bluuebunny/crossref_metadata_2025 huggingface dataset:
Survey Methods for Seriously Ill Hospitalized Adults: Practical Lessons from SUPPORT
Authors: Kreling Barbara , Wu Albert W. , Lynn Joanne
Published: April 2015

OBJECTIVE: To describe issues confronted in collecting questionnaire‐based data in a large study of seriously ill hospitalized adults, discuss methods used to achieve acceptable results, summarize the reliability of selected measures, and explore challenges for patient‐based research in this population.

DESIGN: A prospective cohort study.

SETTING: Five teaching hospitals in the US.

PARTICIPANTS: 9105 patients, with a subset of 80 patients and 10 proxy respondents for reliability testing.

MEASUREMENTS AND MAIN OUTCOMES: Response rates; percent agreement and Kappa statistics to assess test‐retest reliability.

RESULTS: A pretest and pilot test were used to help develop the assessment strategy, establish study procedures, and identify staff characteristics likely to facilitate the project. Achieving adequate response rates required great perseverance and flexibility by interview staff as well as close monitoring and central supervision. Standardized quality assurance with timely feedback, and social support provided by peer and supervising staff were both important. Older women proved to be the best interviewers. Reliability was acceptable for existing and newly developed scales to measure subjective health status, preferences, and satisfaction.

CONCLUSIONS: It was possible to collect reliable and useful data on preferences and subjective health outcomes from a cohort of seriously ill hospitalized patients and their proxies. Achieving acceptable data quality required a large interview team, mature staff, flexibility about modes of administration, and centralized, structured quality assurance. Successful outcomes research in this population is likely to require similar planning and efforts.
Age‐Related Differences in Care Preferences, Treatment Decisions, and Clinical Outcomes of Seriously Ill Hospitalized Adults: Lessons from SUPPORT
Authors: Hamel Mary Beth , Lynn Joanne , Teno Joan M. , Covinsky Kenneth E. , Wu Albert W. , Galanos Anthony , Desbiens Norman A. , Phillips Russell S.
Published: April 2015

OBJECTIVES: To review previously published findings about how patient age influenced patterns of care for seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN: An observational prospective study.

SETTING: Five acute care hospitals.

PARTICIPANTS: A total of 9105 seriously ill patients enrolled in SUPPORT.

MEASUREMENTS: The outcomes examined included patients' preferences for aggressive care, decision making regarding cardiopulmonary resuscitation and use of other life‐sustaining treatments, hospital costs, intensity of resource use, and survival.

RESULTS: Although older patients preferred less aggressive care than younger patients, many older patients wanted cardiopulmonary resuscitation and care focused on life extension. Patients' families and healthcare providers underestimated older patients' desire for aggressive care. After adjustment for illness severity, comorbidity, baseline function, and patients' preferences for aggressive care, older age was associated with lower hospital costs and resource intensity and higher rates of decisions to withhold life‐sustaining treatments. In adjusted analyses, older age was associated with a slight survival disadvantage. This survival disadvantage persisted, even after adjustment for aggressiveness of care, suggesting that the relation between age and survival is not accounted for by less aggressive treatment of older patients.

CONCLUSIONS: Even after adjustment for patients' prognoses and care preferences, seriously ill hospitalized older patients were treated less aggressively than younger patients. SUPPORT cannot fully identify whether the relationship between older age and less aggressive treatment is better explained by the withholding of potentially beneficial treatments from older patients, or by the excessive provision of ineffective treatment to younger patients. However, the latter explanation is favored by the SUPPORT finding that less aggressive treatment for older patients does not contribute to the modest survival disadvantage associated with older age.
Blood Transfusion Administration in Seriously Ill Patients: An Evaluation of SUPPORT Data
Authors: Borum Marie L. , Lynn Joanne , Zhong Zhenshao
Published: April 2015

BACKGROUND: Administration of blood transfusion in seriously ill patients is highly variable. Limited data are available to guide transfusion decisions.

OBJECTIVE: To explore characteristics of patients who received blood transfusions and decisions to forgo transfusions in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN: Prospective study of preferences, decision‐making, and outcomes.

SETTING: Five teaching hospitals.

PARTICIPANTS: 9105 patients aged 18 years and older meeting defined diagnostic and illness severity criteria.

MEASUREMENT: Data included blood transfusions, demographic characteristics, diagnoses, comorbid conditions, acute physiology score (APS), nutritional support, and functional status before hospitalization.

RESULTS: A total of 2863 patients (31.4%) received blood transfusions, usually early in their hospitalization. Transfused patients were more likely male (57.3%; P = .008), with a younger mean age (56 vs 64 years), significantly higher APS (P < .001), and significantly lower 2‐ and 6‐month survival predictions (P < .001). The patients with acute respiratory failure or multiorgan system failure with sepsis (1714; 59.9% of all patients receiving transfusions), multiorgan system failure with malignancy (480, 16.8%), and cirrhosis (248, 8.7%) were more likely to receive blood than those with other diseases. Few patients made a decision not to receive blood before (5; 0.05%) or after (126; 1.4%) study entry. Most patients with decisions to forgo transfusions also had decisions against trying resuscitation.

CONCLUSIONS: Most transfusions occurred in patients with acute respiratory or multiorgan system failure. Few patients decide to forgo transfusions. Additional investigation is necessary to evaluate blood transfusion practices in seriously ill patients.
A Prospective Study of Patient‐Physician Communication About Resuscitation
Authors: Golin Carol E. , Wenger Neil S. , Liu Honghu , Dawson Neal V. , Teno Joan M. , Desbiens Norman A. , Lynn Joanne , Oye Robert K. , Phillips Russell S.
Published: April 2015

OBJECTIVE: To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians.

DESIGN: Prospective cohort.

SETTING: Five academic medical centers.

PARTICIPANTS: Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life‐threatening illness (n = 1288).

MEASUREMENTS: Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow‐up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators.

RESULTS: Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month‐period following hospital admission. Patients whose preference was to forgo CPR (odds ratio (OR) 2.9; (95% CI, 1.9‐4.2)) and whose preference had changed from desiring to forgoing CPR (OR 1.6; (95% CI, 1.1–2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forgo CPR communicated this over a 2‐month period. Having an advance directive and remaining in the hospital at 2‐month follow‐up were also independently associated with communication, whereas patients' preference for participation in decision‐making, health status, and prognostic estimate were not.

CONCLUSIONS: Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forgo resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician‐patient discussions about resuscitation.
Predicting Functional Status Outcomes in Hospitalized Patients Aged 80 Years and Older
Authors: Wu Albert W. , Yasui Yutaka , Alzola Carlos , Galanos Anthony N. , Tsevat Joel , Phillips Russell S. , Connors Alfred F. , Teno Joan M. , Wenger Neil S. , Lynn Joanne
Published: April 2015

OBJECTIVE: To develop a model estimating the probability of a patient aged 80 years or older having functional limitations 2 months and 12 months after being hospitalized.

DESIGN: A prospective cohort study.

SETTING: Four teaching hospitals in the US.

PARTICIPANTS: Enrolled patients were nonelective hospital admissions aged 80 years or older who stayed in hospital at least 48 hours. The 804 patients who survived and completed an interview at 2 months and the 450 who completed an interview at 12 months were from the 1266 patients in the Hospitalized Elderly Longitudinal Project (HELP) (76% and 47% of survivors, respectively). Median age of the 2‐month survivors was 84.7 years.

MEASUREMENTS AND MAIN OUTCOMES: Patient function 2 and 12 months after enrollment was defined by the number of dependencies in Activities of Daily Living (ADLs). Ordinal logistic regression models were constructed to predict functional status. Predictors included demographic characteristics, disease category, geriatric conditions, severity of physiologic imbalance, current quality of life, and exercise capacity and ADLs 2 weeks before study admission.

RESULTS: Before admission, 39% of patients were functionally independent in ADLs. Of patients who survived and were interviewed at 2 months, 32% were functionally independent, and at 12 months, 36% were independent. Among patients with no baseline dependencies, 42% had developed one or more limitations 2 months later, and 41% had limitations 12 months later. The patient's ability to perform activities of daily living at baseline was the most important predictor of functional status at both 2 and 12 months. In a multivariable predictive model, independent predictors of poorer functional status at 2 months included: worse baseline functional status and quality of life; depth of coma, if any; lower serum albumin level; presence of dementia, depression, or incontinence; being bedridden; medical record documentation of need for nursing home; and older age. Model performance, assessed using Somers' D, was 0.61 for 2 months and 0.57 for 12 months (Receiver Operating Characteristic (ROC) area = 0.81 and .79, respectively.) Bootstrap validation of the month 2 model also yielded a Somers' D = 0.60. The models were well calibrated over the entire risk range. The ROC area for prediction of the loss of independence was 0.76 for 2 months and 0.68 for 12 months.

CONCLUSIONS: Many older patients are functionally impaired at the time of hospitalization, and many develop new functional limitations. A limited amount of readily available clinical information can yield satisfactory predictions of functional status 2 months after hospitalization. Models like this may prove to be useful in clinical care. This work illuminates a potential method for risk adjustment in research studies and for monitoring quality of care.
Decision‐Making and Outcomes of Prolonged ICU Stays in Seriously Ill Patients
Authors: Teno Joan M. , Fisher Elliot , Hamel Mary Beth , Wu Albert W. , Murphy Donald J. , Wenger Neil S. , Lynn Joanne , Harrell Frank E.
Published: April 2015

BACKGROUND: Despite concern about the high costs and the uncertain benefit of prolonged treatment in the intensive care unit (ICU), there has been little research examining decision‐making and outcomes for patients with prolonged ICU stays.

OBJECTIVES: To evaluate decision‐making and outcomes for seriously ill patients with an ICU stay of at least 14 days.

DESIGN: A prospective cohort study.

SETTING: Five teaching hospitals.

PARTICIPANTS: Seriously ill patients enrolled in the Study To Understand Prognoses and Preferences for Risks and Outcomes of Treatments (SUPPORT).

MEASUREMENT: Patients, their surrogate decision‐makers, and their physicians were interviewed about prognosis, communication, and goals of medical care. Based on age, diagnoses, comorbid illnesses, and acute physiology data, the SUPPORT Prognostic Model provided estimates of 6‐month survival on study days 1, 3, 7, and 14. Hospital costs were estimated from hospital billing data.

RESULTS: Of the 9105 patients enrolled in SUPPORT, 1494 (16%) had ICU stays of 14 days or longer. The median length of stay in an ICU was 4 days for the entire SUPPORT cohort and 35 days for patients who were treated in an ICU for 14 days or longer. Median hospital costs were $76,501 for patients who had ICU stays 14 days or longer and $10,916 for patients who did not have long ICU stays. Fifty‐five percent of patients with long ICU stays had died by 6 months, and an additional 19% had substantial functional impairment. Among patients with ICU stays of at least 14 days, only 20% had estimates of 6‐month survival that fell below 10% at any time during their hospitalization. For patients with long ICU stays, the mean predicted probability of 6‐month survival was 0.46 on study Day 3 and 0.47 on study Day 14. Fewer than 40% of patients (or their surrogates) reported that their physicians had talked with them about their prognoses or preferences for life‐sustaining treatment. Among the patients who preferred a palliative approach to care, only 29% thought that their care was consistent with that aim. Those who discussed their preferences for care with a physician were 1.9 times more likely to believe that treatment was in accord with their preferences for palliation (95% CI, 1.4–2.5)

CONCLUSIONS: Prolonged ICU stays were expensive and were often followed by death or disability. Patients reported low rates of discussions with their physicians about their prognoses and preferences for life‐sustaining treatments. Many preferred that care focus on palliation and believed that care was inconsistent with their preferences. Patients were more likely to receive care consistent with their preferences if they had discussed their care preferences with their physicians.
Patients Who Want their Family and Physician to Make Resuscitation Decisions for Them: Observations from SUPPORT and HELP
Authors: Puchalski Christina M. , Zhong Zhensbao , Jacobs Michelle M. , Fox Ellen , Lynn Joanne , Harrold Joan , Galanos Anthony , Phillips Russell S. , Califf Robert , Teno Joan M.
Published: April 2015

OBJECTIVE: To determine the extent to which older or seriously ill inpatients would prefer to have their family and physician make resuscitation decisions for them rather than having their own stated preferences followed if they were unable to decide themselves.

DESIGN: Analysis of existing data from the Hospitalized Elderly Longitudinal Project (HELP) and the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT).

SETTING: Five teaching hospitals in the United States.

PARTICIPANTS: 2203 seriously ill adult inpatients (SUPPORT) and 1226 older inpatients (HELP) who expressed preferences about resuscitation and about advance decision‐making.

MEASURES: We used a logistic regression model to determine which factors predicted preferences for family and physician decision‐making.

RESULTS: Of the 513 HELP patients in this analysis, 363 (70.8%) would prefer to have their family and physician make resuscitation decisions for them whereas 29.2% would prefer to have their own stated preferences followed if they were to lose decision‐making capacity. Of the 646 SUPPORT patients, 504 (78.0%) would prefer to have their family and physician decide and 22.0% would prefer to have their advance preferences followed. Independent predictors of preference for family and physician decision‐making included not wanting to be resuscitated and having a surrogate decision‐maker.

CONCLUSIONS: Most inpatients who are older or have serious illnesses would not want their stated resuscitation preferences followed if they were to lose decision‐making capacity. Most patients in both groups would prefer that their family and physician make resuscitation decisions for them. These results underscore the need to understand resuscitation preferences within a broader context of patient values.
Effects of T'ai Chi Training on Function and Quality of Life Indicators in Older Adults with Osteoarthritis
Authors: Hartman Catherine A. , Manos Tina M. , Winter Christa , Hartman Dwight M. , Li Baiqing , Smith John C.
Published: April 2015

OBJECTIVE: To determine the effects of T'ai Chi training on arthritis self‐efficacy, quality of life indicators, and lower extremity functional mobility in older adults with osteoarthritis.

DESIGN: A prospective, randomized, controlled clinical trial. Intervention length was 12 weeks, with outcomes measured before and after intervention using blinded testers. Group (T'ai Chi vs Control) × time (2 × 2) mixed factorial ANOVA.

SETTING: Allied Health Sciences Center at Springfield College, Springfield, MA

PARTICIPANTS: A total of 33 community‐dwelling participants (mean age 68) diagnosed with lower extremity osteoarthritis and having no prior T'ai Chi training longer than 2 weeks.

INTERVENTION: T'ai Chi training included two 1‐hour T'ai Chi classes per week for 12 weeks.

MEASUREMENTS: Arthritis self‐efficacy (Arthritis Self‐Efficacy Scale), quality of life indicators (Arthritis Impact Measurement Scale), functional outcomes (one‐leg standing balance, 50‐foot walking speed, time to rise from a chair).

RESULTS: T'ai Chi participants experienced significant (P < .05) improvements in self‐efficacy for arthritis symptoms, total arthritis self‐efficacy, level of tension, and satisfaction with general health status.

CONCLUSIONS: A moderate T'ai Chi intervention can enhance arthritis self‐efficacy, quality of life, and functional mobility among older adults with osteoarthritis. T'ai Chi training is a safe and effective complementary therapy in the medical management of lower extremity osteoarthritis.
A Double‐Blind, Placebo‐Controlled, Multicenter Study of Cerebrolysin for Alzheimer's Disease
Authors: Bae Chul‐Young , Cho Choo‐Yon , Cho Kyunghee , Oh Byoung Hoon , Choi Kyoung Gyu , Lee Hong Soo , Jung Seung Pil , Kim Dae Hyun , Lee Sangdo , Choi Gyu‐Dong , Cho Hangsuk , Lee Hotaek
Published: April 2015

OBJECTIVE: To assess the efficacy and safety of Cerebrolysin over 4 weeks in patients with probable Alzheimer's disease (AD).

DESIGN: A 4‐week randomized, double‐blind, placebo‐controlled, multicenter clinical trial. An unequal (Cerebrolysin:placebo = 2:1) randomization was used to assign more patients to the treatment group.

SETTINGS: University medical centers and community geriatric hospitals in Korea.

PARTICIPANTS: Fifty‐three men and women at least 50 years of age admitted to hospitals with mild to moderate AD and otherwise in good health.

INTERVENTION: The treatment group (n = 34) received Cerebrolysin (30 mL Cerebrolysin in 100 mL physiologic saline IV) once a day from Monday to Friday for 4 weeks. The control group (n = 19) received placebo.

MEASUREMENTS: Primary outcome measures were the Alzheimer's Disease Assessment Scale‐Cognitive subscale (ADAS‐Cog) and the Clinical Global Impression of Severity/Change (CGIS/C). Secondary outcome measures included Mini‐Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Katz Index of Activities of Daily Living (ADL), and Lawton Instrumental Activities of Daily Living (IADL) Scale.

RESULTS: After 4 weeks of treatment, Cerebrolysin‐treated patients demonstrated significant improvements in the ADAS‐Cog (P = .02), CGIS/C (P = .01), and MMSE (P = .04) compared with placebo‐treated patients. Among Cerebrolysin‐treated patients, 82%, 62%, and 44% were rated improved on ADAS‐Cog, CGIS/C, and MMSE, respectively, compared with 31.6%, 22%, and 17% of placebo‐treated patients, respectively. However, there were no significant improvements in the Cerebrolysin group compared with the placebo group on the GDS, ADL, and IADL. There were no dropouts in either groups, with 100% compliance to Cerebrolysin and placebo. Only one patient reported a febrile sensation, which was transient and mild in severity.

CONCLUSIONS: This study indicates that Cerebrolysin is a safe drug that improves the cognitive deficits and global function in patients with mild to moderate AD. Long‐term efficacy and safety of Cerebrolysin in Alzheimer's patients should be evaluated in the future.
Physical Inactivity and Smoking Increase Risk for Serious Infections in Older Women
Authors: Leveille Suzanne G. , Gray Shelly , LaCroix Andrea Z. , Ferrucci Luigi , Black Douglas J. , Guralnik Jack M.
Published: April 2015

OBJECTIVE: This study examined health and behavioral risk factors for infections that required hospitalization in postmenopausal women who were enrollees of a large health maintenance organization (HMO).

METHODS: Participants were 1365 generally healthy women aged 55 to 80 years who were followed for up to 6 years. Infection diagnoses listed first in the automated hospital discharge records were used to identify hospitalizations for which infections were the primary cause of admission. Potential risk factors for these serious infections were identified from baseline questionnaire information and automated HMO records from before baseline and during follow‐up. Risks for infections associated with hospital admission were examined using multivariate logistic regression methods.

RESULTS: Seventy‐three women had a total of 90 hospital admissions in which infection was the primary discharge diagnosis. Behaviors that were independent predictors of infection were physical inactivity (adj. odds ratio = 4.08; 95% CI, 1.73–9.63) and smoking (adj. odds ratio = 2.64; 95% CI, 1.11–6.26). Incident cancer and lung disease were also associated with increased risk of infection. These associations were independent of age, body mass index, functional status, and other measures of health.

CONCLUSIONS: Modifiable risk factors such as physical inactivity and smoking may place older women at risk for serious infections although the causal link is yet to be explained. Further research in this area may lead to new strategies aimed at reducing the serious burden of infections in the older population.
Legionnaires' Disease in a Newly Constructed Long‐Term Care Facility
Authors: Stout Janet E. , Brennen Carole , Muder Robert R.
Published: April 2015

OBJECTIVES: To determine whether a newly‐constructed long‐term care facility would become colonized with Legionella and whether Legionnaires' disease would occur in residents of this new facility.

DESIGN: Prospective environmental surveillance of the hospital's water distribution system for the presence of Legionella pneumophila during construction. Utilization of diagnostic tests for Legionnaires' disease in cases of nosocomial pneumonia.

SETTING: The Pittsburgh VA Health Care System, Aspinwall Division, a two‐building 400‐bed complex.

PARTICIPANTS: Six patients who acquired Legionnaires' disease while in the facility.

INTERVENTION: Installation of copper‐silver ionization systems.

MEASUREMENTS: Isolation of L. pneumophila from potable water and the occurrence of Legionnaires' disease.

RESULTS: L. pneumophila serogroup 1 was recovered from the water distribution system within 1 month of operation; 74% (61/82) of distal sites were positive during construction. In the first 2 years of occupancy, six cases of legionellosis were diagnosed. Both clinical isolates of L. pneumophila were identical to environmental isolates by pulsed field gel electrophoresis (PFGE). Copper‐silver ionization systems were installed to control Legionella in the water system.

CONCLUSIONS: We conclude that long‐term care residents are at risk for acquiring nosocomial Legionnaires' disease in the presence of a colonized water system, even in a newly constructed building.
Tube Feeding in Nursing Home Residents with Severe and Irreversible Cognitive Impairment
Authors: Gessert Charles E. , Mosier Michael C. , Brown Edward F. , Frey Bruce
Published: April 2015

OBJECTIVES: This study was undertaken to determine the degree to which selected demographic and clinical variables are associated with the use of feeding tubes in older nursing home residents with very severe and irreversible cognitive impairment.

DESIGN: Descriptive, cross‐sectional, population‐based study.

SETTING: Kansas nursing homes from January 1, 1994, through June 30, 1998.

PARTICIPANTS: A total of 4997 nursing home residents with very severe and irreversible cognitive impairment comprised the study population. Subjects were identified using data in Minimum Data Set (MDS) reports. Those who were included in the study population were over the age of 65, had two consecutive Cognitive Performance Scale scores of 6, were without evidence of significant subsequent improvement, and were not comatose.

MEASUREMENTS: The MDS data on each resident were examined to determine subjects' age, ethnicity, gender, Medicaid eligibility, disease diagnoses, physical functioning, and oral/nutritional status, including feeding tube status. The MDS was also used to determine urban versus rural location of the nursing home. The association between the use of feeding tubes and selected demographic and clinical characteristics was then examined using bivariate and logistic regression tests.

RESULTS: Of the 4997 residents in the study population, 577 (11.6%) had feeding tubes. In multivariate analysis, feeding tube use was found to be associated with swallowing problems (odds ratio (OR) 5.4, 95% confidence interval (CI) 4.3–6.8); urban location of nursing home (OR 2.9, 95% CI 2.3–3.5); non‐white race (OR 2.7, 95% CI 1.9–3.6); stroke (OR 2.5, 95% CI 2.0–3.1); and absence of dementia (OR 2.5, 95% CI 2.0–3.1). Feeding tubes were also more weakly associated with age <86 years, male gender, dependency for all activities of daily living, and absence of a living will. Feeding tube use was not found to be associated with chewing problems, Medicaid status, or resuscitation status.

CONCLUSIONS: Clinical variables including swallowing problems, stroke, and absence of dementia were strongly associated with the use of feeding tubes in this cross‐sectional, population‐based study. In addition, urban location of nursing home and non‐white race were significantly associated with feeding tubes. These findings suggest that feeding tube decisions are strongly influenced by nonclinical factors and invite further investigation.
The Validity of the Minimum Data Set in Measuring the Cognitive Impairment of Persons Admitted to Nursing Homes
Authors: Gruber‐Baldini Ann L. , Zimmerman Sheryl Itkin , Mortimore Edward , Magaziner Jay
Published: April 2015

OBJECTIVES: This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument.

DESIGN: A cross‐sectional comparisons of the MDS measures, with scales provided by the resident, a proxy person, and nursing staff.

SETTING: Subjects residing in 59 nursing homes (NHs) in Maryland from 1992 to 1995.

PARTICIPANTS: Subjects were 1939 new admissions to NHs, aged 65 and older, with complete MDS information at admission.

MEASUREMENTS: Two MDS scales, the Cognitive Performance Scale (CPS) and the MDS Cognition Scale (MDS‐COGS), were compared with the Mini‐Mental State Examination (MMSE) and the staff rating on the Psychogeriatric Dependency Rating Scale (PGDRS) Orientation scale, as well as measures of functioning and functional decline.

RESULTS: The CPS and the MDS‐COGS were highly correlated (r = 0.92). Both correlated moderately well with the MMSE (r = −0.65 and −0.68) and with staff's rating on the PGDRS Orientation scale (r = 0.63 and r = 0.66). Correlations with the MMSE (r < 0.70) are lower than previously reported (r ≥ 0.80). The proportion of cognitively impaired residents in this NH admission cohort was higher using the MDS‐COGS than the CPS (65% vs 57%), but both MDS scales produced lower proportions than the MMSE (70%) and higher proportions than the PGDRS (47%). The internal consistency of the CPS was better without the comatose item (alpha = 0.80 vs 0.70). The MDS‐COGS had higher internal consistency (alpha = 0.85) and was simpler to compute.

CONCLUSIONS: This is the first study to examine the validity of the MDS in a large sample of residents and NHs in situations where the MDS was not completed by research‐trained staff. Compared with other instruments, the MDS‐COGS and the CPS had moderate and similar validity for assessing cognitive impairment. Differences in the scales could provide different estimates of impairment among persons admitted to nursing homes.
Body Positions Used by Healthy and Frail Older Adults to Rise from the Floor
Authors: Ulbrich Jessica , Raheja Aarti , Alexander Neil B.
Published: April 2015

OBJECTIVE: The purpose of this study was to describe how older adults, particularly more physically impaired older adults, might differ from healthy controls in the body positions used to rise from the floor.

DESIGN: Cross‐sectional analysis of young, healthy older, and congregate housing older women.

SETTING: University‐based laboratory and congregate housing facility.

PARTICIPANTS: Healthy young university student controls (n = 22, mean age 23 years); healthy old adults living independently in the community (n = 24, mean age 73 years); and congregate housing older adults (n = 29, mean age 81 years).

INTERVENTION: Videotaping and timing of rising from a supine position on the floor to standing.

MAIN OUTCOME MEASURES: In addition to the time taken to rise from the floor, 10 specific trunk and extremity positions used during the rise, termed Intermediate Positions (IP), were identified.

RESULTS: The Young controls had the fastest rise time and used the fewest number of IP, whereas the Congregate residents had the slowest rise time and used the most IP, with the Healthy old adults intermediate in both time and IP use. Prevalence of certain IP, together with correlational and factor analyses, suggest that use of Sit and Crouch was the most preferred rise strategy for the Young controls, whereas use of Tuck, Crouch‐Kneel, All Fours, and Bearwalk was the most preferred rise strategy among the Congregate residents. The Healthy old used IP common to both Young and Congregate residents, reflecting a rise strategy intermediate to the latter groups. A substantial subset of the Congregate residents (38%) were unable to rise without assistance and appeared to use certain preparatory positions (Sit, Kneel, Tuck) but were unable to get into presumably more challenging positions (Crouch‐Kneel, All Fours, Bearwalk).

CONCLUSIONS: With increasing age and physical impairment, body positions used during rising from the floor suggest a preference for maintaining upper and lower extremity contact with the floor, presumably minimizing the lower extremity strength requirements to rise and maximizing stability and postural control. These intermediate body positions may be useful as the basis for training older adults to rise from the floor.
Higher Basal Cortisol Predicts Verbal Memory Loss in Postmenopausal Women: Rancho Bernardo Study
Authors: Greendale Gail A. , Kritz‐Silverstein Donna , Seeman Teresa , Barrett‐Connor Elizabeth
Published: April 2015

BACKGROUND: In animals, higher endogenous or exogenous corticosteroids cause neuronal dysfunction, damage, and loss, especially in the hippocampus. In humans, high cortisol levels have been linked to memory impairment.

OBJECTIVE: To prospectively examine the relation between morning basal cortisol level and change in cognitive performance during an average follow‐up of 2 years.

DESIGN: Longitudinal cohort.

SETTING: Geographic community in southern California.

MEASUREMENTS: Between 1984 and 1987, blood for basal morning cortisol was obtained along with pertinent medical, behavioral, and physical covariates from 749 postmenopausal women, mean age 72 years, who were not taking corticosteroids or postmenopausal hormones. Cognitive function was assessed in 502 women in the period from 1988 to 1991 and repeated in 136 women in the period from 1991 to 1993.

RESULTS: In both age‐ and multiply adjusted linear regression models, higher baseline cortisol was a significant predictor of worsened category fluency. No other cognitive domain tested was related to cortisol.

CONCLUSIONS: These results support the hypothesis that subtle dysregulation of cortisol axis is related to memory loss. Interventions that block this pathway may provide new therapeutic options to prevent cognitive decline.
Physicians Are Less Willing to Treat Suicidal Ideation in Older Patients
Authors: Uncapher Heather , Areán Patricia A.
Published: April 2015

OBJECTIVE: Older adults have the highest rate of suicide of any age group, and reducing the number of late‐life suicides has become a national priority. The objective of this study was to determine if an age bias exists among primary care physicians when they contemplate treating suicidal patients.

DESIGN: Primary care providers were mailed one of two case vignettes of a suicidal, depressed patient. The only difference between the two vignettes was the age of the patient (38 or 78 years old) and employment status (employed vs retired as a factory worker). A questionnaire was included to determine provider recognition of suicidal ideation, and a scale was designed to detect willingness to treat the vignette patient.

SETTING/PARTICIPANTS: Physicians were selected randomly from the University of California, San Francisco physician roster and invited to participate in the study. A total of 342 physicians (63% response rate), including specialists, responded to the mailings. For this study, the responses of 215 primary care physicians were analyzed.

INTERVENTION: The randomly assigned experimental group received a vignette of a geriatric, retired patient who was depressed and suicidal (n = 100 participants). The control group received an identical but younger, employed patient (n = 115 participants).

MEASUREMENTS: A 21‐item Suicidal Patient Treatment Scale measured willingness to treat the suicidal patient.

RESULTS: The physicians in this study recognized depression and suicidal risk in both the adult and the geriatric vignette, but they reported less willingness to treat the older suicidal patient compared with the younger patient. The physicians were more likely to feel that suicidal ideation on the part of the older patient was rational and normal. They were less willing to use therapeutic strategies to help the older patient, and they were not optimistic that psychiatrists or psychologists could help the suicidal patient.

CONCLUSIONS: This study suggests that primary care physicians are capable of recognizing suicidal ideation but are less willing to treat it if the patient is older and retired. Future research needs to determine etiologic factors for this age bias. J Am Geriatr Soc 48: 188–192, 2000.
Fatigue in an Older Population
Authors: Liao Solomon , Ferrell Bruce A.
Published: April 2015

OBJECTIVES: Fatigue is a common symptom that has not been studied well in the older populations. The purpose of this pilot study was to examine the epidemiology of fatigue symptoms in relation to demographic and medical characteristics of older patients in a long‐term care setting.

DESIGN: A cross‐sectional interviewer‐assisted survey.

PARTICIPANTS/SETTING: A total of 199 ambulatory older residents of a single residential care facility.

MEASUREMENTS: Along with medical and demographic characteristics, the survey included mental status (Folstein), activities of daily living (Katz and Lawton), depression (Yesavage GDS), a 3‐minute walk, a 7‐item pain scale, and the modified Piper Fatigue Scale.

RESULTS: One‐hundred ninety‐nine (65%) of 308 potential subjects completed the study (mean age 88 years, 82% female). Of these 199 subjects, 195 (98%) reported some fatigue symptoms (median duration 44 weeks). Significant (P < .0005) relationships were found between fatigue and GDS (r = 0.57), 3‐minute walk (r = −0.29), Lawton IADLs (r = 0.31), pain (r = 0.36), and number of medications (r = 0.26). No significant relationships were found between fatigue and age, sex, Folstein score, or number of medical diagnoses. Multivariate regression analysis identified GDS, pain, number of medications and 3‐minute walk as significant predictors of fatigue intensity (multiple R = 0.68, r2 = 0.46, P < .02).

CONCLUSIONS: Fatigue is a symptom often found among older residents of a residential facility and has important implications for quality of life. Fatigue is poorly recognized and probably undertreated in older people. J Am Geriatr Soc 48: 426–430, 2000.
Effects of an Abilities‐Focused Program of Morning Care on Residents Who Have Dementia and On Caregivers
Authors: Mezey Mathy , Fulmer Terry , Wells Donna L. , Dawson Pamela , Sidani Souraya , Craig Dorothy , Pringle Dorothy
Published: April 2015

OBJECTIVE: To conduct a controlled investigation to examine the effects of an abilities‐focused program of morning care on the interaction behaviors and functioning of residents with dementia and on caregivers' interaction behaviors and perceptions of caregiving.

DESIGN: A quasi‐experimental, repeated measures design.

SETTING: The study was conducted on four, nursing‐home‐level cognitive supports units in a geriatric care center. One of the units was randomly selected as the experimental unit; the other three served as controls.

PARTICIPANTS: The final sample consisted of 40 residents (20 each in the experimental and three control groups) and 44 caregivers (16 on the experimental unit and 28 on the three control units).

INTERVENTION: An educational program on delivering abilities‐focused morning care, designed by the authors, was provided to caregivers on the experimental unit.

MEASUREMENTS: Measures were taken at baseline and at 3 and 6 months postintervention with regard to residents' interaction behaviors, level of agitation, and level of function and to caregivers' interaction behaviors, perceived ease of caregiving, and level of stress.

RESULTS: Repeated measures analysis of variance (RM‐ANOVA) was used to compare the experimental and control groups in regard to changes in the outcomes over time. Results indicated that the abilities‐focused program had statistically significant effects on (a) residents' personal attending and calm/functional behaviors, level of agitation, and levels of overall and social function, and (b) caregivers' verbal relevance and personal attending, relaxed, and social/flexible behaviors.

CONCLUSIONS: The evidence suggests that both residents and caregivers benefit from morning care that is oriented toward the abilities of people with dementia. J Am Geriatr Soc 48: 442–449, 2000.
Depressed Mood and Body Mass Index as Predictors of Muscle Strength Decline in Old Men
Authors: Rantanen Taina , Penninx Brenda W.J.H. , Masaki Kamal , Lintunen Taru , Foley Dan , Guralnik Jack M.
Published: April 2015

OBJECTIVE: To study depressed mood as a predictor of strength decline within body weight categories over a 3‐year follow‐up period.

DESIGN: A prospective cohort study over 3 years.

SETTING: Honolulu, Hawaii.

PARTICIPANTS: The subjects were 2275 men participating in the Honolulu Heart Program with an average age of 77.1 years (range 71–92 years), who were not cognitively impaired at baseline (Exam 4), and who participated in maximal hand grip strength measurements at baseline and 3 years later (Exam 5).

MEASUREMENTS: Hand grip strength was measured using a dynamometer. Depressive symptoms were studied using an 11‐item version of Center for Epidemiologic Studies Depression Scale with 9 as a cutoff. Body weight categories were formed on the basis of body mass index (BMI) (BMI = weight/height2; underweight: BMI < 20; normal weight: BMI 20–24.99, overweight: BMI ≥ 25).

MAIN RESULTS: At baseline, 9.4% of the participants were rated as having depressed mood. The mean individual strength change over 3 years was −6.9% (standard deviation 14.0). Steep strength decline was determined as losing ≥14% (lowest quartile). The proportions of those with steep strength decline in the groups based on combined distributions of BMI and depressed mood were: underweight/depressed (n = 22) 41%, underweight/not depressed (n = 200) 28%, normal weight/depressed (n = 127) 30%, normal weight/not depressed (n = 1181) 25%, overweight/depressed (n = 55) 31%, overweight/not depressed (n = 675, referent) 21%. After adjusting for baseline strength, age, height, sociodemographic variables and diseases, the odds ratio for steep strength decline was more than four times greater among those who were depressed and underweight, and twice as great among people who were depressed and normal weight compared with those who were nondepressed and overweight. The risks of nondepressed under‐ and normal weight people and depressed overweight people did not differ from the reference group.

CONCLUSIONS: Depressed mood was associated with increased risk of steep strength decline, in particular in older men with low body weight. Low body weight in combination with depressed mood may be an indicator of frailty or severe disease status that leads to accelerated strength loss and disability. J Am Geriatr Soc 48:613–617, 2000.
Delirium Is Independently Associated with Poor Functional Recovery After Hip Fracture
Authors: Marcantonio Edward R. , Flacker Jonathan M. , Michaels Mary , Resnick Neil M.
Published: April 2015

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status.

DESIGN: Prospective cohort study.

SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow‐up extending into rehabilitation hospitals, nursing homes, and the community.

PARTICIPANTS: One hundred twenty‐six consenting subjects older than 65 years (mean age 79 ± 8 years, 79% women) admitted emergently for surgical repair of hip fracture.

MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini‐Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement.

RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1‐ 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03–6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1–8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved.

CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture. J Am Geriatr Soc 48:618–624, 2000.
Predicting 10‐Year Care Requirements for Older People with Suspected Alzheimer's Disease
Authors: Kinosian Bruce P. , Stallard Eric , Lee Jason H. , Woodbury Max A. , Zbrozek Arthur S. , Glick Henry A.
Published: April 2015

OBJECTIVE: To describe the types and costs of care received for 10 years after the identification of an older person with suspected Alzheimer's disease (AD) by using data from 3254 patients with suspected AD who participated in the National Long Term Care Survey (NLTCS).

METHODS: By using a Markov model derived using grade of membership techniques, the following were determined: survival probabilities at 10 years; years of survival during the 10 years; years in institutions; years with two or more impairments in basic activities of daily living; hours of paid and informal care while the older person lived in the community; and costs of paid community, institutional, and medical care.

RESULTS: Greater degrees of cognitive impairment present when AD was identified were associated with reduced predicted probability of surviving 10 years, increased predicted number of years spent in institutions, increased hours of care required while affected individuals remained in the community, and increased costs of paid community, institutional, and medical care. Substantial differences between men and women were seen: severity‐adjusted 10‐year costs were almost two times higher for women with AD than for men ($75,000 compared with $44,000); according to sensitivity analysis, average 10‐year costs might be as high as $109,000 for women and $67,000 for men.

CONCLUSIONS: AD imposes a substantial burden on older persons. Interventions that slow the progression of the disease may therefore affect community survival as well as healthcare costs. J Am Geriatr Soc 48:631–638, 2000.