bluuebunny/crossref_metadata_2025 huggingface dataset:
Baseline Correlates with Quality of Life Among Men and Women with Medication‐Controlled Hypertension. The Trial of Nonpharmacologic Interventions in the Elderly (TONE)
Authors: Anderson Roger T. , Hogan Patricia , Appel Lawrence , Rosen Raymond , Shumaker Sally A.
Published: April 2015

OBJECTIVES: To examine Quality of Life (QOL) and its correlates among older adults with medication‐controlled hypertension.

DESIGN: Baseline data from the TONE clinical trial. MEASUREMENTS: Demographic variables (age, race, income), hypertension treatment (medication class, years treated), health status (obesity, physical symptoms), and QOL status (MOS‐Short‐Form 36, Jenkins Sleep Disturbance, and CES‐D Depression).

PARTICIPANTS: A total of 975 men and women, aged 60 to 81 years and free of major diseases and disability, with a screening blood pressure (BP) of < 145/85 mm Hg, treated medically for hypertension with antihypertensive medication.

RESULTS: On average, TONE participants reported a QOL level on the SF‐36 that was similar to or better than that reported by older adults in the general population. However, there was a strikingly high prevalence of physical complaints or symptoms: 90.3% of men and 93.3% of women experienced one or more physical symptoms or complaints, and nearly 50% reported that such symptoms had disrupted their daily functioning. Among variables considered, only the physical symptoms index score, number of severe symptoms, and obesity status were correlated consistently with QOL among TONE men and women. Lower QOL scores were associated with higher symptom scores and with obesity. Neither medication class nor age were appreciably associated with QOL status.

CONCLUSIONS: Physical symptoms, rather than medication class and age, were the strongest correlates of QOL in TONE. This underscores the importance of identifying the etiology of symptoms as a means to improve the QOL of older hypertensive persons rather than substituting medication. The association of poorer physical well‐being with obesity suggests that weight reduction to manage BP may also improve QOL for some individuals.
Circumstances of Falls Resulting in Hip Fractures Among Older People
Authors: Norton Robyn , Campbell A. John , Lee‐Joe Trevor , Robinson Elizabeth , Butler Meg
Published: April 2015

OBJECTIVES: To describe the circumstances of falls resulting in hip fractures among older people and to determine whether the circumstances differ by gender, age, and residential status.

DESIGN: Cross‐sectional study.

SETTING: Two hospitals in Auckland, New Zealand, in which all individuals aged 60 years or older with a fracture of the proximal femur are hospitalized. PARTICIPANTS: A total of 911 individuals (97% response rate) were hospitalized with fractures of the proximal femur; 77% were women, 66% were aged 80 years or older, and 58% were living in private homes at the time of fracture. MEASUREMENTS: Data were collected face‐to‐face by a trained interviewer using a standardized questionnaire.

RESULTS: Ninety‐six percent of the fractures were associated with a fall, with fewer that 2% of subjects reporting that their fractures occurred spontaneously before a fall. Sixteen percent of fractures were associated with an acute medical or physical condition. Although 85% of the fractures involving a fall occurred at home, only about 25% of these were associated with an environmental hazard, and only a proportion of these were likely to have been amenable to modification. The circumstances of falls differed significantly by age and residential status.

CONCLUSION: Strategies aimed at preventing fall‐related hip fractures among the old old and among institutionalized individuals should focus primarily on the modification of intrinsic factors. Modification of environmental hazards has the greatest potential for prevention among the young old and those living in private homes. J Am Geriatr Soc 45:1108–1112,1997.
Characteristics of Patients Receiving or Forgoing Resuscitation at the Time of Cardiopulmonary Arrest
Authors: Ghusn Husam F. , Teasdale Thomas A. , Boyer Kathryn
Published: April 2015

OBJECTIVE: To compare clinical, functional and social characteristics of DNR patients at the time of their cardiopulmonary arrest with characteristics of patients who receive cardiopulmonary resuscitation.

DESIGN: Retrospective chart review of all 261 patients who had a cardiopulmonary arrest during a 6‐month period in an academic institution.

SETTING: Teaching Veterans Affairs Medical Center serving a large metropolitan area.

MEASUREMENTS: Demographic characteristics, medical diagnoses, and measures of functional status were collected when DNR orders were initiated and at the time of cardiopulmonary arrest.

RESULTS: The mean age of the studied group was 62 years. Ninety‐nine percent were males, and the majority were non‐ Hispanic white men. One hundred ninety‐eight (76%) patients/proxies elected for limiting treatment. Most (85%) elected a DNR order only. Patients were the most frequently documented participants in advance directive decisions in the DNR group. At the time of cardiopulmonary arrest, a higher proportion of the CPR group had coronary artery disease or chronic renal failure, and a higher proportion of the DNR group had cancer or AIDS. The functional status of the DNR group deteriorated from the time of DNR order to death. At the time of cardiopulmonary arrest, the majority of both groups were dependent in all functional domains, and 70% of the DNR group were stuporous or comatose compared with 47% of the CPR group (P =.05). DNR patients were hospitalized for an average of 13.7 ± 29.5 days after a DNR order was initiated. Six of the 81 patients who received CPR (7.4%) were alive at discharge.

CONCLUSIONS: Patients and physicians deciding to implement a DNR order may be overly focused on medical diagnoses and less so on functional status. A significant proportion of patients with clinical characteristics associated with poor CPR outcome are electing for CPR.
Visual Impairment and Falls in Older Adults: The Blue Mountains Eye Study
Authors: BOptom Rebecca Q. Ivers , Cumming Robert G. , Mitchell Paul , Attebo Karin
Published: April 2015

OBJECTIVES: To examine the association between visual impairment and falls in older people.

DESIGN: Cross‐sectional survey of eye disease with retrospective collection of falls data.

SETTING: Two postcode areas in the Blue Mountains west of Sydney, Australia.

PARTICIPANTS: All people 49 years of age and older were invited to participate, 3654 (82.4%) of 4433 eligible residents took part, and 3299 answered questions about falls.

MEASUREMENTS: Subjects had a detailed eye examination and answered questions about health and vision status, use of medication, and number of falls in the previous 12 months.

RESULTS: Tests of visual function that had a statistically significant association with two or more falls after adjustment for confounders were visual acuity (prevalence ratio (PR) 1.9 for visual acuity worse than 20/30), contrast sensitivity (PR 1.2 for a 1‐unit decrease at 6 cycles per degree), and suprathreshold visual field screening (PR 1.5 for 5 or more points missing). However, only visual acuity and contrast sensitivity were significantly associated with two or more falls per 1 standard deviation decrease. The presence of posterior subcapsular cataract (PR 2.1) and use of nonmiotic glaucoma medication (PR 2.0) had a statistically significant association with two or more falls; presence of age‐related macular degeneration, diabetic retinopathy, and cortical or nuclear cataract did not.

CONCLUSION: Visual impairment is strongly associated with two or more falls in older adults. In addition to poor visual acuity, visual factors such as reduced visual field, impaired contrast sensitivity, and the presence of cataract may explain this association.
Pemphigus Vulgaris in Older Adults
Authors: Tehranchi‐Nia Zohreh , Qureshi Tabarak A. , Ahmed A. Razzaque
Published: April 2015

OBJECTIVE: Pemphigus vulgaris (PV) affects primarily middle‐aged persons in North America. Conventional therapy suggests use of high doses of systemic corticosteroids and immunosuppressive agents. We have observed a group of older patients with PV and determined their clinical characteristics, treatment, and clinical course.

DESIGN, SETTING, AND PARTICIPANTS: Eighteen patients with PV, in whom the onset of the disease was at age 65 or older, were observed and followed at the New England Baptist Hospital in Boston, Massachusetts, between 1985 and 1992. We determined sex and race distribution, disease severity, clinical presentation, autoantibody levels, treatment, response to treatment, and clinical course in these patients.

RESULTS: Men and women were affected equally. All the patients were white, and 50% were Jewish. Extensive disease was observed in only 27.8%. The disease was localized in 44.4%; in eight patients (44.4%), the use of sublesional corticosteroid (SLS) injection alone produced satisfactory clinical response. In patients with severe disease, the maximum dose of 60 mg/day of prednisone was sufficient. Patients with moderate disease responded to 20 to 40 mg/day of prednisone. Immunosuppressive agents were used in only four patients. The patients were followed for 3 to 15 years (mean 5.2 years). None of them died of the disease or the complications of therapy. At the time we reported this experience, most of the patients were in clinical remission without any therapy.

CONCLUSIONS: Our observations suggest that prognosis for older patients with PV is favorable. In several older patients, PV was controlled by SLS or lower doses of systemic corticosteroids. Systemic agents should be used cautiously and judiciously, and supportive measures should be offered frequently and aggressively.
MODELS OF GERIATRICS PRACTICE*: Outpatient Geriatric Evaluation and Management
Authors: Reuben David B. , Boult Chad , Boult Lisa , Morishita Lynne , Smith Stanley L. , Kane Robert L.
Published: April 2015

OBJECTIVE: To describe the development and operation of a practical model of outpatient geriatric evaluation and management (GEM) for high‐risk, community‐dwelling older adults.

PARTICIPANTS: Community‐dwelling Medicare beneficiaries age 70 years and older who were medically stable but had a high probability of repeated admission to hospitals (Pra > .40) in the future (n = 248).

INTERVENTION: Outpatient GEM.

MEASUREMENTS: Demographic, clinical, and use‐of‐hospital characteristics of patients; nature and quantity of GEM services; satisfaction of patients and their established primary physicians.

RESULTS: At enrollment, the average patient was 78.7 years old, took 5.0 long‐term prescription medications and was unable to perform 0.5 (of six) activities of daily living (ADL) and 1.4 (of seven) instrumental ADL. Many patients (71.3%) reported hospital days during the previous year. Each of three interdisciplinary teams (geriatrician, gerontological nurse practitioner, nurse and social worker) performed comprehensive assessments and then provided primary care and case management to a case load of 45 to 52 patients. On average, GEM required 6 months, during which patients visited the GEM clinic 7.4 times, had 10.4 active problems addressed, spoke to GEM staff members weekly by telephone, and were referred to two other providers. Most patients (94.4%) completed the GEM program; 66.7% completed advance directives. Satisfaction with GEM was high among the patients and their established primary physicians. The cost of the GEM personnel averaged about $1540 per patient treated.
Reviews of the Geriatric Literature
Authors: Katz Paul R.
Published: April 2015

Effects of Residence in Alzheimer Disease Special Care Units on Functional Outcomes. Phillips C, Sloane P, Hawes C, et al. Journal of the American Medical Association 278:1340–1344; 1997

RATIONALE: To assess the impact of Alzheimer's Special Care Units (SCUs) on the rates at which residents decline in functional status.

METHODOLOGY: Utilizing information collected as part of the Minimum Data Set (MDS) in four states (Kansas, Mississippi, Maine, South Dakota), the authors followed functional decline in a group of residents in special care units and compared these findings with traditional care provided in facilities with SCUs as well as non‐SCU facilities. Complete MDS assessments are performed at the time of admission and annually and are followed by quarterly assessment reviews.

RESULTS: Residents in SCUs were younger, had more impaired decision‐making abilities, and were less impaired in physical functioning than non‐SCU residents. No statistically significant difference was observed in the amount of decline for residents in SCUs compared with non‐SCU residents in any of the nine outcomes studied (locomotion, transferring, toileting, eating, dressing, summary of activities of daily living (ADLs), urinary and bowel continence, and significant weight loss).

CONCLUSION: This study did not demonstrate that residence in a special care unit slowed the rate of decline in functional status or weight.
Acceptability to Patients of a Home Hospital
Authors: Burton Lynda C. , Leff Bruce , Harper Michael , Ghoshtagore Ipsita , Steinwachs Donald A. , Greenough William B. , Burton John R.
Published: April 2015

OBJECTIVE: To examine the acceptability to older patients of receiving care in the home for acute medical conditions that require hospital level care by current standards.

DESIGN: Interviews with patients during hospitalization regarding their views of a hypothetical “home hospital.”

PARTICIPANTS: Patients (n = 87) admitted to a community‐based academic medical center with a primary diagnosis of pneumonia, congestive heart failure, or chronic obstructive airway disease, their nurses (n = 111), and resident physicians (67).

MEASUREMENTS: A questionnaire was developed to measure several domains of acceptability and expectations for care.

RESULTS: A majority of patients agreed that treatment in a home hospital would be more comfortable compared with treatment in a hospital (78.5%), would be less likely to result in an infection (62.5%), and would not be a burden to their family (71.8%). There was less certainty that medical care at home can be as good as in the hospital (56.9%). Nearly three‐quarters (72.3%) of patients would choose home hospital if it were available.

CONCLUSION: Patients may be ready to accept home hospital as an alternative for acute care. The acceptability of home hospital to acutely ill older patients is a critical factor in the development of this alternative for care and has the potential for improving satisfaction with care, reducing complications, hastening return to function, and, possibly, of lowering costs of care. J Am Geriatr Soc 46:605–609, 1998.
GERIATRICS IN MANAGED CARE: The Effect of HMO Status on the Outcomes of Home‐Care After Hospitalization in a Medicare Population
Authors: Brummel‐Smith Kenneth , Holtzman Jeremy , Chen Qing , Kane Robert
Published: April 2015

OBJECTIVE: The literature suggests that Medicare health maintenance organization (HMO) patients may have poorer outcomes with formal home‐health care than do fee‐for‐service (FFS) patients, but it is unclear whether this is related to case‐mix or quality. Our objective was to compare the home‐health care outcomes for HMO and FFS Medicare patients after hospitalization for stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement while controlling for site of discharge and other patient characteristics.

DESIGN: Patients were identified before hospital discharge with data collected at that time and then prospectively for 1 year.

SETTING: Nineteen acute general hospitals in Minneapolis/St. Paul, Minnesota.

PATIENTS: All Medicare patients in the above hospitals identified predischarge with stroke, COPD, CHF, hip replacement, or hip fracture with fixation or replacement.

MEASURES: Outcome: weighted ADL scale and hospital readmission. Independent factors: site of discharge, HMO status, comorbidity, severity, and demographic factors.

RESULTS: A total of 970 subjects were studied, 211 of whom were discharged to home‐care. HMO patients were more likely to be discharged to a nursing home than to home‐care after controlling for other factors (OR = 1.7; P = .015). After controlling for site of discharge and patient characteristics through either propensity scores or regression analysis, there was no statistically significant difference in ADL function at 6 weeks or at 6 months between HMO and FFS patients. Nor was there was a statistically significant difference in hospital readmission rates at 6 weeks and 6 months between HMO and FFS home‐care patients.

CONCLUSIONS: The outcomes of Medicare HMO patients discharged to home‐care are not worse than those of FFS patients. J Am Geriatr Soc 46:629–634, 1998.
Aging, Esophageal Motility, and Gastroesophageal Reflux
Authors: Ferriolli E. , Oliveira R. B. , Matsuda N. M. , Braga F. J. H. N. , Dantas R. O.
Published: April 2015

OBJECTIVES: To compare esophageal motility and gastroesophageal reflux characteristics in young, middle‐aged, and older healthy volunteers.

DESIGN: Comparison of conventional esophageal manometry and scintigraphic study of gastroesophageal reflux in volunteers aged 20 to 30 years, 50 to 60 years, and 70 to 80 years.

SETTING: Gastroenterology and nuclear medicine laboratories of a tertiary care university hospital.

PARTICIPANTS: Forty healthy adult volunteers recruited from the community, 20 aged 20 to 30 years, 10 aged 50 to 60 years, and 10 aged from 70 to 80 years.

MEASUREMENTS: Each volunteer underwent conventional esophageal manometry and scintigraphic study of gastroesophageal reflux. Contractile wave amplitude, duration, velocity, and lower esophageal sphincter relaxation duration, as well as the presence of abnormal peristalsis, were correlated with the proportion of volunteers with gastroesophageal reflux and the number and duration of gastroesophageal reflux episodes.

RESULTS: Quantitative manometric parameters showed no correlation with gastroesophageal reflux patterns. Abnormal peristalsis was found more frequently in the older volunteers. The number of gastroesophageal reflux episodes per volunteer was similar in the three age groups, but the duration of gastroesophageal reflux episodes was longer in the older volunteers.

CONCLUSION: Healthy older persons have impaired clearance of refluxed materials associated with a high incidence of defective esophageal peristalsis. This may explain the higher severity of reflux esophagitis in older people.
Evaluating the Use of Angiotensin‐Converting Enzyme Inhibitors For Older Nursing Home Residents with Chronic Heart Failure
Authors: Forman Daniel E. , Cbander Ravi B. , Lapane Kate L. , Shah Parul , Stoukides John
Published: April 2015

BACKGROUND: Despite their well noted therapeutic benefits for heart failure (HF), angiotensin‐converting enzyme (ACE) inhibitors may be underprescribed and underdosed among older nursing home patients.

OBJECTIVES: To assess the use of ACE inhibitor therapy in older (≤70 years) nursing home residents with systolic heart failure (HF).

DESIGN: A cross‐sectional, retrospective analysis.

SETTING: Five long‐term care facilities in Providence, Rhode Island.

SUBJECTS: Adults aged 70 years or older with left ventricular (LV) ejection fractions ≤40%.

MEASUREMENTS: New York Heart Association (NYHA) class, comorbid diseases, and cardiac medications with logistic regression analysis to clarify their bearing on the prescription of ACE inhibitors.

RESULTS: Of the 819 nursing home residents who were evaluated, 119 (24 men, 95 women) fulfilled exacting entry criteria, i.e., heart failure signs/symptoms and documented LV systolic dysfunction. Forty‐one of these 119 (35%) older persons were receiving ACE inhibitor therapy, predominantly in doses (≤50 mg captopril/day or ≤5 mg enalapril/day) less than those of proven therapeutic efficacy. Compared with older residents not receiving ACE inhibitors, those receiving ACE inhibitors included fewer with NYHA Class I HF (0 vs 21%, P = .017), more men (58 vs 28%, P ≤ .01), and more people with hypertension (61 vs 35%, P ≤ .01). In contrast, diuretics were prescribed more frequently among those not receiving ACE inhibitors (83 vs 56%, P ≤ .001).

CONCLUSIONS: ACE inhibitors are underprescribed and underdosed among elderly nursing home patients carefully screened to include systolic HF and no contraindications to the medication. ACE inhibitors are particularly underused in those elderly with NYHA Class I HF and in those receiving diuretics.
Undertreatment of Hypertension in Older Mexican Americans
Authors: Satish Shiva , Stroup‐Benham Christine A. , Espino David V. , Markides Kyriakos S. , Goodwin James S.
Published: April 2015

OBJECTIVE: To identify the prevalence of hypertension and factors associated with nontreatment and poor control of hypertension in Mexican Americans aged 65 years and older.

DESIGN: A population‐based survey of older Mexican Americans conducted in 1993–1994.

SETTING: Subjects residing in five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS: An area probability sample of 3050 non‐institutionalized Mexican American men and women aged 65 and older took part in a 90‐minute in‐home interview, which included review of all medications taken and two sitting blood pressure measurements.

OUTCOME MEASURES: Measured were previous diagnoses of hypertension, current medication for hypertension, and current blood pressure.

RESULTS: Sixty‐one percent of older Mexican‐Americans were hypertensive, and 51% of those with hypertension were taking antihypertensive medications. Only 25% of hypertensive subjects (18% of males and 30% of females) were in good blood pressure control (i.e., systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg). In multivariate analyses, factors associated with increased likelihood of treatment included female gender (OR = 1.9), history of heart disease (OR = 2.4), possessing a regular source of health care (OR = 2.7), and having seen a physician two or more times in the previous year (OR = 3.8). These were also independent predictors of good blood pressure control.

CONCLUSION: Nontreatment of hypertension is still a major public health concern in older Mexican Americans. We estimate that adequate blood pressure control in this population would prevent approximately 30,000 adverse cardiovascular events over 10 years, affecting approximately 6% of the entire Mexican American older population.
Predicting Hospitalization and Functional Decline in Older Health Plan Enrollees: Are Administrative Data as Accurate as Self‐Report?
Authors: Coleman Eric A. , Wagner Edward H. , Grothaus Louis C. , Hecht Julia , Savarino James , Buchner David M.
Published: April 2015

OBJECTIVE: To compare the predictive accuracy of two validated indices, one that uses self‐reported variables and a second that uses variables derived from administrative data sources, to predict future hospitalization. To compare the predictive accuracy of these same two indices for predicting future functional decline.

DESIGN: A longitudinal cohort study with 4 years of follow‐up.

SETTING: A large staff model HMO in western Washington State.

PARTICIPANTS: HMO Enrollees 65 years and older (n = 2174) selected at random to participate in a health promotion trial and who completed a baseline questionnaire.

MEASUREMENT: Predicted probabilities from the two indices were determined for study participants for each of two outcomes: hospitalization two or more times in 4 years and functional decline in 4 years, measured by Restricted Activity Days. The two indices included similar demographic characteristics, diagnoses, and utilization predictors. The probabilities from each index were entered into a Receiver Operating Characteristic (ROC) curve program to obtain the Area Under the Curve (AUC) for comparison of predictive accuracy.

RESULTS: For hospitalization, the AUC of the self‐report and administrative indices were .696 and .694, respectively (difference between curves, P = .828). For functional decline, the AUC of the two indices were .714 and .691, respectively (difference between curves, P = .144).

CONCLUSIONS: Compared with a self‐report index, the administrative index affords wider population coverage, freedom from nonresponse bias, lower cost, and similar predictive accuracy. A screening strategy utilizing administrative data sources may thus prove more valuable for identifying high risk older health plan enrollees for population‐based interventions designed to improve their health status.
Thioridazine Dose‐Related Effects on Biomechanical Force Platform Measures of Sway in Young and Old Men
Authors: Liu Yan Juan , Stagni Grazia , Walden Judith G. , Shepherd Alexander M.M. , Lichtenstein Michael J.
Published: April 2015

OBJECTIVE: Thioridazine (TDZ) is associated with an increased risk of falls. The purpose of this study was to determine whether (1) thioridazine increases Biomechanics Force Platform (BFP) measures of sway in a dose‐related manner, (2) there is a difference in sway between young and old men, (3) there is a correlation between sway and orthostatic changes in BP and HR.

DESIGN: Seven younger (aged 20–42) and five older (aged 70–76) healthy male volunteers received, in a randomized order double‐blind design, a single oral dose of 0, 25, and 50 mg of TDZ on three separate days at least 7 days apart and 75 mg on the fourth day of the study. Sway and blood pressure were measured for 24 hours.

SETTING: A general clinical research center.

MEASUREMENTS: Biomechanics force platform measures of postural sway were measured as the movement of the center of pressure. The elliptical area (EA) and average velocity (AV) were calculated with eyes open and eyes closed. Blood pressure and heart rate were measured for 5 minutes supine and 5 minutes standing.

RESULTS: Thioridazine increases BFP sway in a dose‐dependent manner. EA increased from 0.56 (SD = .51) cm2 for placebo to 0.88 (SD = 1.09) cm2 for 75 mg TDZ. AV increased from 1.07 (SD = .27) cm/sec, placebo, to 1.43 (SD = .55) cm/sec, 75 mg TDZ. Older men swayed more than younger men. Changes followed the expected time course for TDZ. EA and AV were associated with HR and BP, e.g., SBP versus ln(EA) and ln(AV) (r = −0.21 and r = −0.22, respectively; P < .0001).

CONCLUSIONS: Thioridazine increases validated measures of fall risk dose dependently in young and old men. This may explain the effects of neuroleptic drugs on fall risk in older people.
Atrial Natriuretic Peptide Level Contributes to a Model of Future Mortality in the Oldest Old
Authors: Knight Eric L. , Kiely Dan K. , Fish Loretta C. , Marcantonio Edward R. , Minaker Kenneth L.
Published: April 2015

OBJECTIVES: To determine if atrial natriuretic peptide (ANP) level is associated with mortality in the oldest old and to develop a comprehensive model of mortality in the oldest old using clinical and laboratory parameters.

DESIGN: Prospective cohort study with 7 years of follow‐up.

SETTING: A 725‐bed life care facility.

PARTICIPANTS: 282 frail older individuals (mean age 88, range 70–102).

MEASUREMENTS: Variables measured included age, gender, Charlson Comorbidity Index, functional measurements, weight, blood pressure, and multiple laboratory variables, including ANP. Main outcome measurement was death.

RESULTS: Eighty‐four percent (237/282) of subjects died during the 7‐year follow‐up period. On univariate analysis, the risk ratio (RR) for ANP tertile was 1.28. On bivariate analysis, adjusting for the development of congestive heart failure, the RR was 1.22. On multivariate analysis, the following variables were associated with mortality: ANP tertile (RR 1.24), age (RR 1.04), female gender (RR 0.43), Charlson Comorbidity Index score (RR 1.13), mentation score (RR 1.27), BUN/Cr ratio (RR 1.04), albumin level (RR 0.63), and hemoglobin level (RR 0.84).

CONCLUSIONS: ANP level and other variables are independent risk factors for mortality in frail individuals. ANP level may indicate homeostatic failure to adapt to fluid volume changes or may reflect subclinical heart disease. ANP level contributes to a multivariate model of mortality in frail older individuals.
Variation in Estimates of Urinary Incontinence Prevalence in the Community: Effects of Differences in Definition, Population Characteristics, and Study Type
Authors: Thom David
Published: April 2015

OBJECTIVES: Prevalence estimates for urinary incontinence among community‐dwelling adults vary from 2 to 55%. A review of the literature was undertaken to investigate the degree to which differences in definitions of incontinence, age, and gender of the populations studied, response rates, measurement techniques, or location could explain differences in reported prevalences.

DESIGN: A literature search was conducted to locate all studies published in English reporting the prevalence of urinary incontinence in a population‐based sample of adults.

MEASUREMENT: Information was abstracted for study size, response rate, type of survey, definition of urinary incontinence, and prevalence of incontinence by age group and gender. Prevalence by type of incontinence was also abstracted where available. Stratification was used to obtain prevalence estimates specific for age, gender, and frequency of incontinence. Data were examined for associations between prevalence and survey type, response rate, year, and location of survey.

RESULTS: A total of 21 studies met inclusion criteria. Stratification of reported prevalence by frequency, gender, and age substantially reduced the variation in prevalence estimates. For older women, the estimated prevalence of urinary incontinence ranged from 17 to 55% (median = 35%, pooled mean = 34%), and for daily incontinence it ranged from 3 to 17% (median = 14%, pooled mean = 12%). For older men, incontinence prevalence was estimated to be 11 to 34% (median = 17%, pooled mean = 22%), and 2 to 11% reported daily incontinence (median = 4%, pooled mean = 5%). Within studies, the prevalence of any incontinence was 1.3 to 2.0 times greater for older women than for older men. Among middle‐aged and younger adults, prevalence of incontinence ranged from 12 to 42% (median = 28%, pooled mean = 25%) for women and from 3 to 5% (median = 4%, pooled mean = 5%) for men. The ratio of prevalence of any incontinence for women to men in this age group ranged from 4.1 to 4.5. Stress incontinence predominated in younger women, whereas urge and mixed incontinence predominated in older women. There was a tendency for studies using in‐person interviews to report higher prevalences.

CONCLUSIONS: An accurate estimate of the prevalence of urinary incontinence depends on specifying the definition of incontinence and the age and gender groups of interest.
Vancomycin‐Resistant Enterococcus faecium in a Long‐Term Care Facility
Authors: Brennen Carole , Wagener Marilyn M. , Muder Robert R.
Published: April 2015

OBJECTIVE: To describe the epidemiology and natural history of colonization with vancomycin‐resistant Enterococcus faecium (VREF) in a long‐term care facility.

DESIGN: All patients in whom VREF was isolated were followed prospectively, with rectal swab cultures at 2‐week intervals, until discharge, death, or clearance of VREF. Clearance was defined as two consecutive negative cultures. In addition, three prevalence surveys were conducted of all patients in residence on one 34‐bed intermediate care ward.

SETTING: A 400‐bed, long‐term care Veterans Affairs facility.

PARTICIPANTS: Thirty‐six patients colonized with VREF.

RESULTS: Vancomycin‐resistant Enterococcus faecium was identified in 24 of the 36 patients at the time of transfer from an acute care facility. Seventeen patients had concomitant methicillin‐resistant Staphylococcus aureus, and seven patients had a recent history of Clostridium difficile‐associated diarrhea. VREF in these patients persisted for a median of 67 days after identification. Treatment of VREF colonization with antimicrobials was associated with prolongation of colonization. Serial surveillance of the 34‐bed ward found stable rates of colonization, with only three documented instances of VREF acquisition. During 2.5 years of surveillance for infection, a single case of bacteremia occurred in a patient in whom colonization with VREF could not be demonstrated by rectal swab culture. No infections occurred in patients colonized with VREF.

CONCLUSIONS: Long‐term care patients have protracted carriage of VREF. Most will improve over time; however, receipt of antimicrobial therapy is associated with prolongation of VREF carriage. The risk of VREF infection is low in this population. When there are appropriate contact precautions, patient to patient transmission occurs at a low rate. These observations can be used to design a practical infection control strategy for long‐term care facilities.
Mobility After Hip Fracture Predicts Health Outcomes
Authors: Fox Kathleen M. , Hawkes William G. , Hebel J. Richard , Felsenthal Gerald , Clark Meredith , Zimmerman Sheryl Itkin , Kenzora John E. , Magaziner Jay
Published: April 2015

OBJECTIVES: Balance and gait are essential to physical functioning and the performance of activities of daily living. The objective of this study was to determine the predictive value of a balance and gait test on subsequent mortality, morbidity, and healthcare utilization among older hip fracture patients.

DESIGN: A prospective study of hip fracture recovery.

SETTING: Patients with a new hip fracture admitted from the community to one of eight Baltimore hospitals and followed in their homes for 2 years postfracture.

PARTICIPANTS: A total of 306 patients with hip fracture, 65 years of age and older, who completed a gait and balance assessment at 2 months postfracture.

MEASUREMENTS: The relationship between gait and balance test performance at 2 months postfracture and mortality, physician visits, rehospitalizations, nursing home placement, and falls up to 24 months postfracture was assessed by Cox proportional hazards and least squares regression.

RESULTS: After adjusting for age, sex, race, and comorbidity, the balance score and the summary mobility score predicted mortality. A 17% increase in the risk of mortality was demonstrated for each unit decrease in the balance score (range 0–17), and a 10% increase was demonstrated for each decrease in the summary score (range 0–26). Unsteady balance during immediate standing, turning, sitting down, and rising from a chair were associated significantly with increased mortality. Poor balance, but not poor gait, was associated with an increase in hospitalizations up to 24 months postfracture. Both poor balance and poor gait were associated with nursing home placement, with 20% and 17% increased odds, respectively. Mobility did not predict future physician visits or falls.

CONCLUSIONS: These findings demonstrate that balance and gait are predictive of future health outcomes for older hip fracture patients.
The Nighttime Environment and Incontinence Care Practices in Nursing Homes
Authors: Cruise Patrice A. , Schnelle John F. , Alessi Cathy A. , Simmons Sandra F. , Ouslander Joseph G.
Published: April 2015

OBJECTIVES: To determine the variability in noise, light, and incontinence care practices between nursing homes (NHs) and the association between these factors and residents' nighttime sleep.

DESIGN: Prospective descriptive study of a sample of incontinent NH residents.

SETTING: Ten nursing homes.

SUBJECTS: Two hundred twenty‐five incontinent NH residents.

MAIN OUTCOME MEASURES: Measurements of residents' sleep by wrist actigraphs, bed mobility by pressure sensitive Kynar strips, and environmental noise and light changes were recorded by bedside monitors in consecutive 2‐minute intervals for two 10‐hour nighttime data collection periods (7 PM to 5 AM).

RESULTS: Forty‐two percent of waking episodes lasting 4 minutes or longer were associated with noise, light, or incontinence care events. Twenty‐two percent of waking episodes of 4 minutes or longer were associated with noise alone, 10% with light or light + noise, and 10% with incontinence care routines. Seventy‐six percent of all incontinence care practices resulted in awakenings. There was variability between the 10 NHs, with the percentage of waking episodes associated with environmental events (noise, light, or incontinence care events) ranging from 23.6 to 66.0%.

CONCLUSION: Noise and incidents of incontinence care practices were associated with a substantial amount of sleep disruption in residents in all 10 nursing homes, even though there was variability between homes. Interventions minimizing such environmental events are needed to promote better sleep in incontinent NH residents.
MODELS OF GERIATRICS PRACTICE: When the Patient Cannot Come to the Doctor: A Medical Housecalls Program
Authors: Reuben David B. , Fried Terri R. , Wachtel Tom J. , Tinetti Mary E.
Published: April 2015

OBJECTIVES: To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients.

PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems.

PARTICIPANTS: Patients are eligible for the housecalls program if they live within a 15‐ minute drive of the center and are unable to leave their home.

PROGRAM EVALUATION: The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient‐year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one‐quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes.

CONCLUSIONS: A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.
Lack of an Association Between Insulin‐like Growth Factor‐I and Body Composition, Muscle Strength, Physical Performance or Self‐Reported Mobility Among Older Persons with Functional Limitations
Authors: Kiel Douglas P. , Puhl Jacqueline , Rosen Clifford J. , Berg Katherine , Murphy John B. , MacLean David B.
Published: April 2015

OBJECTIVE: The hypothesis that decreased growth hormone (GH) secretion contributes to the functional decline that occurs with aging is far from substantiated. There have been few studies addressing the distribution and correlates of IGF‐I, an indicator of GH activity, in nonclinical populations. As part of a growth hormone intervention trial, we examined the cross‐sectional relations between IGF‐I levels and multiple measures of physical function, body composition, and strength in a group of older men and women exhibiting mild to moderate reductions in measured physical performance.

METHODS: Using a variety of advertising techniques, 155 older subjects were recruited from a metropolitan area to participate in a growth hormone and exercise intervention study. At baseline, all subjects had blood drawn for IGF‐I and underwent testing of body composition using dual X‐ray absorptiometry, muscle strength using isokinetic dynamometry, and functional assessment using timed performance measures and self‐report. Associations between levels of IGF‐I, body composition, strength, and physical function were assessed after dividing men and women separately into tertiles of IGF‐I as well as treating IGF‐I as a continuous variable.

RESULTS: Men had higher IGF‐I levels than women, and a significant inverse correlation was observed between age and IGF‐I in men (r = −0.29, P =.009). There were no clear trends for associations between tertiles of IGF‐I, and any of the variables tested. Linear regression models with IGF‐I treated as a continuous measure were not associated significantly with any of the measures of physical function, body composition, or strength (all P > 0.05).

CONCLUSIONS: In conclusion, although IGF‐I levels declined with age in men, these data did not demonstrate an association between IGF‐I and measures of muscle strength, body composition, or physical functioning. These findings support the growing body of evidence that IGF‐I levels may not be an indicator of growth hormone activity in older persons.
Nontreatment and Aggressive Narcotic Therapy Among Hospitalized Pancreatic Cancer Patients
Authors: Brown Norman K. , Thompson Donovan J. , Prentice Ross L.
Published: April 2015

OBJECTIVES: Strong feelings about patient autonomy as expressed in living wills, polls, and legislative referenda have been challenging the medical establishment to increase nontreatment, defined as foregoing a life‐prolonging treatment, and even to provide treatments having life‐shortening potential to selected patients. Because there are little data about the actual practice of these procedures, including aggressive narcotic therapy as defined herein, we studied the terminal management of 417 pancreatic cancer patients.

DESIGN AND PARTICIPANTS: The medical records of 417 residents of King County, Washington, who died of pancreatic cancer in the time periods 1959–1962, 1969–1972, and 1985–1990, were reviewed to study the frequency of, and risk factors for, end‐of‐life nontreatment decisions and aggressive narcotic therapy decisions, defined here as the decision to administer treatment doses of narcotics or major sedatives to already comatose patients within 4 hours of death.

RESULTS: Antibiotics were not provided to 71% of the 70 febrile patients (two readings > 38.33–38.83°C or one reading of 38.88°C), intravenous fluid was not provided to 43% of 294 dehydrated patients (oral intake < 500 mL/24 hours), transfusions were not provided to 39% of 57 severely anemic patients (hematocrit < 20%), and laparotomy was not performed for 86% of 36 patients with abdominal emergencies (obstruction, bleeding, dehiscence). Also, 46% of the 118 patients who were comatose for at least 24 hours before death received aggressive narcotic therapy, as defined above. A total of 335 of the 417 patients had documentation of at least one of the above life‐threatening conditions or were comatose for at least 24 hours before death, and 289 (86%) of these patients experienced nontreatment of one or more of these conditions or received aggressive narcotic therapy. Nontreatment decisions for febrile, dehydrated, or anemic patients tended to be more frequent if the patient was comatose (P =.004,.010, and.065, respectively), if there was a nontreatment statement in the medical record (P =.009,.035, and.001, respectively), or if the patient was described as terminal (P =.262,.029, and.002, respectively). Aggressive narcotic therapy in comatose patients was more common among patients who had regular visitors (P =.002), who had pre‐coma pain (P =.006), who had nontreatment statements in their charts (P =.031), whose in‐charge physician was an oncologist (P <.001), who were treated in a community nonprofit hospital compared with a Catholic hospital (P =.007), or who were treated in recent years (P =.011).

CONCLUSION: Both nontreatment and aggressive narcotic therapy forms of medical management have been occurring commonly in terminal pancreatic cancer patients in King County, Washington, during the past 3 decades, the latter with greater frequency in recent years.
Assessing Life Expectancies of Older Nursing Home Residents
Authors: Breuer Brenda , Wallenstein Sylvan , Feinberg Ghana , Camargo Maria‐Jose F. , Libow Leslie S
Published: April 2015

OBJECTIVE: Care of nursing home (NH) residents is often based on the usual survival of the home's residents. In order to improve our understanding of this population, and, thus, ultimately facilitate individualization of their care, we developed a mathematical model that predicts their survival.

SETTING: The Jewish Home and Hospital (JHH), a nursing home.

PARTICIPANTS: 1145 older residents who were at the JHH from January 1, 1986, through July 1, 1986.

MEASUREMENTS: Information abstracted from medical records and JHH computerized data: clinical, demographic, and dependencies in activities of daily living (ADLs). Main outcome measure: survival from July 1, 1986.

DESIGN: Retrospective cohort study via medical chart review. The study period covered admission to JHH through January 17, 1996. Accelerated failure time (AFT) models generated the life expectancy model derived from 50% of the study group and were validated on the remaining sample. We computed predicted AFT and proportional hazards (PH) life expectancies.

RESULTS: Significant, independent predictors of decreased survival were male gender, increased age, increase in summary ADL index, and impairment of cardiac, respiratory, neurological, and endocrine/metabolic systems. The interaction between gender and respiratory system impairment was significant. The Spearman correlation coefficients between the observed survivals and those predicted by the Phase I model are 0.49 for Phase I residents and 0.42 for Phase II residents. Our sample life table includes NH residents with different risk profiles and their associated survival estimates as well as interquartile ranges. AFT and PH survivals were similar.

CONCLUSION: This first comprehensive model that predicts survival of NH residents can help formulate public health policies and identify appropriate NH residents for clinical trials. The model is a promising step toward improving the health care of NH residents. J Am Geriatr Soc 46:954–962, 1998.
Risk of Left Ventricular Dysfunction in Patients with Probable Alzheimer's Disease with APOE*4 Allele
Authors: van der Cammen T.J.M. , Verschoor C.J. , van Loon C.P.M. , van Harskamp F. , de Koning I. , Schudel W.J. , Slooter A.J.C. , Van Broeckhoven C. , van Duijn C.M.
Published: April 2015

OBJECTIVE: To examine the association between the APOE genotype and cardiovascular disease in Alzheimer's disease (AD) patients.

DESIGN: Case register study of 100 consecutive referrals to a Memory Clinic where type of dementia and cardiovascular comorbidity were diagnosed and APOE genotype was determined.

SETTING: The Memory Clinic, University Hospital Rotterdam Dijkzigt.

PARTICIPANTS: One hundred Memory Clinic patients, 59 to 91 years of age, who attended the Memory Clinic in the period between January 1994 and March 1996.

MEASUREMENTS: Relative risk of cardiovascular morbidity in probable AD, based on clinical and ECG findings.

RESULTS: The diagnosis of probable AD was more frequent in APOE*4 allele‐carrying AD patients. When comparing homozygotes for APOE*4 with homozygotes for APOE*3, a nine‐fold increase in prevalence of cardiac ischemia on ECG was found in the former. When grouping parameters of left ventricular dysfunction, the prevalence was 7.2 (95% confidence interval 1.2–42.6) times greater in probable Alzheimer patients with APOE4/4.

CONCLUSIONS: In patients with probable AD, APOE*4 is associated with cardiac disease indicative of left ventricular dysfunction. J Am Geriatr Soc 46:962–967, 1998.