bluuebunny/crossref_metadata_2025 huggingface dataset:
Reducing Hospital Costs for the Geriatric Patient Admitted from the Emergency Department: A Randomized Trial
Authors: Naughton Bruce J. , Moran Maureen B. , Feinglass Joe , Falconer Judith , Williams Mark E.
Published: April 2015

OBJECTIVE: To test the impact of a geriatric evaluation and management model on the costs of acute hospital management of emergently admitted older adults.

DESIGN: Randomized controlled trial. Patients were followed in the acute hospital from admission through discharge. Results based on both univariate and multiple regression analyses.

SETTING: Private, nonprofit, academic medical center in a densely populated urban area.

PATIENTS: Adults 70 years of age and older admitted from the Emergency Department to the medicine service (non‐ICU admission) who did not have an internist on staff at the admitting hospital. Of 141 randomized patients, 111 (78.7%) met eligibility criteria.

INTERVENTION: Assignment of a geriatrician and a social worker as the primary managing team during the hospital stay.

MAIN OUTCOME MEASURES: Length of stay, total cost of acute hospital care, cost of laboratory, pharmacy, and rehabilitation services.

RESULTS: Patients in the intervention group had 2.1 fewer days of hospitalization, but this shorter length of stay was not statistically significant (P = 0.108). There were no differences in mortality or discharge disposition. In risk‐adjusted, multiple regression analysis the intervention group had a statistically significant lower predicted total cost per patient than the usual care group (‐$2,544, P = 0.029); assignment to the intervention group was associated with a lower predicted cost per patient for laboratory (including cardiology graphics) services (P = 0.007) and pharmacy costs (P = 0.047).

CONCLUSIONS: When controlled for important predictors of expected resource use, care provided by a geriatric management team resulted in a significant reduction in the cost of hospitalization. A reduction in the cost of laboratory, cardiographic, and pharmacy services is consistent with the team's philosophy of defining the services needed based on goals related to functional outcomes.
Dietary Sodium and Bone Mineral Density: Results of a 16‐Year Follow‐up Study
Authors: Greendale Gail A. , Barrett‐Connor Elizabeth , Edelstein Sharon , Ingles Sue , Haile Robert
Published: April 2015

BACKGROUND AND PURPOSE: It has been proposed that high dietary sodium intake, resulting in a sodium‐mediated increase in renal calcium excretion, is a risk factor for osteoporosis. To evaluate the relationship between dietary sodium intake and bone mineral density (BMD), a prospective study of the Rancho Bernardo cohort was performed.

METHOD: A 24‐hour diet recall was done for the period 1973 through 1975; follow‐up bone mineral density of the ultradistal radius, midradius, total hip, and spine was measured between 1988 and 1991. Covariates were ascertained by self‐report and examination at baseline. Multivariable analysis of the sodium‐BMD association was performed using gender and menopause‐specific linear regressions.

RESULTS: All subjects were white. At the bone evaluation, there were 258 women (average age 73.3 years) and 169 men (average age 72.4 years). In both men and women, higher levels of sodium intake were strongly associated with higher levels of calcium intake and total calories. Body mass index increased with sodium quartile in women, while a modest negative association was seen in men. In women, after age adjustment, positive associations between dietary sodium and bone density were found at the ultradistal radius (β = 0.01, P = 0.03) and the total hip (β = 0.019, P = 0.02). BMD increased by 0.01 to 0.02 g/cm2 per gram increase in sodium ingested. After adjustment for estrogen use, body mass, dietary calcium, alcohol, and total calories, these effects were no longer significant. Similar patterns were seen in pre‐ and postmenopausal women. In men, age and multivariate‐adjusted BMD increased with higher sodium intake at the ultradistal radius only (β = 0.013, P = 0.05). Stratification by gender‐specific median calcium level did not significantly effect the results.

CONCLUSIONS: After control for confounders, a small, statistically significant protective effect of sodium was found at the ultradistal radius in men only. At other sites in women and men, no effect of sodium on BMD was apparent in the multivariable models. These results do not support a detrimental effect of dietary sodium on bone mineral density. Rather, the findings suggest that sodium intake, in the range measured, is not a major osteoporosis risk factor.
Colonization and Infection with Antibiotic‐Resistant Bacteria in a Long‐Term Care Facility
Authors: Terpenning Margaret S. , Bradley Suzanne F. , Wan Jim Y. , Chenoweth Carol E. , Jorgensen Karen A. , Kauffman Carol A.
Published: April 2015

OBJECTIVE: To assess colonization and infection with methicillin‐resistant Staphylococcus aureus (MRSA), high‐level gentamicin‐resistant enterococci (R‐ENT) and gentamicin and/or ceftriaxone‐resistant Gram‐negative bacilli (R‐GNB) and the factors that are associated with colonization and infection with these organisms.

DESIGN: Monthly surveillance for colonization and infection over a period of 2 years. In the second year, an intervention to decrease MRSA colonization by the use of mupirocin ointment was carried out.

SETTING: Long‐term care facility attached to an acute care Veterans Affairs Medical Center.

PATIENTS: A total of 551 patients in the facility were followed for a period of 2 years.

MEASUREMENTS: Colonization and infection rates with MRSA, R‐ENT, and R‐GNB. Analysis of risk factors associated with colonization and infection with these three groups of organisms.

MAIN RESULTS: In the first year, colonization rates were highest for MRSA (22.7 ± 1% patients colonized each month) and R‐ENT (20.2 ± 1%) and lower for R‐GNB (12.6±1%). After introduction of decolonization of nares and wounds with mupirocin, the rate of MRSA colonization fell significantly to 11.5 ± 1.8%, but rates remained unchanged for R‐ENT and R‐GNB. Risk factors for MRSA colonization included the presence of wounds and decubitus ulcers. For R‐ENT, the presence of wounds, renal failure, intermittent urethral catheterization, low serum albumin, and poor functional level were significant. For R‐GNB, intermittent urethral catheterization, chronic renal disease, inflammatory bowel disease, presence of wounds, and prior pneumonia were significantly associated with colonization. Overall, of infections caused by known organisms, 49.6% were due to MRSA, R‐ENT, or R‐GNB, and 50.4% were due to susceptible organisms. Infections were more commonly due to R‐GNB (21.1% of all infections) than to R‐ENT (8.3%) or MRSA (4.6%). The most common infections were urinary tract infections (42.9% of all infections) and skin and soft tissue infections (31.9% of all infections). Risk factors for MRSA infections were diabetes mellitus and peripheral vascular disease, for R‐GNB infections were intermittent urethral catheterization and indwelling urethral catheters, and no one factor was associated with R‐ENT infection.

CONCLUSIONS: In our long‐term care facility, colonization with resistant MRSA and R‐ENT was more common than R‐GNB, but infections were more often due to R‐GNB than R‐ENT and MRSA. Several host factors, which potentially could be modified in order to prevent infections, emerged as important in colonization and infection with these antibiotic‐resistant organisms.
Rehospitalization Rates in Older Depressed Adults After Antidepressant and Electroconvulsive Therapy Treatment
Authors: Stoudemire Alan , Hill Connie D. , Dalton Sandra T. , Marquardt Martha G.
Published: April 2015

OBJECTIVE: To determine (1) if a “high risk” period for rehospitalization can be identified in a population of depressed older adults and (2) if age of onset and previous history of depression is associated with an increased risk of rehospitalization.

DESIGN: Naturalistic, longitudinal treatment outcome study.

SETTING: Medical‐psychiatry unit and outpatient clinic at a university hospital.

PATIENTS: Ninety‐four older adults diagnosed with major depression based on SCID and DSM‐III‐R criteria who were hospitalized for treatment.

INTERVENTIONS: All patients were initially hospitalized on a medical‐psychiatry unit and treated with either antide‐pressants or electroconvulsive therapy.

MEASUREMENTS: Patients were initially evaluated with the Structured Clinical Interview for DSM‐III‐R (SCID), the Hamilton Depression Rating Scale, and a battery of neuro‐psychological and behavioral tests. Patients were followed over time with an average follow‐up interval of 3.09 + 1.45 years, and the date of the first psychiatric rehospitalization (if any) was recorded.

RESULTS: Approximately 43.6 percent of the total sample required at least one psychiatric rehospitalization. The greatest risk of rehospitalization occurred in the first 18 months. No significant differences were noted between patient groups treated with ECT and those treated with antidepressants or between patients with a younger and those with an older age of onset of depressive disorder. A statistical trend was observed in which patients without previous episodes of depression had a lower overall rate of rehospitalization compared with patients with one or more previous episodes of depression.

CONCLUSIONS: There appears to be a relatively high risk of psychiatric rehospitalization in depressed older adults, particularly in the first 18 months. This rate of rehospitalization underscores the importance of providing maintenance therapy and intensive psychiatric supervision for a minimum of 18 months to 2 years during the course of a depressive episode requiring inpatient hospitalization.
Medical Conditions and Motor Vehicle Collision Injuries in Older Adults
Authors: Koepsell Thomas D. , Wolf Marsha E. , McCloskey Lon , Buchner David M. , Louie Douglas , Wagner Edward H. , Thompson Robert S.
Published: April 2015

OBJECTIVETo determine whether medical conditions that can impair sensory, cognitive, or motor function increase the risk of injury due to motor vehicle collision in older drivers.

DESIGNCase‐control study.

SETTINGGroup Health Cooperative of Puget Sound, a large prepaid health plan.

PARTICIPANTSGroup Health members age 65 or older who were licensed drivers in 5 counties. Cases were injured while driving during 1987 or 1988. Controls were matched to cases on age, gender, and county of residence but experienced no such injury during the study years.

MEASUREMENTSThe outcome was injury requiring medical care due to a police‐investigated motor vehicle collision. Risk factors evaluated included selected medical conditions active within the previous 3 years, as determined from the medical record.

MAIN RESULTSInjury risk was 2.6‐fold higher in older diabetic drivers (95% CI: 1.4–4.7), especially those treated with insulin (odds ratio [OR] = 5.8, 95% CI: 1.2–28.7) or oral hypoglycemic agents (OR = 3.1, 95% CI: 0.9–11.0), those with diabetes for over 5 years (OR = 3.9, 95% CI: 1.7–8.7), and those with both diabetes and coronary heart disease (OR = 8.0, 95% CI: 1.7–37.7). Increases were also found for older drivers with coronary artery disease (OR = 1.4), depression (OR = 1.7), alcohol abuse (OR = 2.1), or falls (OR = 1.4), but these associations could easily have arisen by chance.

CONCLUSIONSCounseling about driving risks may be warranted for certain elderly diabetic drivers. Further research is needed to determine whether transient hypoglycemia or long‐term complications explain these effects.
Test‐Retest Reliability of a Questionnaire That Identifies Elders at Risk for Hospital Admission
Authors: Boult Lisa , Boult Chad , Pirie Phyllis , Pacala James T.
Published: April 2015

OBJECTIVE: To determine the test‐retest reliability of a questionnaire designed to measure elderly persons' probability of repeated admission (Pra) to a hospital within 4 years.

DESIGN: Participants received the test questionnaire by mail; respondents to the test questionnaire received the retest questionnaire 3 weeks later.

PARTICIPANTS: Elderly (65+) community‐dwelling enrollees in the Medical Assistance (Medicaid) program of Ramsey County, MN (n = 192).

MAIN OUTCOME MEASURE: The correlation (r) between the Pra values computed from the test‐retest correlations (k) of the questionnaire's individual items were also measured.

RESULTS: The response rate was 63% (121/192) for the test questionnaire and 69% (84/121) for the retest questionnaire. The test and retest values of Pra computed from responses to the questionnaires were highly correlated (r = 0.78, P < 0.0001). For the individual questionnaire items, the range of k values was 0.50–1.00 (P < 0.0001 for all items). Slightly higher values of r and k were obtained when the respondents were women and when the same person (either proxy or self) completed both questionnaires. Age was not consistently related to reliability.

CONCLUSION: the test‐retest reliability of individual items and of the computed Pra was high, suggesting that responses by elderly persons to mailed questionnaires pertaining to health status are stable over brief periods of time. The resulting Pra values may be useful in identifying elders at high risk for hospital admission.
Age and Functional Correlations of Markers of Coagulation and Inflammation in the Elderly: Functional Implications of Elevated Crosslinked Fibrin Degradation Products (D‐dimers)
Authors: Currie Mark S. , Rao K. Murali Krishna , Blazer Dan G. , Cohen Harvey J.
Published: April 2015

OBJECTIVE: To measure markers of inflammation in a cohort of young and old subjects and relate these findings to the functional level of the individuals.

DESIGN: For the pilot study, blood samples were obtained from 18 young (age 20–35 years) and 18 old (age 68–83 years) subjects. The main study population included community‐dwelling subjects between the ages of 70 and 79. The group consisted of 282 subjects with minimal physical limitations, 17 subjects from the middle third, and 16 from the lower third of physical function rankings.

METHODS: Plasma markers were measured by ELISA techniques, and certain biochemical values were obtained through routine clinical tests performed by a commercial laboratory.

RESULTS: D‐Dimers were higher for physically impaired subjects in all groups, but most prominently among black females, who also had significantly higher D‐Dimer levels in every functional group. To inquire whether higher D‐Dimers were associated with markers of inflammation, we also examined the macrophage metabolite, neopterin, the neutrophil product, elastase complexed to antitrypsin (E/a), and the albumin globulin ratio (A/G ratio). No differences were found in neopterin or E/a levels on the basis of gender, race, or functional status. The A/G ratio was significantly lower in functionally impaired subjects.

CONCLUSION: These preliminary findings demonstrate racial/ethnic and gender differences in D‐Dimers in a population of community‐dwelling elderly, and suggest that factors influencing hemostasis may be particularly relevant to physical functional status in black women. A sample containing more subjects with lower physical function will be needed to establish the relationship between inflammation, altered hemostasis, and physical function decline.
Physician Staffing Patterns Correlates of Nursing Home Care: An Initial Inquiry and Consideration of Policy Implications
Authors: Karuza Jurgis , Katz Paul R.
Published: April 2015

BACKGROUND: To determine, post‐OBRA 1987, medical organization in nursing facilities (ie, medical director and staff profile, closing of medical staff, use of physician contract); structural correlates of medical organization; and links between medical organization, especially closed staffing, and medical care.

METHOD: Mail survey of New York state nursing facility administrators (63% response). Survey consisted of open and closed end items that focused on facility and staff demographics, medical organization, and markers of medical care delivery, ie, physicians' daily presence, average response time to emergency calls, cross coverage for acute conditions and emergencies, attendance at care conferences, and offering of in‐services.

RESULTS: On average, facilities had 8.6 attending physicians, 32 residents per physician, 70% of residents cared for by non‐staff physicians, no daily physician presence (60%), and no cross coverage. Most medical directors were from family (42%) or internal (55%) medicine, had a tenure of 7.5 years, did not have a certificate of added qualification in geriatrics (73%), and attended residents (66%). Forty‐three percent of facilities had closed medical staffs, and 12% had physician contracts. Closed staffs were more likely in facilities that were larger, had more Medicaid residents, used physician extenders, and had more residents per nurse. Facilities with closed medical staffs had fewer physicians, more residents per physician, reported medical care practice patterns that would be associated with quality of care. These effects were independent of nursing and facility characteristics. Physician contract was unrelated to care.

CONCLUSIONS: Medical organization and practice patterns emerge as important factors in considerations of nursing home quality. Results argue that, as in acute settings, limiting practice privileges in nursing homes may be a useful organizational strategy to improve quality of care.
The Evolution of Nursing Homes Into Comprehensive Geriatrics Centers: A Perspective
Authors: Burton John R.
Published: April 2015

Nursing homes typically have been a relatively isolated component of health care in the United States. Now, however, nursing homes are experiencing a change in the patients they serve. In recent years, nursing home patients have been admitted sicker and after a shorter hospital stay than in the past. Such changes are likely to continue to occur as the size of the population of frail elderly continues to increase and as insurers look for alternatives to high cost hospital care. An additional stimulus to change is that the public is asking for innovation in noninstitutionalized long‐term care.

This essay advocates that nursing homes are the ideal component of the health care system to lead innovative program development focused on the creation of a highly organized continuum of care for the frail elderly. Physicians must be a fundamental part of this process, providing the guidance and leadership necessary for nursing homes to evolve into comprehensive geriatrics centers. Strategies are provided for developing physician office practices in nursing homes, a fundamental first step in the process of change. Additionally, ideas are provided for developing day care centers and physician house call programs based in nursing homes. Also, tight and highly functional relationships among nursing homes and acute hospitals must be developed. The example of the Johns Hopkins Geriatrics Center is described briefly as one such program now in place.

As nursing homes evolve into comprehensive geriatrics centers and provide a full continuum of health care programs, they will serve the needs of the elderly much more effectively than is now possible.
Age and the Renal Blood Supply: Renal Vascular Responses to Angiotensin Converting Enzyme Inhibition in Healthy Humans
Authors: Hollenberg Norman K. , Moore Thomas J.
Published: April 2015

OBJECTIVE: To assess the relation between age, sodium intake, renal blood flow (RBF) and the renal vascular response to an angiotensin converting enzyme (ACE) inhibitor, captopril.

DESIGN: Blood flow studies were performed before and during the acute response to an oral 25‐mg dose of captopril, selected to induce a maximal response, after 5 to 7 days on a metabolic ward, sufficient time to have achieved external balance on a fixed low‐salt (10 mEq/day) or high salt (200 mEq/day) diet. Blood flow was measured as radioxenon transit through the kidney.

SETTING: The study was performed on a metabolic ward, the Clinical Research Center, and in the Cardiovascular Radiology Laboratories of the Brigham and Women's Hospital in Boston.

PARTICIPANTS: The participants, all community dwellers, were potential kidney donors, in a renal transplant program. They were thought to be sufficiently healthy to consider donation of a kidney. The age range was 18 to 69 years.

RESULTS: Renal blood flow showed the anticipated decline with increasing age, whether the subjects were on a restricted or a liberal salt intake. Captopril induced an acute increase in RBF, averaging 88 ± 7 mL/100 g/min in subjects on a low‐salt diet, and 49 ± 9 mL/100 g/min in subjects on a high‐salt diet, but no influence of age was identified on the renal vasodilator response on either diet. Increasing age did not limit the renal vasodilator response, although subjects beyond the sixth decade were not studied.

CONCLUSIONS: The limited renal vascular response to vasodilators we had documented in earlier studies does not extend to ACE inhibitors. Although ACE inhibitors lack the pharmacological specificity required to prove a role for angiotensin II (Ang II), the data are compatible with a contribution of Ang II to the maintenance of renal vascular tone that does not change with increasing age, at least to 70 years of age.
Delirium in Hospitalized Older Persons: Outcomes and Predictors
Authors: Pompei Peter , Foreman Marquis , Rudberg Mark A. , Inouye Sharon K. , Braund Victoria , Cassel Christine K.
Published: April 2015

OBJECTIVE: The purpose of this study was fourfold: to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients.

DESIGN: Two prospective cohort studies

SETTING: Medical and surgical wards of 2 university teaching hospitals

PATIENTS: In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale‐New Haven Hospital were studied.

MEASUREMENTS: Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM‐III‐R criteria. Duration of hospitalization was adjusted for diagnosis‐related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Socio‐demographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium.

MAIN RESULTS: The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in‐hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%.

CONCLUSIONS: This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized older persons.
Functional Status and Mobility Among Elderly Women with Lower Extremity Arterial Disease: The Study of Osteoporotic Fractures
Authors: Vogt Molly T. , Cauley Jane A. , Kuller Lewis H. , Nevitt Michael C.
Published: April 2015

OBJECTIVE: To investigate the relationship between lower extremity arterial disease, functional status, and mobility among elderly women.

DESIGN: Cross‐sectional study.

SETTING: Community.

PARTICIPANTS: 1492 healthy white women, 65 years of age or older, residing in a rural community, able to walk without the assistance of another person, and enrolled in the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures. Those with bilateral hip replacement were excluded.

MEASUREMENTS: Ankle/arm index (AAI); instrumental activities of daily living (IADLs); measures of recent physical activity, muscle strength, gait and balance; general demographic, lifestyle, and physical variables.

RESULTS: Women with lower extremity arterial disease (defined as an AAI of 0.9 or less) were more likely to report difficulty with one or more IADLs than were women free of this disease. After adjusting for age and other potential confounders, only difficulty with walking 2–3 blocks remained highly correlated with disease (relative risk (RR) 2.8, 95% confidence interval (CI) 1.6, 4.8). Several measures of physical activity were inversely and independently related to a low AAI. Muscle strength in the hip, arm, knee, and hand and measures of static and dynamic balance were correlated with low AAI in the univariate analysis, but most of these trends were not statistically significant after adjustment for age and other confounders. Exclusion of women with symptomatic arterial disease did not substantially affect the results obtained.

CONCLUSION: Women with mild, predominantly subclinical, lower extremity arterial disease living in the community have decreased functional status and mobility.
Constipation: Assessment and Management in an Institutionalized Elderly Population
Authors: Harari Danielle , Gurwitz Jerry H. , Avorn Jerry , Choodnovskiy Igor , Minaker Kenneth L.
Published: April 2015

OBJECTIVES: To examine prescribing and utilization patterns of laxatives, stool softeners, and enemas in a large, long‐term care facility, to compare self‐reports of constipation with specific, bowel‐related symptoms in residents of this facility, and to examine concordance between bowel symptoms reported by residents and the assessments of the nursing staff.

DESIGN: Cross‐sectional study.

SETTING AND SUBJECTS: All individuals residing in an academically oriented long‐term care facility in the United States for at least 1 month (n = 694).

MEASUREMENTS: Clinical, functional, and medication data were abstracted from the medical and nursing records. Individual interviews regarding bowel‐related symptoms were conducted with all able participants (n = 456 (66%)) and their respective primary nurses, and concordance was determined. The study definition of symptom‐specific constipation was no more than 2 bowel movements per week and/or straining on more than 1 in 4 bowel movements.

RESULTS: Fifty percent (n = 367) of all residents used at least 1 daily laxative, stool softener or enema during a 1‐month study period. Over half of all laxative users (n = 200) took more than 60 doses per month. Stool softeners were most commonly prescribed, followed by saline laxatives, stimulant laxatives, hyperosmolar laxatives, and bulk laxatives. Forty‐seven percent (n = 213) of the 456 interview responders reported constipation (“self‐reporters”), but only 62% of self‐reporters met the study criteria for symptom‐specific constipation. Concordance between resident's and nurse's report regarding specific bowel symptoms was only fair to slight (kappa 0.12–0.38). Self‐reporters of constipation took almost twice as many laxatives, stool softeners, and enemas as residents who did not report constipation.

CONCLUSION: Our findings emphasize the need for a more systematic approach to the assessment of constipation in the long‐term care setting, particularly when pharmacologic treatment is being considered.
Falls Among Nursing Home Residents: An Examination of Incident Reports Before and After Restraint Reduction Programs
Authors: Ejaz Farida K. , Jones James A. , Rose Miriam S.
Published: April 2015

OBJECTIVE: To examine changes in the rate of falling of an experimental group of restrained subjects who underwent restraint reduction, and to compare their rate of falling with a group of subjects who did not have restraint orders during the study period.

DESIGN: A quasi‐experimental, multiple time‐series study utilizing the principles of single‐subject design. Each subject was followed for 25 weeks before and 25 weeks after initiation of the intervention.

SETTING: Seven nursing homes.

INTERVENTION: Formal programs aimed at reducing all bed and chair restraints were initiated in all sites after staff received education and training. Multidisciplinary teams implemented the restraint reduction process on a case‐by‐case basis, beginning with 1 unit/floor at a time in each site. Most experimental subjects reached their optimum restraint‐elimination/reduced status within 2 weeks of intervention initiation. The implementation periods ranged from 4 months to more than a year.

PARTICIPANTS: Subjects with chart orders for restraints at the start of the study comprised the experimental group and participated in the restraint reduction program (184 subjects). Subjects with no orders for restraints during the study period comprised the nonequivalent control group (111 subjects) and, therefore, did not undergo the intervention.

MEASUREMENTS: Incident reports documenting all falls during the study period were examined. Falls, the dependent variable, were classified as serious or nonserious. The independent variable (intervention) was the restraint reduction program offered to experimental subjects. Based on the principles of single subject design, the impact of the intervention on falls was calculated before and after the date the restraint reduction process was initiated for an individual (experimental group) subject. For the control group, the pre‐ and posttest period was calculated from the start date of the restraint reduction program on the unit on which each subject resided.

RESULTS: Serious falls did not increase, but nonserious falls increased significantly after restraints were removed or reduced in experimental subjects. The total mean weekly fall rate for this group increased from 1.87% of residents falling per week during preintervention to 3.01% during postintervention. The mean weekly fall rate of the control group was 3.18% at pretest and did not change statistically over time.

CONCLUSIONS: The increase in nonserious falls among the experimental group may be attributed to restraint reduction. The mean weekly fall rate in the experimental group postintervention (25 weeks) became comparable to the mean weekly fall rate for the control group during the entire study period (50 weeks). In light of such findings, policy makers have to confront the ethical choice between tying some frail, elderly subjects to beds and chairs versus exposing them to the risks of freedom in their old age.
Lipoprotein(a) Is a Risk Factor for Diabetic Retinopathy in the Elderly
Authors: Morisaki Nobuhiro , Yokote Koutaro , Tashiro Jun , Inadera Hidekuni , Kobayashi Junji , Kanzaki Tetsuto , Saito Yasushi , Yoshida Sho
Published: April 2015

OBJECTIVE: To assess whether serum lipoprotein(a) is a risk factor for diabetic retinopathy in the elderly.

DESIGN: A cross‐sectional study.

SETTING: Outpatient diabetic clinic.

PATIENTS: One hundred four noninsulin‐dependent diabetic patients (35 males, 69 females). Twenty‐three were less than 60 years of age (middle‐aged), and 81 were 60 years or older (elderly).

MEASUREMENT: Levels of lipoprotein(a) (Lp(a)) and lipids were measured in fasting serum. HbA1c was also measured as an indicator of diabetic control. Other indicators possibly related to retinopathy were also checked. Retinopathy was estimated by photographs of fundi.

RESULTS: Significantly higher indicators in the group with retinopathy than in the group without were: HbA1c, Lp(a), duration of diabetes, and systolic blood pressure (BP) in the total cases; HbA1c, duration of diabetes, and Lp(a) in the middle‐aged; HbA1c, systolic BP, and Lp(a) in the elderly. Multiple logistic regression analysis showed that only HbA1c and Lp(a) were independent risk factors for retinopathy in all cases and in the elderly. The incidence of retinopathy was positively correlated to serum Lp(a) levels.

CONCLUSION: Lp(a) is an independent risk factor for diabetic retinopathy.
Projecting Patients' Preferences from Living Wills: An Invalid Strategy for Management of Dementia with Life‐Threatening Illness
Authors: Reilly Rebecca B. , Teasdale Thomas A. , McCullough Laurence B.
Published: April 2015

OBJECTIVE: To examine variation in elders' choices of therapies in different clinical scenarios and to assess the validity of extending preferences expressed in scenarios of usual health, terminal illness, and coma to preferences in a scenario of moderately advanced Alzheimer disease.

DESIGN: Questionnaire study of community‐dwelling elders.

SETTING: Houston metropolitan area.

PARTICIPANTS: 218 community‐dwellers age 60 years and older.

MEASUREMENTS: Responses regarding choices of 10 interventions in 4 scenarios. Interventions were: cardiopulmonary resuscitation (CPR), ventilator, total parenteral nutrition (TPN), IV medication and hydration, any medication, enteral feeding, dialysis, ICU admission, hospitalization, and antibiotics. Interventions were selected “never,” “always,” or a “trial of intervention to assess efficacy.” Independent variables were responses in scenarios of usual state of health with a life‐threatening illness, irreversible coma, and terminal illness causing pain. Dependent variables were responses in a scenario of moderately advanced Alzheimer disease with a life‐threatening illness. Frequencies of responses were calculated using “never,” “trial,” and “always.” Subsequently “trial” and “always” were collapsed into a category of “accepting intervention” for dichotomous analysis with “refusing intervention” (the “never” category). Logistic regression was used to assess validity of predicting responses in one scenario from the others.

MAIN RESULTS: Preferences regarding medical therapies varied across scenarios (P < 0.01). In the Usual Health scenario, all interventions were accepted more frequently than refused. In Terminal Illness and Coma scenarios, CPR, ventilator, TPN, enteral feedings and dialysis were refused more frequently than accepted. In the Alzheimer scenario, medications, ICU admission, hospitalization, and antibiotics were accepted more often than rejected. Trial was preferred to always in 90% of all choices across all scenarios. Preferences expressed in Terminal Illness, Coma, and Usual Health scenarios predicted choices in the Alzheimer disease scenario poorly.

CONCLUSIONS: (1) Use of a scenario‐based advance directive may be limited to the precise scenario described. (2) The common acceptance of interventions in the Alzheimer disease scenario differs from findings in earlier studies, possibly because of differences in populations surveyed or the stage of the disease described, highlighting the variability of preferences in this scenario. (3) Trial of intervention is attractive to many respondents, perhaps because it allows the advantage of potentially beneficial therapies without commitment to a course of therapy not leading to cure. (4) Results of this study should be interpreted in light of the study population, consisting largely of well educated, healthy Caucasians. Findings are likely not to be generalizable to other populations.
Flight Simulator Performance of Younger and Older Aircraft Pilots: Effects of Age and Alcohol
Authors: Yesavage Jerome A. , Dolhert Nancy , Taylor Joy L.
Published: April 2015

Objective: To determine if older pilots forgot more about a learned flight task after a 10‐month delay than did younger pilots and if the anticipated greater skill loss led older pilots' performance to be more disrupted by alcohol.

Design: Repeated measures comparative group design examining the effects of alcohol versus placebo in two age groups (younger and older) and at two timepoints: acute intoxication, at a Blood Alcohol Concentration (BAC) of 0.10%, and 8 hours post‐drink.

Setting: University medical center research laboratory.

Subjects: Fourteen younger (mean age = 27; SD = 4.21; range 21–34) and 13 older (mean age = 60; SD = 6.27; range 51–69) pilots, recruited from local flying clubs, with current FAA medical certificates.

Methods: We examined the effects of alcohol versus placebo in the two age groups and at two times, ie, acute intoxication (target BAC 0.10%) and 8‐hour post‐drink. Subjects flew a Frasca 141 simulator in a flight task that they had previously learned but not practiced for several months. After completing a baseline flight, pilots were tested during either an alcohol or a placebo condition at the two timepoints. The main outcome measure was a composite measure of flight performance based upon the mean of eight component standardized scores from different aspects of the flight task.

Results: We found detrimental effects of alcohol on the main outcome measure both at the acute and 8‐hour post‐drink testing. There was also no significant difference between the older and younger pilots' performance of the flight task or in susceptibility to alcohol either while intoxicated or during hangover.

Conclusions: This study replicates the findings of earlier studies that an 8‐hour waiting period from “Bottle‐to‐Throttle” is insufficient but finds little difference according to age in recollection of a previously learned task or in susceptibility to either acute or hangover effects of alcohol.
Impact of Special Care Unit for Patients with Advanced Alzheimer's Disease on Patients' Discomfort and Costs
Authors: Volicer Ladislav , Collard Ann , Hurley Ann , Bishop Christine , Kern Donald , Karon Sarita
Published: April 2015

Objective: To compare outcomes in patients with the clinical diagnosis of probable dementia of the Alzheimer type (DAT) cared for in a Dementia Special Care Unit (DSCU) with those in traditional long‐term care (TLTC).

Design: Two‐year prospective cohort study.

Setting: Two Veterans Administration Hospitals. The DSCU concentrated on assuring patients' comfort instead of promoting maximal survival; in some patients this excluded transfer to acute medical settings, the use of antibiotics, and tube feeding.

Measurements: Data were collected regarding disease severity, patient discomfort, use of medical resources, and mortality rate.

Results: Patients at both settings were similar on baseline measures, and most were severely demented. The monthly levels of observed discomfort were lower in DSCU than in TLTC patients. The costs of medications, radiology, and laboratory procedures were lower in DSCU than in TLTC patients. DSCU patients were also transferred less frequently to an acute medical setting. The average 3‐month cost for a DSCU patient was $1477 less than the cost of care for a TLTC patient. However, DSCU patients with lower severity of DAT had a higher mortality rate then TLTC patients.

Conclusions: These results suggest that management of patients with advanced DAT on a DSCU using a palliative care philosophy may result in less patient discomfort and lower costs than management on a TLTC.
Carbamazepine Treatment of Agitation in Nursing Home Patients with Dementia: A Preliminary Study
Authors: Tariot Pierre N. , Erb Rosemary , Leibovici Adrian , Podgorski Carol Ann , Cox Christopher , Asnis Jamie , Kolassa John , Irvine Carrie
Published: April 2015

OBJECTIVE: To determine the effects of carbamazepine versus placebo on ratings of behavior in agitated nursing home patients with dementia.

DESIGN: Nonrandomized, placebo‐controlled, crossover trial conducted in 25 patients in two nursing homes.

INTERVENTION: Carbamazepine and placebo were administered during two 5‐week periods separated by a 2‐week washout. The carbamazepine dose was determined for each patient by a nonblinded physician who did not participate in ratings (modal dose 300 mg/day).

MEASUREMENTS: The primary outcome measures were Brief Psychiatric Rating Scale scores and Clinical Global Impression of Change, rated by blind observers. Secondary measures of behavior, adversity, cognition, and functional status were also included.

MAIN RESULTS: Median total Brief Psychiatric Rating Scale score decreased 7 points on carbamazepine versus 3 on placebo (P = 0.03). Sixteen subjects were rated as improved globally on carbamazepine versus four on placebo (P = 0.001). Secondary measures of behavior showed similar changes at significant or suggestive (P <0.10) levels. One subject developed carbamazepine‐induced tics, and one died with a pneumonia. There was minimal other adversity.

CONCLUSION: This preliminary study suggests that carbamazepine in low doses can reduce agitated behaviors in some patients, with limited adversity resulting. Further research is required to confirm and extend this finding before it can be considered routine clinical practice.
Dizziness in Elderly Men
Authors: Davis Larry E.
Published: April 2015

OBJECTIVE: To evaluate the causes of dizziness in elderly men.

DESIGN: A descriptive study involving the clinical and laboratory features of elderly men with dizziness.

SETTING: A university‐affiliated Veterans Affairs medical center.

PATIENTS: One hundred seventeen consecutive men more than 50 years of age attending a general neurology clinic with the chief complaint of dizziness.

RESULTS: The median duration of dizziness at first office visit was 45 weeks. Forty‐nine percent of patients had more than one diagnosis that contributed to their dizziness. Dysfunctions of the peripheral vestibular system were found in 71% and were the principal causes in 56%. Benign positional vertigo was present in 34%. Disorders of the visual system were found in 26% but were the major cause in only 1%. Diagnoses involving the proprioceptive system were present in 17% and were the principal cause in 7%. Structural lesions of the brainstem or cerebellum or metabolic disorders that affected normal brainstem function were identified in 59% and were the major diagnoses in 22%. A psychophysiologic diagnosis was made in 6% but was the major diagnosis in only 3%. At the 6‐months follow‐up, 55% of patients improved, 34% were unchanged, 4% worsened, and 7% were lost to follow‐up.

CONCLUSIONS: Contrary to reports in the literature, dizziness in the elderly is more persistent, has more causes, is less often due to a psychophysiologic cause, and seems to be more incapacitating than dizziness in younger patients. J Am Geriatr Soc 42:1184–1188, 1994.
Use of a Portable Ultrasound Device To Measure Post‐Void Residual Volume Among Incontinent Nursing Home Residents
Authors: Ouslander Joseph G. , Simmons Sandi , Tuico Edward , Nigam Jennifer Glatler , Fingold Susan , Bates‐Jensen Barbara , Schnelle John F.
Published: April 2015

OBJECTIVE: To determine the accuracy of a portable ultrasound device for the assessment of post‐void residual (PVR) volume among incontinent nursing home (NH) residents.

DESIGN: Prospective, clinical series.

SETTING: Seven community‐based nursing homes.

STUDY POPULATION: Two hundred one consecutively assessed incontinent NH residents who were participating in a larger clinical trial.

MEASUREMENTS: PVR volumes measured by trained research associates using a portable ultrasound device and by in‐and‐out catheterization were compared. The accuracy of the ultrasound was calculated using the volume obtained by catheterization as the gold standard.

RESULTS: The ultrasound demonstrated excellent test‐retest and interrater reliability. For low PVRs, the device was highly sensitive (.90 for PVR <50 mL and .95 for PVR < 100 mL) and moderately specific (.71 for PVR <50 mL and .63 for PVR < 100 mL). For PVRs of more than 200 mL (n = 26), the ultrasound had a sensitivity of .69 and a specificity of .99.

CONCLUSION: The portable ultrasound we used was reliable and reasonably accurate for assessing PVR in a representative sample of incontinent NH residents. Because the sensitivity for clinically significant urinary retention (PVR >200 mL) was only .69, repeated measurements may be necessary to exclude high PVR in individual NH residents. Recent changes in ultrasound design should improve its ease of use and accuracy. Although measuring PVR by ultrasound is much easier and more comfortable than catheterization for both NH residents and staff, the cost of the device may be a barrier to its widespread use in the NH setting.
Seven Consecutive Days of Exercise Lowers Plasma Insulin Responses to an Oral Glucose Challenge in Sedentary Elderly
Authors: Cononie Carmen C. , Goldberg Andrew P. , Rogus Ellen , Hagberg James M.
Published: April 2015

Objective: To assess the effects of 1 and 7 consecutive days of exercise on glucose and insulin responses to an oral glucose challenge.

Design: Intervention group assessed at baseline and after 1 and 7 days of exercise.

Setting: Academic medical institution.

Participants: Nine healthy 60 to 80‐year‐old men and women.

Intervention: Seven days of 50 minutes of exercise at 70% VO2 max.

Measurements: Body weight, body composition, and glucose and insulin levels and responses to an oral glucose challenge at baseline and after 1 and 7 days of exercise.

Main Results: Fasting plasma insulin levels and plasma insulin responses to an oral glucose challenge were reduced by 15% and 20%, respectively, with 7 consecutive days of exercise that resulted in no change in body weight or body composition. No changes in glucose or insulin levels or responses to the oral glucose challenge were evident after a single day of exercise.

Conclusion: The hyperinsulinemia associated with aging can be blunted significantly by repeated bouts of exercise in the elderly, independent of any changes in body composition.
Clean Intermittent Catheterization: Safe, Cost‐Effective Bladder Management for Male Residents of VA Nursing Homes
Authors: Duffy Linda M. , Cleary James , Ahern Sharon , Kuskowski Michael A. , West Melissa , Wheeler Lenea , Mortimer James A.
Published: April 2015

OBJECTIVES: To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long‐term care in whom urinary retention is a documented problem.

DESIGN: Randomized clinical trial.

SETTING: Three long‐term care sites having predominantly male populations.

PARTICIPANTS: Eighty male veterans, residents of three long‐term care facilities, ranging in age from 36 to 96 years with a mean age of 72.

INTERVENTIONS: Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident.

MEASUREMENTS: We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed.

RESULTS: No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies.

CONCLUSIONS: Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost‐effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique. J Am Geriatr Soc 43:865–870, 1995.