus 30 (–99 to 97) seconds in the younger patients, P < 0.001]. There was no significant correlation between prolonged APT and autonomic dysfunction when younger and older groups were analyzed independently or together. When, however, the high APT subgroup (APT > 30 seconds) was analyzed separately, there was a significant correlation between APT prolongation and impaired valsalva response (r = −0.4; P < 0.005).

In study II, 21 of 23 patients (91.3%) with positive exercise test but with no angina (group B) had at least one abnormal autonomic function test compared with 5 of 26 (19%) patients with good anginal perception (group A). Of note, group A was significantly younger than group B [60 (53–63) years vs 66 (62–70 years, P < 0.001].

CONCLUSION: Elevation of APT in the elderly suggests that warning of critical myocardial ischemia is delayed. Autonomic dysfunction may be one of the underlying mechanisms.
Fall Frequency and Characteristics and the Risk of Hip Fractures
Authors: Cumming Robert G. , Klineberg Robin J.
Published: April 2015

OBJECTIVES: The 2 objectives of this study were to investigate the association between history of falls and risk of hip fracture and to identify characteristics of falls that determine whether or not a hip fracture will occur.

DESIGN: Population‐based case‐control study.

SETTING: Subjects were selected from the community and from nursing homes in Sydney, Australia.

PATIENTS: There were 412 subjects (205 cases, 207 controls) in the part of the study concerned with falls frequency and risk of hip fracture (age range 65–100 years). Differences between hip fracture‐related falls and other falls were studied in 209 cognitively intact subjects: 84 controls who had fallen at least once in the previous 3 years and 125 cases.

MEASUREMENTS: Data were collected with an interviewer‐administered questionnaire.

MAIN RESULTS: There was a strong relationship between reported number of falls in the past year and risk of hip fracture. This relationship was stronger among men than among women. There was only 1 statistically significant fall characteristic associated with risk of hip fracture; falling while turning was much more likely to lead to a hip fracture than falling when walking in one direction (age‐ and sex‐adjusted odds ratio: 7.9, 95% confidence interval: 1.4–43.0).

CONCLUSIONS: (1) Taking a simple falls history is a useful way of identifying elderly people, particularly men, at increased risk of hip fracture; (2) The direction of a fall is an important determinant of hip fracture occurrence.
Longitudinal Study of Depression and Health Services Use Among Elderly Primary Care Patients
Authors: Callahan Christopher M. , Hui Siu L. , Nienaber Nancy A. , Musick Beverly S. , Tierney William M.
Published: April 2015

OBJECTIVE: To describe the prevalence and 9‐month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use.

DESIGN: Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES‐D) scale and identification of patients' outpatient health services use through an electronic medical record system.

SETTING: An academic primary care group practice at an urban ambulatory care clinic.

PATIENTS/PARTICIPANTS: 1711 patients aged 60 and older who completed the CES‐D at baseline and 9 months later; 935 of these patients also completed the CES‐D at 6 months.

MEASUREMENT AND MAIN RESULTS: The prevalence of significant symptoms of depression (CES‐D ≥ 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES‐D either at baseline or 9 months, and the 9‐month incidence was 11.7%. Among the patients re‐interviewed at both 6 and 9 months, the 6‐month incidence was 12%, and the incidence between the 6‐ and 9‐month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9‐month follow‐up. Baseline and 6‐month CES‐D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9‐month CES‐D score. Patients above the threshold on the CES‐D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES‐D threshold over the 9‐month window (all P values < 0.01).

CONCLUSIONS: Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9‐month period. Patients who exceeded the threshold on the CES‐D at any time during the study had significantly greater health services use and poorer perceived health.
Psychological Factors Associated with Chronic Dizziness in Patients Aged 60 and Older
Authors: Sloane Philip D. , Hartman Marilyn , Mitchell C. Madeline
Published: April 2015

OBJECTIVE: To identify the prevalence and character of psychological disorders accompanying chronic dizziness in older patients.

DESIGN: Case series of patients from a geriatric dizziness clinic, with comparison data from age‐ and sex‐matched healthy community controls. Both cases and controls received screening psychological testing; all cases were evaluated by a clinical psychologist as part of the dizziness clinic evaluation.

SETTING: Multidisciplinary Geriatric Dizziness Clinic.

PARTICIPANTS: Fifty six consecutive patients with chronic dizziness, evaluated by a multidisciplinary Geriatric Dizziness Clinic, and 68 healthy volunteers whose age and sex distribution matched that of the dizziness clinic patients.

MEASUREMENTS: Standardized questionnaire for medical, functional, and demographic data; the anxiety, depression, somatization, and phobic anxiety subscales of the Symptom Checklist‐90 (SCL‐90‐R); the Tinetti gait and motor screen; a physical therapy evaluation; selected laboratory tests; evaluation by a geriatrician; and a formal evaluation by a clinical psychologist, including a semi‐structured interview. Psychological diagnoses were assigned based on DSM‐III‐R criteria.

MAIN RESULTS: Of these patients with chronic dizziness, 37.5 percent had a psychological diagnosis causing or contributing to their dizziness problem. Of these, only 3 were felt to have a primary psychological cause of their dizziness, and 18 had secondary psychological diagnoses. Anxiety disorders, depression, and adjustment reactions were the most common diagnoses. On multivariate analysis, factors predicting a psychological diagnosis were a positive response to hyperventilation testing, a high score on the SCL‐90 anxiety subscale, and fatigue as a precipitant of dizziness. In addition, dizziness clinic patients scored significantly higher (P< 0.001) on all 4 subscales of the SCL‐90 when compared with the healthy elderly, suggesting a greater degree of psychological distress among these elderly with chronic dizziness.

CONCLUSIONS: Psychological disorders are rare as primary causes but are common as contributing or modulating factors in older persons with dizziness.