bluuebunny/crossref_metadata_2025 huggingface dataset:
A Predictive Model for ADL Dependence in Community‐Living Older Adults Based on a Reduced Set of Cognitive Status Items
Authors: Gill Thomas M. , Williams Christianna S. , PhD Emily D. Richardson , Berkman Lisa F. , Tinetti Mary E.
Published: April 2015

OBJECTIVE: To develop and validate a simple tool, based on a reduced set of Mini‐Mental State Examination (MMSE) items, that can be used to predict the onset of ADL dependence, and to compare the predictive accuracy of this new tool with that of the MMSE.

DESIGN: Two prospective, population‐based cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort.

SETTING: General community in New Haven, Connecticut.

PARTICIPANTS: For the development cohort, 775 community‐living persons, 72 years of age and older, who were independent at baseline in their ADL function. For the validation cohort, 1038 comparable subjects.

MEASUREMENTS: All subjects underwent a baseline interview and cognitive assessment in their homes by a trained research nurse using standard instruments. Self‐reported ADLs were ascertained at 1 year and 3 years for the development cohort and at 1 year and 2 1/2 years for the validation cohort.

RESULTS: ADL dependence developed in 221 (28.5%) subjects in the development cohort. Although the rate of ADL dependence increased within each MMSE domain as the number of incorrect items increased, only orientation and short‐term memory remained significantly associated with ADL dependence in multivariable analysis. A predictive model, based on the presence of impairments in these two domains, was developed that stratified subjects into three risk groups. Rates of ADL dependence were 22% (neither domain impaired), 44% (one domain impaired), and 68% (both domains impaired) (P < .001). The corresponding rates in the validation cohort, in which 191 (18.4%) subjects developed ADL dependence, were 15%, 26%, and 45% (P < .001). The area under the ROC curves for the MMSE and the reduced item strategy were nearly identical at 0.63 and 0.62, respectively.

CONCLUSIONS: A simple and valid six‐item strategy, based on the presence of impairments in orientation and short‐term memory, predicts the onset of ADL dependence as effectively as does the 30‐item MMSE. This new tool may be useful as part of a more comprehensive assessment when determining an older person's risk for developing ADL dependence.
Do Advance Directives Provide Instructions That Direct Care?
Authors: Teno Joan M , Licks Sandra , Lynn Joanne , Wenger Neil , Connors Alfred F. , Phillips Russell S. , O'Connor Mary Ann , Murphy Donald P. , Fulkerson William J. , Desbiens Norman , Knaus William A.
Published: April 2015

OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision‐making in SUPPORT might arise, in part, from the content of the actual documents.

DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life‐sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives.

SETTINGS: Five teaching hospitals in the United States.

PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self‐Determination Act. Patients were part of a randomized controlled trial to improve decision‐making and outcomes.

RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life‐sustaining medical treatment, and only 22 of these directed forgoing life‐sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff.

CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision‐making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.
The Process of Care in Preventive In‐Home Comprehensive Geriatric Assessment
Authors: Alessi Cathy A. , Stuck Andreas E. , Aronow Harriet U. , Yuhas Karen E. , Bula Christophe J. , Madison Rodger , Gold Marcia , Segal‐Gidan Freddi , Fanello Roslyn , Rubenstein Laurence Z. , Beck John C.
Published: April 2015

OBJECTIVES: To describe the process of care of a program of in‐home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA.

DESIGN: Descriptive prospective study of subjects allocated to the intervention group of a 3‐year randomized trial of preventive in‐home CGA.

SETTING: Homes of participants living in an urban setting.

PARTICIPANTS: Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone).

INTERVENTION: Annual in‐home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years.

MEASUREMENTS: Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded.

RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One‐third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P <.001); adherence was better for referrals to a physician than for referrals to a non‐physician professional or community service or for recommendations involving self‐care activities (Scheffe's test, P < .001).

CONCLUSION: In these community‐dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.
Prospective Evaluation of Clinical Criteria to Select Older Persons with Acute Medical Illness for Care in a Hypothetical Home Hospital
Authors: Leff Bruce , Burton Lynda , Bynum Julie Walter , Harper Michael , Greenough William B. , Steinwachs Donald , Burton John R.
Published: April 2015

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital.

DESIGN: Prospective record review.

SETTING AND PARTICIPANTS: Patients aged 65 and older admitted to the general medical service of a community‐ based university hospital.

MEASUREMENTS: We developed illness‐specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community‐dwelling older patients admitted to the general medical service of a community‐based university hospital over a 4‐month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course.

RESULTS: One hundred fifty‐seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P =.012), fewer mean number of procedures performed (0.98 vs 1.70, P =.001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P =.036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home.

CONCLUSIONS: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.
Moderate Wine Consumption Is Associated with Decreased Odds of Developing Age‐Related Macular Degeneration in NHANES‐1
Authors: Obisesan Thomas O. , Hirsch Robert , Kosoko Omofolasade , Carlson Letitia , Parrott Marian
Published: April 2015

OBJECTIVE: To determine the association between alcohol intake and the risk of developing age‐related macular degeneration (AMD).

DESIGN: Case control study.

PARTICIPANTS: The sample consisted of 3072 adults 45 to 74 years of age with macular changes indicative of AMD who participated in a nationally representative sample of the first National Health Nutrition and Examination Survey (NHANES‐1) between 1971 and 1975: (a) the ophthalmology data set and (b) the medical history questionnaire.

MAIN OUTCOME MEASURES: Alcohol intake and the risk of developing AMD were measured. AMD was determined by staff at the National Eye Institute by fundoscopy examination using standardized protocol.

RESULTS: Overall, 184 individuals (6%) had AMD. We observed a statistically significant but negative association between AMD and the type of alcohol consumed in a bivariate model (OR 0.86; 95% CI 0.73, 0.99). In the same model, age maintained a consistently strong association with AMD (OR 1.08; 95% CI 1.06–1.11; P < .001). Among the different types of alcohol consumed in NHANES‐1 (beer, wine, and liquor), the effect of wine, either alone (OR 0.66; 95% CI 0.55–0.79) or in combination with beer (OR 0.66; 95% CI 0.55–0.79) or liquor (OR 0.74; 95% CI 0.63–0.86), dominated the negative association observed between AMD and alcohol type. Additionally, a statistically significant and negative association between wine and AMD was noted after adjusting for the effect of age, gender, income, history of congestive heart failure, and hypertension (OR 0.81; 95% CI 0.67–0.99).

CONCLUSION: Moderate wine consumption is associated with decreased odds of developing AMD. Health promotion and disease prevention activities directed at cardiovascular disease may help reduce the rate of AMD‐associated blindness among older people. The nature and pathophysiology of this association warrant further investigation.
The Effect of Zinc and Vitamin A Supplementation on Immune Response in an Older Population
Authors: Fortes Cristina , Forastiere Francesco , Agabiti Nerina , Fano Valeria , Pacifici Roberta , Virgili Fabio , Piras Giovanna , Guidi Luisa , Bartoloni Carlo , Tricerri Augusto , Zuccaro Piergiorgio , Ebrahim Shah , MD Carlo A. Perucci
Published: April 2015

OBJECTIVE: To determine if either supplemental vitamin A, zinc, or both increases cell‐mediated immune response in an older population.

DESIGN: A double‐blind, randomized, controlled trial of supplementation with vitamin A and zinc.

SETTING: Casa Di Riposo Roma III, a public home for older people in Rome, Italy.

SUBJECTS: The health and nutritional status of 178 residents were evaluated. One hundred thirty‐six residents agreed to participate in the trial and were randomized into four treatment groups, and 118 of these residents completed the trial.

INTERVENTION: The four treatments consisted of: (1) Vitamin A (800 μg retinol palmitate); (2) Zinc (25 mg as zinc sulfate); (3) Vitamin A and Zinc (800 μg retinol palmitate and 25 mg as zinc sulfate); (4) Placebo capsules containing starch.

MAIN OUTCOME MEASUREMENTS: Immune tests – counts of leucocytes, lymphocytes, T‐cell subsets, and lymphocyte proliferative response to mitogens – were measured before and after supplementation.

RESULTS: Zinc increased the number of CD4+DR+ T‐cells (P = .016) and cytotoxic T‐lymphocytes (P = .005). Subjects treated with vitamin A experienced a reduction in the number of CD3+ T‐cells (P = .012) and CD4+ T‐cells (P = .012).

CONCLUSIONS: These data indicate that zinc supplementation improved cell‐mediated immune response, whereas vitamin A had a deleterious effect in this older population. Further research is needed to clarify the clinical significance of these findings.
Major Depression in a Population of Demented and Nondemented Older People: Prevalence and Correlates
Authors: Forsell Yvonne , Winblad Bengt
Published: April 2015

OBJECTIVE: To analyze the differences between variables associated with depression and symptoms of depression in demented and nondemented persons.

DESIGN: A survey design was used.

SETTING/PARTICIPANTS: A total of 1101 older persons registered in a district of Stockholm, Sweden, participated in the study.

MEASUREMENTS: Subjects were given physical and psychiatric examinations by physicians, and informants interviews and medical records were assessed. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM‐III‐R) criteria and major depression according to DSM‐IV. The variables studied were age, gender, marital status, institutionalization, Mini‐Mental State Exam score, disability in daily life, physical disorders with symptoms affecting daily life, and a previous history of depression (early and late).

RESULTS: 27.8% of the patients in the study sample were demented according to DSM‐III‐R. Major depression was diagnosed in 3.9% of the nondemented and in 11.8% of the demented subjects. Some of the depressive symptoms, such as lack of energy, thinking/concentration difficulties, loss of interest, and psychomotor disturbance, were found more commonly in demented than in nondemented persons. Increased disability was associated with major depression both in demented and nondemented persons.

CONCLUSION: In this study, the prevalence of depression was higher in demented than in nondemented persons. Among the factors that were studied, increased disability was associated with depression both in demented and nondemented persons. No differences were found regarding the other studied variables.
Balance and Gait Performance in an Urban and a Rural Population
Authors: Ringsberg Karin A. M. , Gärdsell Per , Johnell Olof , Jónsson Brynjolfur , Obrant Karl J. , Sernbo Ingemar
Published: April 2015

OBJECTIVE: To compare the differences in standing balance and gait performance between two populations, correlated with age and physical activities of daily living.

DESIGN: A cross‐sectional study.

SETTINGS: Malmö, the third largest city in Sweden, and Sjöbo, a typical agricultural community 60 km east of Malmö.

PARTICIPANTS: Participants were 570 men and women from the urban community (urban) and 391 from the rural community (rural), born in 1938, 1928, 1918, and 1908, and women born in 1948. The two cohorts were subdivided into true urbans, who had lived only in the city (n = 269), and true rurals, who had never lived in a city (n = 354).

MEASUREMENTS: Information about workload, housing, spare time activities, medication, and illness during different decades of life was gathered using two questionnaires. The first questionnaire was sent to the home after agreement to participate, and the second was presented at the test session. The clinical measurements were standing balance, gait speed, and step length.

RESULTS: The urban subjects had significantly (P <.001) impaired balance compared with rural subjects. This difference increased with increasing age. The urban subjects walked faster than the rural subjects (P <.001), and the urban subjects used fewer steps than their rural counterparts (P <.001). Spare time activities had a significant influence on the above tests, but, except for gait velocity (P =.011), workload was of minor importance according to analysis of covariance.

CONCLUSION: Background factors such as usual daily activities of living and lifestyle seem to be of importance when evaluating and comparing different populations with respect to their balance and gait performance.
The Impact of Regular Multidisciplinary Team Interventions on Psychotropic Prescribing in Swedish Nursing Homes
Authors: Schmidt Ingrid , B. Claesson Cecilia , Westerholm Barbro , Nilsson Lars G. , Svarstad Bonnie L.
Published: April 2015

OBJECTIVE: To evaluate the impact of regular multidisciplinary team interventions on the quantity and quality of psychotropic drug prescribing in Swedish nursing homes.

DESIGN: A randomized controlled trial.

SETTING: A sample of 33 nursing homes: 15 experimental homes and 18 control homes representing 5% of all Swedish nursing homes.

PARTICIPANTS: The sample consisted of 1854 long‐term care residents with an average age of 83 years. Seventy percent of the residents were women, and 42% had a documented diagnosis of dementia. An additional 5% had a psychotic disorder, and 7% had a diagnosis of depression.

INTERVENTION: Experimental homes participated in an outreach program that was designed to influence drug use through improved teamwork among physicians, pharmacists, nurses, and nurses' assistants. Multidisciplinary team meetings were held on a regular basis throughout the 12‐month study period.

MEASUREMENTS: Lists of each resident's prescriptions were collected 1 month before and 1 month after the 12‐month intervention. Measures included the proportion of residents with any psychotropic drug, polymedicine, and therapeutic duplication and proportion of residents with nonrecommended and acceptable drugs in each psychotropic drug class, as defined by current Swedish guidelines.

RESULTS: Baseline results show extensive psychotropic drug prescribing, with the most commonly prescribed drugs being hypnotics (40%), anxiolytics(40%), and antipsychotics (38%). After 12 months of team meetings in the experimental homes, there was a significant decrease in the prescribing of psychotics (‐19%), benzodiazepine hypnotics (‐37%), and antidepressants (‐59%). Orders for more acceptable antidepressants also increased in the experimental homes. In the control homes there was increased use of acceptable antidepressants, but there were no significant reductions in other drug classes.

CONCLUSIONS: There is excessive prescription of psychotropic drugs in Swedish nursing homes. Improved teamwork among caregivers can improve prescribing as defined by clinical guidelines.
Relation of Colonic Transit to Functional Bowel Disease in Older People: A Population‐Based Study
Authors: Evans Jonathan M. , Fleming Kevin C. , Talley Nicholas J. , Schleck Cathy D. , Zinsmeister Alan R. , Melton L Joseph
Published: April 2015

OBJECTIVE: The pathophysiology underlying chronic constipation in older people is poorly understood. Our objective was to determine if functional bowel disease (particularly constipation) in this population is associated with risk factors (age, immobility, low dietary fiber intake, and medication use) or directly with slow colonic transit.

METHODS: A previously validated questionnaire was administered to a random sample of older residents (age range 65–104 years, n = 1609) of Olmsted County, MN. A random subset who met standard diagnostic criteria for functional constipation (n = 52) or irritable bowel syndrome (IBS) (n = 55) and a group without gastrointestinal symptoms (n = 93) were selected for further study. Each subject underwent structured interview and physical examination. Total caloric and fiber intake were assessed by dietitian interview, a food frequency questionnaire, and a food diary. Physical activity was assessed using a previously validated instrument. Medication use was determined by self‐report, physician interview, and review of medical records. Total and segmental colonic transit was assessed radiographically using radio‐opaque markers.

RESULTS: Total colonic transit times were prolonged in subjects with functional constipation (median 50.4 hours) but not in subjects with IBS (median 34.2 hours) or in healthy controls (median 28.8 hours); however, only rectosigmoid transit was delayed significantly. Age, gender, physical activity, and dietary fiber intake were not associated with total transit times, nor could they discriminate among the three patient groups. Laxative use was associated with prolonged total transit times independent of patient group.

CONCLUSIONS: Older subjects can be classified by abdominal pain and bowel symptoms, which reflect colonic transit times. Older subjects with constipation symptoms generally have prolonged rectosigmoid transit. Other potential risk factors do not distinguish symptom subgroups, nor are they associated with altered colonic transit although older people who use laxatives regularly have prolonged colonic transit.
Assessment of Insulin Sensitivity in Older Adults Using the Hyperglycemic Clamp Technique
Authors: Meneilly Graydon S. , Elliott Thomas
Published: April 2015

OBJECTIVE: The euglycemic glucose clamp technique is the gold standard for the measurement of insulin sensitivity in older adults, whereas the hyperglycemic glucose clamp technique is used to assess insulin release. The objective of this study was to evaluate the ability of the hyperglycemic glucose clamp technique to assess insulin sensitivity and insulin release in older people.

RESEARCH DESIGN AND METHODS: Healthy older controls (n = 26, age 72 ± 1) and older non‐insulin‐dependent diabetes mellitus (NIDDM) patients (n = 35, age 75 ± 1) underwent a 2‐hour hyperglycemic glucose clamp study (glucose 5.4 mM above basal) and a 3‐hour euglycemic clamp study (insulin infusion rate 40 mU/m2/min). The average glucose infusion rate (last 30 minutes) of each clamp was divided by the average insulin value (last 30 minutes). This value was then divided by the average plasma glucose value to give glucose clearance per plasma insulin concentration.

RESULTS: In control subjects (Eug: 0.80 ± .05 mL/kg/min/pM; Hyper: 0.88 ± .07 mL/kg/min/pM, P = .357) and NIDDM patients (Eug: 0.48 ± .03 mL/kg/min/pM; Hyper: 0.42 ± .03 mL/kg/min/pM, P = .162), glucose clearance values were similar whether calculated from the euglycemic or the hyperglycemic clamp. The correlation between glucose clearance values derived from the euglycemic and hyperglycemic clamp was excellent in normal controls (r = .76, P < .001) and patients with NIDDM (r = .71, P < .001).

CONCLUSIONS: We conclude that the hyperglycemic glucose clamp technique can reliably assess both insulin release and insulin sensitivity in older people.
Pharmacologic Treatment of Geriatric Depression: Key Issues in Interpreting the Evidence
Authors: Rigler Sally K. , Studenski Stephanie , Duncan Pamela W.
Published: April 2015

OBJECTIVE: A framework for critical appraisal of antidepressant trial literature involving geriatric subjects is presented. Among older adults, treatment decisions are complicated by comorbid medical and cognitive illness, the variable course of recovery, and the overlap of depressive symptoms with other disease symptoms. Consumers of the literature on competing antidepressant therapies for older adults must consider disease and population‐specific outcome assessment issues.

DESIGN: An appraisal guide, adapted for geriatric depression, is developed from literature on methodological challenges of outcome assessment and published clinical trials comparing competing antidepressant therapies in older subjects.

CONCLUSIONS: The clinical utility of pharmacologic treatment of depression can be difficult to assess because depression scales in current use provide an important but limited perspective on treatment outcome and because the scales vary in actual content and ability to detect change. The use of indicators of function, independence, and self‐perceived well‐being as outcomes offers additional patient relevance and should be included. Key considerations involve (1) general characteristics: whether the depression outcome measure is valid and reproducible for the aged population under study, whether the outcome measure is sensitive to treatment‐related change, and whether the time‐frame of outcome assessment is appropriate for the treatment goal; (2) cognitive impairment: how subjects with dementia are assessed, and whether the impact of the intervention on caregivers and healthcare systems is considered as a relevant outcome; (3) pharmacologic issues: whether the comparator agent is a reasonable usual‐care standard in the older adult and whether ascertainment for adverse effects is similar for all agents under study; and (4) broader general health status issues: whether functional or quality of life measures are used as outcome indicators.
Association of Dehydroepiandrosterone Sulfate, Body Composition, and Physical Fitness in Independent Community‐Dwelling Older Men and Women
Authors: Abbasi Adil , Duthie Edmund H. , Sheldahl Lois , Wilson Charles , Sasse Edward , Rudman Inge , Mattson Dale E.
Published: April 2015

OBJECTIVES: To determine the association of dehydroepiandrosterone sulfate (DHEAS), body composition, and physical fitness in independent community‐dwelling men and women aged 60 to 80 years.

DESIGN: Cross sectional analysis.

PARTICIPANTS: Independent men and women, 60 years of age and older, living in urban and suburban communities of Southeastern Wisconsin.

MEASUREMENTS: History, physical examination, physical activity level, and anthropometrics were measured for every subject. Total adipose mass (TAM) and lean body mass were measured using dual energy X‐ray absorptiometry. Dehydroepiandrosterone sulfate, insulin‐like growth factor‐1 (IGF‐1), total testosterone (TT), and free testosterone (FT) were measured using radioimmunoassay. Physical fitness was measured as V̇O2max using exercise stress tests. Blood for lipids was analyzed using standard assays.

RESULTS: In men, the DHEAS was significantly correlated to age (r = ‐.32), TAM (r = ‐.27), percent fat (r = ‐.30), HDL cholesterol (r = .34), TT (r = .30), V̇O2max (r = .23), and percent lean body mass (% LBM) (r = .33). In women, the DHEAS was not significantly correlated to any of the variables examined except body mass index (BMI) (r = .23). In men, after partialling out age, DHEAS was significantly correlated to HDL, % fat, TAM, % LBM, and TT. Multivariate analysis for men revealed that high density lipoprotein cholesterol (HDL) was the strongest predictor of serum DHEAS level, followed by % LBM, BMI, and age. The men in the highest quartile of serum DHEAS levels were different from those in the lowest quartile in terms of age, TT, FT, % fat, TAM, % LBM, HDL, and low density lipoprotein (LDL) cholesterol level. No such differences were found in the two groups of women.

CONCLUSION: In this group of independent community‐dwelling older men, several factors were found to be associated with the serum DHEAS concentration, whereas in a group of older women, no such associations were identified with the exception of BMI. Men in the highest quartile of serum DHEAS level, compared with those with a serum DHEAS level in the lowest quartile, were younger, leaner, more fit, had higher TT and FT levels, and had a favorable lipid profile. No such differences were identified between the women in the highest and the lowest quartiles of serum DHEAS level.
Barriers to Obtaining Consent in Dementia Research: Implications for Surrogate Decision‐Making
Authors: Baskin Shari A. , Morris Jane , Ahronheim Judith C. , Meier Diane E. , Morrison R. Sean
Published: April 2015

OBJECTIVE: To identify barriers to informed consent in research involving subjects with advanced dementia.

DESIGN: A randomized controlled clinical trial of palliative care approaches, compared with usual care, in subjects with advanced dementia who are hospitalized.

SETTING: A large metropolitan teaching hospital.

PARTICIPANTS: All patients older than 65 years of age who have advanced dementia and a Functional Assessment Staging score of 6d to 7f and have been admitted to the hospital.

MEASUREMENTS: Surrogates for all eligible subjects were approached for consent to enroll their family members in the trial. Reasons for refusal to enroll in the study were recorded and categorized as either informed refusal (i.e., the surrogate understood the research protocol but declined to give consent for participation) or as a barrier to informed consent (i.e., the surrogates could not participate in the informed consent process or there was no functional surrogate).

RESULTS: Forty‐nine percent of 146 eligible subjects could not be enrolled in the study. Only four surrogates refused consent for their family members. Of the remaining 68 patients, 41 eligible subjects' surrogates could not be engaged in the informed consent process, and 22 subjects did not have a functional surrogate to consent for research.

CONCLUSIONS: Absence of functional surrogate decision‐makers is a major barrier to research and clinical decision‐making for hospitalized patients with advanced dementia.
GERIATRICS IN MANAGED CARE*: Essential Components of Geriatric Care Provided Through Health Maintenance Organizations The HMO Workgroup on Care Management
Authors: Brummel‐Smith Kenneth V. , Fox Peter D. ,   The HMO Workgroup on Care Management
Published: April 2015

The rapid growth in the number of older adults enrolling in health maintenance organizations (HMO) presents a number of opportunities and challenges. Older HMO enrollees have needs that differ from those of younger enrollees, such as the medical conditions they face, their likelihood of having functional deficits, and differences in their living arrangements. In addition, their health‐related needs often extend beyond medical care and may include relationships with families, caregivers, and community agencies. This article describes the types of services that should realistically be available to older adults who are enrolled in an HMO with a Medicare risk contract in order to meet the goals of geriatric care: to promote health, independence, and optimal functioning, to prevent avoidable decline in health status, and to enhance quality of life. The findings are based on deliberations during the past year by the HMO Workgroup on Care Management, which was convened under the auspices of The Robert Wood Johnson Foundation's national program, “Chronic Care Initiatives in HMOs.”
A Preliminary Assessment of the Medical and Functional Factors Associated with Vehicle Crashes by Older Adults
Authors: Sims Richard V. , Owsley Cynthia , Allman Richard M. , Ball Karlene , Smoot Tonya M.
Published: April 2015

OBJECTIVES: To examine associations between medical and functional variables and at‐fault car crashes in a cohort of older drivers.

DESIGN: A case‐control study.

SETTING: A tertiary care medical center.

PARTICIPANTS: Older drivers (ages 55–90 years) residing in Jefferson County, Alabama (n = 174). Cases were drivers who had at least one at‐fault crash in the previous 6 years; controls were crash‐free during the same period.

MEASUREMENTS: Self‐reported medical conditions, reported and observed functional measures, and urinary drug screens. The occurrence of one or more at‐fault car crashes in the 6 years preceding the 1991 assessment date represented the outcome measure.

RESULTS: Ninety‐nine older drivers experienced between one and seven at‐fault vehicle crashes during the period 1985 through 1991, whereas 75 drivers did not. Logistic regression models indicated that the following variables were independently associated with crash involvement: A 40% or greater reduction in the useful field of view (OR = 6.1; 95% CI, 2.9 to 12.7; P < 0.001), black race (OR = 6.6; 95% CI, 1.7 to 26.2; P = .007), a history of falling in the previous 2 years (OR = 2.6; CI, 1.1 to 6.1; P = .025), and not taking a beta‐blocking drug (OR = 4.3; CI, 1.2 to 15.0; P = .023).

CONCLUSIONS: Functional assessments, such as a comprehensive test of visual processing, a falls history, and a review of current medications may be of greater relevance than specific medical conditions in the identification of older at‐risk drivers. If prospective studies determine that falling and crashing share risk factors, a unified approach to the prevention of these mobility disorders could result. The finding of an independent association of black race with at‐fault crashing is in need of further clarification because of the low representation of black drivers in this sample. J Am Geriatr Soc 46:556–561, 1998.
Development of a Test Battery to Identify Older Drivers at Risk for Self‐Reported Adverse Driving Events
Authors: Marottoli Richard A. , Richardson Emily D. , Stowe Meredith H. , Miller Eydie G. , Brass Lawrence M. , Cooney Leo M. , Tinetti Mary E.
Published: April 2015

OBJECTIVES: The purposes of this study were (1) to develop a battery of tests that assessed a wide range of functional abilities relevant to driving yet could be performed in a clinician's office and (2) to determine which of these tests were most closely associated with self‐reported adverse driving events.

DESIGN: A cohort study.

SETTING: An urban community.

PARTICIPANTS: Participants were drawn from the Project Safety cohort, a probability sample of noninstitutionalized older persons in New Haven, Connecticut, initiated in 1989. The current study included surviving, active drivers in the cohort (N= 125).

MEASURES: The test battery assessed visual, cognitive, and physical abilities potentially relevant to driving, and was administered in participants' homes by trained interviewers between October 1994 and July 1995. Outcome measures included the self‐report of a crash, moving violation, or being stopped by police in any Project Safety interview since the inception of the cohort. Analyses compared performance on the elements of the test battery with participants' histories of adverse driving events.

RESULTS: Of the 125 drivers, 50 (40%) had reported an adverse event in a mean period of 5.76 (±.25) years before the current interview. The elements of the test battery independently associated with a history of events, adjusting for driving frequency, included near visual acuity worse than 20/40 (adjusted odds ratio 11.90), limited neck rotation (OR 6.10), and poor performance on a test of visual attention, the number cancellation task (OR 3.00). The resulting regression equation yielded a sensitivity of 80%, a specificity of 55%, and an area under the curve of .75 by receiver operating characteristic analysis.

CONCLUSION: These findings suggest it may be possible to identify individuals potentially at risk for self‐reported adverse driving events using simple tests of functional ability. If validated, such an approach could be used to identify individuals who need a more detailed assessment of functional abilities to determine the severity and etiology of impairments, and their effect on driving performance, as well as possible interventions to correct or compensate for the impairments. J Am Geriatr Soc 46:562–568, 1998.
Relation Between Intellectual Dysfunctioning and Mortality in Community‐Residing Older People
Authors: Nakanishi Noriyuki , Tatara Kozo , Ikeda Kazunori , Hino Youichi , Yamada Atsuhiro , Nishioka Chisato
Published: April 2015

OBJECTIVE: To examine the relationship between intellectual dysfunctioning and mortality in a community‐residing older population.

DESIGN: Of the 1473 randomly selected people aged 65 years and older living in Settsu, Osaka Prefecture, in October 1992, 1405 were contacted. Data for assessment of intellectual dysfunctioning were obtained from 1383 people (98.4%), who constituted the study cohort. Follow‐up for 42 months was completed for 1300 subjects (94.0%; 1117 living, 183 deceased).

MEASURES: Data on general health status, history of health management, psychosocial conditions, and intellectual dysfunctioning were collected by means of interviews during home visits at the time of enrollment. Intellectual dysfunctioning was determined with the assessment instrument developed by the Social Survey Division of the Office of Population Censuses (OPCS) in Great Britain.

RESULTS: The Kaplan‐Meier analysis indicated that the estimated survival rates for men and women decreased with a decline in intellectual function in two age groups: 65 to 74 and 75 years and older. For both sexes, the log rank test showed that the curves among the four groups based on intellectual dysfunctioning (intact, mild, moderate, and severe) achieved statistical significance for the age group of 75 years and older. For both age groups and each of the levels of intellectual dysfunctioning, the estimated survival rate for men was lower than that for women.

Application of the Cox proportional hazards model resulted in unadjusted hazard ratios of mild, moderate, and severe intellectual dysfunctioning for mortality of 1.68, 2.44, and 5.37, respectively. Multivariate analysis on the other hand, yielded adjusted hazard ratios of mild, moderate, and severe intellectual dysfunctioning of 1.19, 1.12, and 1.74, respectively, leaving severe dysfunctioning as the only statistically significant factor associated with mortality. Other factors such as sex, age, general health status, history of management, and psychosocial conditions were controlled.

CONCLUSION: Intellectual dysfunctioning, as measured by an assessment instrument developed by OPCS, represents an increased risk factor for mortality among community‐residing older people. J Am Geriatr Soc 46:583–589, 1998.
Executive Cognitive Abilities and Functional Status Among Community‐Dwelling Older Persons in the San Luis Valley Health and Aging Study
Authors: Grigsby Jim , Kaye Kathryn , Baxter Judith , Shetterly Susan M. , Hamman Richard F.
Published: April 2015

OBJECTIVES: The purpose of this study was to evaluate the contribution of the executive cognitive functions to self‐reported and observed performance of activities of daily living and instrumental activities of daily living.

DESIGN: These data were collected as part of a cross‐sectional survey of community‐dwelling older persons, using statistical sampling, in a two‐county area of southern Colorado.

SETTING: Participants were interviewed and administered measures of general cognition, depression, executive functioning, and performance of self‐care and instrumental activities, either in their homes or at the study clinic.

PARTICIPANTS: A total of 1158 community‐dwelling persons between the ages of 60 and 99 participated. Of these, 657 were female, 501 were male, 637 were Hispanic, and 521 were non‐Hispanic whites.

MEASUREMENTS: Subjects were administered the Mini‐Mental State Exam (MMSE), a measure of executive functioning (the Behavioral Dyscontrol Scale), the Center for Epidemiologic Studies Depression scale (CES‐D), and the Structured Assessment of Independent Living Skills (SAILS, a measure of observed performance of daily tasks). They also were interviewed regarding their reported ADL and IADL status using measures from the Longitudinal Study on Aging.

RESULTS: Both general mental status and executive functioning demonstrated statistically significant univariate associations with all seven functional status measures (both self‐report and observed performance). In a series of ordinary least squares regression models, executive functioning was a predictor for self‐reported ADLs and observed performance of complex IADL tasks such as managing money and medications. Mental status did not predict self‐reported functioning but was a predictor of observed performance. Depression was a significant variable for self‐report measures but not for observed performance. Executive functioning and general mental status demonstrated some degree of independence from one another.

CONCLUSION: Executive functioning is an important determinant of functional status for both self‐reported and observed ADLs and IADLs and should be assessed routinely when evaluating the mental status and functional abilities of older people. These results replicate and extend previous research on executive functioning among older persons by examining these factors in a large bi‐ethnic community sample. J Am Geriatr Soc 46:590–596, 1998.
Absence of Vascular Dementia in an Autopsy Series from a Dementia Clinic
Authors: Nolan Karen A. , Lino M. Maddelena , Seligmann Arthur W. , Blass John P.
Published: April 2015

OBJECTIVE: The role of cerebrovascular disease in dementia in older people has been the subject of controversy. This study was undertaken to examine the prevalence of vascular disease in a prospective autopsy series of patients with clinically diagnosed dementia.

DESIGN: Structured review of clinical and neuropathological examinations. Clinical diagnoses were assigned in accordance with the recommendations of the NINCDS/ADRDA consensus panel. Neuropathological examinations were performed at an academic neuropathology service using published consensus criteria for the diagnosis of Alzheimer's disease and other forms of dementia.

SETTING: A subspecialty, outpatient dementia clinic in a university‐affiliated suburban American hospital.

PARTICIPANTS: Eighty‐seven unselected patients coming to autopsy who had undergone clinical dementia evaluation.

RESULTS: Dementia could not be attributed to the effects of cerebrovascular disease alone in any of the 87 patients coming to autopsy. Seventy‐six (87%) of the patients were found to have Alzheimer's disease (AD), 44 had AD alone, and 32 had AD in combination with cerebrovascular disease (CVD). All of the patients with signs of CVD at autopsy were also found to have some concomitant neurodegenerative disease. The absence of patients in whom vascular dementia could be diagnosed at neuropathology was not the result of recruitment bias.

CONCLUSION: Clinicians should maintain a high index of suspicion of AD or other neurodegenerative process in older patients whose presenting complaint is dementia, even in the presence of well documented cerebrovascular disease. J Am Geriatr Soc 46:597–604, 1998.
The Effect of a Physician Assistant on the Hospitalization of Nursing Home Residents
Authors: Ackermann Richard J. , Kemle Kathy A.
Published: April 2015

OBJECTIVES: To describe the impact of regular visits to a nursing home by a gerontologist physician assistant (PA) on the hospitalization and medical costs of patients.

DESIGN: A 6‐year case series (1992–1997) incorporating events before and after introduction of a PA in May 1994. The PA visited the nursing home 3 to 4 times per week, provided nearly all of the acute medical care, and alternated routine visits with supervising physicians.

SETTING: A 92‐bed teaching nursing home in central Georgia.

MEASUREMENTS: Demographics of the nursing home population; hospitalizations of residents, including major diagnosis and length of stay; number and site of all resident deaths; costs of physician and PA services and hospital costs.

RESULTS: After the introduction of the physician assistant, the number of annual hospital admissions fell by 38.0%, and the total number of hospital days per 1000 patient years fell by 68.6% (from 4170 in 1992 to 1310 in 1997). The number of nursing home visits increased by 62.1%. Annual Medicare‐allowed charges for MD and PA services increased by $22,304, but this was more than offset by a decline in hospital DRG reimbursements of $96,043.

CONCLUSIONS: The introduction of regular visits to nursing home patients by a physician assistant can reduce hospitalization and medical costs of these frail older people. J Am Geriatr Soc 46:610–614, 1998.
Underutilization of Aspirin in Older Patients with Prior Myocardial Infarction at the Time of Admission to a Nursing Home
Authors: Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of aspirin use in older patients with prior myocardial infarction at the time of admission to a nursing home.

DESIGN: In a prospective study, the prevalence of aspirin use in 350 consecutive older patients with documented Q‐wave myocardial infarction and no contraindications to aspirin use was investigated in patients aged 60 years or older at the time of admission to a nursing home.

SETTING: A large, long‐term, healthcare facility.

PATIENTS: The patients included 231 women and 119 men, mean age 81 ± 8 years (range 60 to 100).

MEASUREMENTS AND MAIN RESULTS: Of the 350 patients with documented Q‐wave myocardial infarction and no contraindications to aspirin therapy, 60 patients (17%) were receiving aspirin at the time of admission to the nursing home.

CONCLUSION: There is a marked underutilization of aspirin in the treatment of older patients with documented prior myocardial infarction at the time of admission to a nursing home. J Am Geriatr Soc 46:615–616, 1998.
Depression and Disability Associated with Impaired Vision: The MoVIES Project
Authors: Rovner Barry W. , Ganguli Mary
Published: April 2015

OBJECTIVE: To assess how depression and impaired vision relate to disability in older people.

DESIGN: An epidemiological survey of an age‐stratified random community sample.

SETTING: The rural mid‐Monongahela Valley in Southwestern Pennsylvania.

PARTICIPANTS: A total of 872 noninstitutionalized persons aged 68 and older, fluent in English, and with at least a grade 6 education.

MEASUREMENTS: Demographics, self‐reported vision impairment, OARS Instrumental Activities of Daily Living (IADL), and modified Center for Epidemiologic Studies‐Depression scale to assess depression.

RESULTS: Compared with subjects with intact vision, those with impaired vision were more likely to have five or more depressive symptoms (29.7% vs 8.5%; OR = 4.6, 95% CI = 2.2, 9.6) and to be more functionally impaired (OR = 9.7, 95% CI = 4.9, 19.2). The number of depressive symptoms (1–4: OR = 2.4, CI = 1.8,3.4) and (5 +: OR = 5.9, CI = 3.6, 9.8) was associated independently with IADL impairment after controlling for vision, age, and gender.

CONCLUSIONS: Impaired vision and depression are both associated strongly with functional impairment in this community population of older adults. Depression, however, increases the odds of functional impairment independent of vision impairment. Treating depression may reduce excess disability associated with impaired vision. J Am Geriatr Soc 46:617–619, 1998.