bluuebunny/crossref_metadata_2025 huggingface dataset:
A Practical Approach to Identifying Mortality‐Related Factors in Established Long‐Term Care Residents
Authors: Flacker Jonathan M. , Kiely Dan K.
Published: April 2015

OBJECTIVE: Determining prognosis is an important part of medical planning for long‐term care residents. Clarifying the resident characteristics associated with increased mortality has received little attention from investigators, and many approaches that have been suggested are unsuitable for widespread use. Using a readily available database, we sought to determine factors associated with 1‐year mortality in established long‐term care residents.

DESIGN: A retrospective cohort study.

SETTING: A 725‐bed long‐term care facility.

MEASUREMENTS: We examined Minimum Data Set (MDS) information on 780 residents from April 1994 through August 1997. The association between death and 65 resident factors, covering a broad array of physical, functional, medical, and psychosocial measures, was examined initially in bivariate proportional hazards models. Putative factors with P values <.10 in bivariate analysis were considered in the multivariate analysis. Using these factors, we employed a forward step‐wise multivariate proportional hazards regression method to select the set of factors associated independently with mortality at a P value <.05. A mortality score was developed by assigning points to each factor based on the risk ratio in the multivariate proportional hazards model. The performance characteristics of the model were examined using logistic regression.

RESULTS: Forty‐four of the 65 factors examined were associated with 1‐year mortality in bivariate proportional hazards analysis. Eight of these 44 factors were associated with 1‐year mortality in the multivariate proportional hazards regression. These factors were functional impairment, weight loss, shortness of breath, male gender, low body mass index, swallowing problems, congestive heart failure, and advanced age. A higher mortality score was associated with a higher death rate in the subsequent year. The model demonstrated good performance with an area under the ROC curve of 0.77.

CONCLUSIONS: Using a widely available database that requires no additional medical testing or staff training, a useful model for identifying factors associated with 1‐year mortality in established long‐term care residents can be developed. Widespread use of such a practical approach to assess mortality risk could be of benefit to patients, their families, and physicians for informing care plan decisions. J Am Geriatr Soc 46:1012–1015, 1998.
The Epidemiology of Cardiac Pacemakers in the Older US Population
Authors: Daley W. Randolph , Kaczmarek Ronald G.
Published: April 2015

OBJECTIVES: This study estimates the age distribution of older patients (>64 years) receiving implantable cardiac pacemakers in non‐federal US hospitals and determines major characteristics of this group using a massive, nationally representative sample of inpatient discharge records.

DESIGN: Discharge records were obtained from the 1992 Nationwide Inpatient Sample. Correlation with census data from 1992 was used to determine age and gender specific rates.

SETTING: The Nationwide Inpatient Sample is a 20% stratified probability sample of non‐federal US hospitals.

PATIENTS: Records of all recipients (26,425) of an initial or replacement pacemaker were selected.

RESULTS: Individuals 65 years of age and older received an estimated 131,361 initial and replacement pacemaker pulse generators (87% of the total) in non‐federal US hospitals in 1992. Pacemaker implantation was performed in urban teaching hospitals (28.9%), non‐teaching urban hospitals (57.8%), and rural hospitals (13.3%). The age specific implantation rates per 100,000 population were 226.5 (age 65–74 years), 585.9 (age 75–84 years), 874.9 (age 85–94 years), and 540.4 (more than 94 years). The age‐adjusted rate for men was 70% greater than the corresponding rate for women. Major diagnoses of implant recipients included atrioventricular block (37.8%) and atrial fibrillation (28.5%). Two percent of pacemaker recipients died before discharge.

CONCLUSIONS: The rate of pacemaker implantation increases sharply up to age 95. As the number of older people in the US population grows, particularly those in the age ranges greater than 75 and 85 years, a sharply increased number of pacemakers will be implanted unless other factors decrease the need for these devices. The data also demonstrate diffusion of this technology from academic centers. J Am Geriatr Soc 46:1016–1019, 1998.
Iatrogenic Benzodiazepine Withdrawal Delirium in Hospitalized Older Patients
Authors: Moss Jay H. , Lanctôt Krista L.
Published: April 2015

OBJECTIVE: The purpose of this review was to identify cases of benzodiazepine withdrawal delirium in a population of older hospitalized patients and to determine whether the withdrawal was caused by iatrogenic factors.

DESIGN: Retrospective chart review of selected cases from a referred sample. A Bayesian Adverse Reactions Diagnosis Instrument (BARDI) was applied to cases of benzodiazepine withdrawal delirium to quantify the probability that drug withdrawal was the causative mechanism.

SETTING: A university‐affiliated health sciences center.

PATIENTS: A review of the psychiatric consultation liaison service database for a consecutive 4‐month period yielded 21 cases of delirium in a referred sample of 119 patients more than 65 years of age. Four cases of benzodiazepine withdrawal were identified within the group of patients with delirium, and retrospective chart review identified potential iatrogenic causes for withdrawal in three patients.

RESULTS: The posterior possibilities calculated by the BARDI for the three cases of delirium were 0.98, 0.95, and 0.75, indicating a high probability that the delirium was caused by benzodiazepine withdrawal.

CONCLUSIONS: Benzodiazepine withdrawal delirium in older hospitalized patients may be associated with iatrogenic factors. J Am Geriatr Soc 43:1020–1022, 1995.
Managed Care as a Vehicle for Delivering More Effective Chronic Care for Older Persons
Authors: Brummel‐Smith Kenneth , Kane Robert L.
Published: April 2015

Chronic illness is now the dominant feature of health care, and its impact will grow with the aging of the population. Managed care could provide an environment conducive to better care for chronically ill patients. A precondition for these activities is a shift in Medicare payment approaches to managed care organizations to recognize differences in risk. To improve care for the chronically ill, changes need to occur in two major areas: (1) The approach to chronic care needs to become more aggressive, with higher expectations about the benefits from care (even if measured by slowing the rate of decline), and (2) an information infrastructure is needed to help focus clinicians' attention on changes in patients' status. Some of these changes may eventually evolve spontaneously in managed care's search for more efficient ways of meeting its service obligations, but external forces, such as certification and federal mandates, could catalyze the transition. J Am Geriatr Soc 46:1034–1039, 1998.
That Was the Year That Was: An Evidence‐Based Clinical Geriatrics Update
Authors: Leipzig Rosanne M.
Published: April 2015

BACKGROUND: Physicians are faced with an ever‐growing information base in medical practice. Studies regularly show a disparity between science and patient care, with scientifically validated practices often taking 20 years and more to enter mainstream clinical practice.

OBJECTIVES: To review the recent medical literature for high quality studies that practicing geriatricians should be aware of, either because they provide evidence that might lead to a change in clinical practice or because they provide insight into common geriatric syndromes.

DESIGN: Overview

DATA SOURCES: All articles abstracted or noted in ACP Journal Club, Evidence‐Based Medicine, or The New York Times from July 1996 to June 1997.

STUDY SELECTION: Studies that met the standards for inclusion in ACP Journal Club

STUDY DESIGN: Sampling plan (including eligibility criteria), sample size, response rate, data analysis plan, proportion available for follow‐up, main outcomes and measures, main results.

RESULTS: Review of the 98 articles that met criteria resulted in the identification of several themes of importance to geriatricians, including the hazards of hospitalization, the prevention of NSAID‐induced peptic ulcers, and the treatment and prevention of Alzheimer's disease. The results of these studies expand the therapeutic armamentarium of practicing geriatricians, provide new insights into geriatric syndromes, and raise cautions about the use of certain therapies in older adults.

CONCLUSIONS: Many methodologically rigorous studies relevant to the medical care of older people have recently been published. Evidence‐based medicine and the use of journals of secondary publication are useful tools to enhance the efficiency of journal reading for geriatric practitioners whose interests span the journals of several disciplines and subspecialties. J Am Geriatr Soc 46:1040–1049,1998.
Home Environmental Hazards and the Risk of Fall Injury Events Among Community‐Dwelling Older Persons
Authors: Sattin Richard W. , Rodriguez Juan G. , DeVito Carolee A. , Wingo Phyllis A. ,   Study to Assess Falls Among the Elderly (SAFE) Group
Published: April 2015

OBJECTIVE: To determine if home environmental hazards increase the risk of fall injury events among community‐dwelling older persons.

DESIGN: Population‐based case‐control study.

SETTING: South Miami Beach, Florida.

PARTICIPANTS: 270 persons aged 65 years and older who sought treatment at six area hospitals for injuries resulting from falls within the dwelling unit and 691 controls, frequency matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files.

MAIN INDEPENDENT VARIABLES: The home environment of each person, assessed directly by interviewers using a standardized instrument.

RESULTS: Environmental hazards were present in nearly all dwelling units. After adjusting for important confounding factors, most of these hazards were not associated with an increased risk of fall injury events among most older persons. Increasing numbers of tripping hazards, or total hazards in the dwelling unit, did not increase the risk of fall injury events, nor was there an increasing trend in risk.

CONCLUSIONS: Current fall‐prevention strategies of finding and changing all environmental hazards in all community‐dwelling older persons' homes may have less potential effect than previously thought. The usefulness of grab bars, however, appears to warrant further evaluation.
The Association Between Chronic Illness and Functional Change Among Participants in a Comprehensive Geriatric Assessment Program
Authors: Cho Choo‐Yon , Alessi Cathy A. , Cho Meehyung , Aronow Harriet U. , Stuck Andreas E. , Rubenstein Laurence Z. , Beck John C.
Published: April 2015

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3‐year period in older people enrolled in an in‐home comprehensive geriatric assessment (CGA) and preventive care program.

DESIGN: Secondary analysis of data from a longitudinal cohort study.

SETTING: Santa Monica, California.

PARTICIPANTS: Two hundred two community‐dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in‐home comprehensive geriatric assessment and preventive care.

MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses.

RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3‐year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects.

CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.
Psychometric Characteristics of the Minimum Data Set I: Confirmatory Factor Analysis
Authors: Casten Robin , Lawton M. Powell , Parmelee Patricia A. , Kleban Morton H.
Published: April 2015

OBJECTIVE: To determine the structure and statistical reliability of the federally mandated Minimum Data Set (MDS).

DESIGN: Confirmatory, hypothesis‐testing factor analysis was performed on MDS protocols of 733 nursing home residents.

SETTING: All participants were residents of the Philadelphia Geriatric Center.

PARTICIPANTS: Participants represented consecutively admitted skilled and intermediate care residents and another pool of residents with probable dementia.

MEASUREMENTS: MDS protocols were completed by nurse care coordinators. Item composites hypothesized represented the domains of cognition, activities of daily living, time use, social quality, depression, and problem behaviors.

RESULTS: For higher functioning residents (n = 336) and for all residents together, all domain clusters except social quality were confirmed. None of the domain clusters were confirmed within the more impaired (n = 391) group.

CONCLUSIONS: The MDS does provide usable indicators of five areas of basic competence of nursing home residents. Lack of reliability in rating many aspects of the behavior and states of cognitively impaired residents is evident, however. Improvement of such measures and rating procedures constitutes a major research priority.
Psychometric Characteristics of the Minimum Data Set II: Validity
Authors: Lawton M. Powell , Casten Robin , Parmelee Patricia A. , Van Haitsma Kimberly , Corn Julie , Kleban Morton H.
Published: April 2015

OBJECTIVE: To determine the validity of the Minimum Data Set (MDS).

DESIGN: MDS domain scores were correlated with a variety of independently obtained measures of basic behavioral and mental health functions of 513 nursing home residents.

SETTING: All participants were residents of the Philadelphia Geriatric Center.

PARTICIPANTS: One group of residents (n = 260) represented consecutive admissions who were able to respond to formal testing. The other group of residents (n = 253) represented presumably cognitively impaired residents whose data did not depend on self‐report.

MEASUREMENTS: MDS item‐composite scores based on a confirmatory factor analysis were derived for the domains of cognition, activities of daily living (ADL), time use, depression, and problem behaviors. Hypotheses stating how these MDS domains should be related to standard measures of cognitive function, ADL, depression, agitation, social behavior, and irritability were tested.

CONCLUSIONS: The majority of the hypotheses were upheld, thus suggesting that the MDS is usable as a source of research data. The sizes of the validity coefficients were modest, however. Depression and problem behavior were less well affirmed than cognition, ADL, and Time Use. There is a clear need for improvement in training and probably in the form of MDS measurement in some areas.
Accuracy of Medical Records in Hip Fracture
Authors: Fox Kathleen M. , Reuland Melissa , Hawkes William G. , Hebel J. Richard , Hudson James , Zimmerman Sheryl Itkin , Kenzora John , Magaziner Jay
Published: April 2015

OBJECTIVE: To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients.

DESIGN: A validation sample of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries for patients in a prospective study of functional recovery.

SETTING: Eight Baltimore hospitals with the highest volume of older hip fracture patients.

PATIENTS: Study subjects were 343 community‐dwelling patients, 65 years of age and older, admitted to one of eight Baltimore hospitals between January 1990 and June 1991 with a diagnosis of hip fracture.

MAIN OUTCOME MEASURES: Facesheet diagnosis codes were compared with admitting notes, discharge summary, and/or progress notes. The abstracted surgical procedure was compared with postoperative radiographs.

RESULTS: Excess coding of diagnoses on the hospital facesheet was evident in 12% of charts. In 17% of charts, a complication identified in the chart was not coded on the facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure review and radiograph readings for arthroplasty was 84%. In 15% of patients, the abstractor coded total arthroplasty when hemiarthroplasty was done.

CONCLUSIONS: Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radiographs was found for hip fracture patients. This may make findings from health outcomes research relying on administrative databases uncertain and reimbursement inaccurate.
Time and Cost for Recruiting Older Adults
Authors: Taylor‐Davis Stephanie , Smiciklas‐Wright Helen , Davis Andrew C. , Jensen Gordon L. , Mitchell Diane C.
Published: April 2015

OBJECTIVES: The purpose of this study was to examine the time requirements and costs of recruiting older adults for participation in a medical center‐/university‐sponsored, home‐based nutrition education study. A two‐step recruitment strategy consisting of an introductory letter followed by a telephone call was used.

DESIGN: A random selection of 1300 individuals aged 60 to 74 years was drawn from a patient database of a large, rural, tertiary care hospital to receive introductory letters and recruitment telephone calls. One week after the mailing, potential subjects were contacted by trained interviewers and asked to participate in a home‐based nutrition education study.

PARTICIPANTS: Men and women, aged 60 to 74 years, whose names appeared in a rural, tertiary care hospital database.

MEASUREMENTS: Recruitment rate, time required for recruitment by telephone, and cost of the combined mailing and telephone recruitment effort.

RESULTS: Of the 1300 individuals selected, 1077 (83%) people were contacted by phone and 223 (17%) people were unable to be reached. A total of 2895 calling attempts were required to determine the recruitment status of those identified as potential participants. Of those reached by phone, the recruitment rate was 45%. The total cost (mailing, telephone, and database management) per recruited subject was $8.56.

CONCLUSION: This study has helped to establish the costs of recruitment for home‐based education interventions using a two‐step strategy of an introductory mailing and follow‐up telephone interview.
Attention, Frailty, and Falls: The Effect of a Manual Task on Basic Mobility
Authors: Lundin‐Olsson Lillemor , Nyberg Lars , Gustafson Yngve
Published: April 2015

OBJECTIVE: To investigate the effect of a second task on balance and gait maneuvers used in everyday life. Our hypothesis was that those who were more distracted by a familiar manual task performed concurrently with functional maneuvers were more frail and more prone to falls.

DESIGN: A cross‐sectional design with prospective follow‐up for falls.

SETTING: Sheltered accommodation in Umeå, Sweden.

PARTICIPANTS: Forty‐two residents (30 women, 12 men; mean age ± SD = 79.7 ± 6.1 years), ambulant with or without a walking aid, able to follow simple instructions and able to carry a tumbler.

MEASUREMENTS: Timed Up & Go (TUG), i.e., the time taken to rise from an armchair, walk 3 meters, turn round, and sit down again. TUG was repeated with an added manual task (TUGmanual), which was to carry a glass of water while walking. The Montgomery‐Åsberg Depression Rating Scale, Barthel Index, Functional Reach, Mini‐Mental State Examination, and Line Bisection test were used to assess for frailty. The subjects were followed‐up prospectively regarding falls indoors for a period of 6‐months.

RESULTS: Subjects with a time difference (diffTUG) between TUGmanual and TUG of ≥ 4.5 seconds were considered to be distracted by the second task. Ten subjects had a difference in time of ≥ 4.5 seconds. These subjects were more frail, and seven of them fell indoors during the follow‐up period (odds ratio 4.7, 95% Confidence Interval (CI) 1.5–14.2).

CONCLUSION: The time difference between the TUGmanual and the TUG appears to be a valid marker of frailty and a useful tool for identifying older persons prone to falling.
Correlates of Prescription and Over‐the‐Counter Medication Usage Among Older Mexican Americans: The Hispanic EPESE Study
Authors: Espino David V. , Lichtenstein Michael J. , Hazuda Helen P. , Fabrizio Dennis , Wood Robert C. , Goodwin James , Stroup‐Benham Christine A. , Markides Kyriakos S.
Published: April 2015

OBJECTIVES: To determine the prevalence rates of prescription and over‐the‐counter (OTC) medication usage among community‐dwelling older Mexican Americans.

DESIGN: Cross‐sectional survey of a regional probability sample of older Mexican Americans.

SETTING: The 1992–1997 Hispanic Established Population for the Epidemiologic Study of the Elderly (H‐EPESE), a probability sample of noninstitutionalized Mexican Americans, age 65 and over, living in the five Southwestern states of Texas, New Mexico, Colorado, Arizona, and California.

PARTICIPANTS: 2899 persons, age 65 and over, considered Mexican American, using appropriate weighting procedures to produce regional estimates.

OUTCOME MEASURES: Use of prescription and OTC medication within the last 2 weeks before the survey confirmed by in‐home review of medication containers.

RESULTS: Medication users consumed a mean of 2.9 prescription and 1.3 OTC medications. Over half (58.9%, n = 1,798) of the participants used at least one prescribed medication, and 31.3% (n = 847) used at least one OTC medication within the 2 weeks before their participation in the study. Factors associated with both prescription and OTC medication usage were self‐perceived health and number of co‐morbid conditions. Factors associated only with prescription medication usage included female gender, alcohol usage, ADL dependency, and presence of additional insurance. Structural assimilation was associated only with OTC medication usage.

CONCLUSIONS: These data show lower prevalence rates of prescription medication usage among Mexican American older men and lower rates of OTC medication usage in older Mexican Americans of both genders than previously reported in other ethnic groups. This may reflect differences in time and geographic location of the Hispanic EPESE relative to other EPESE studies, ethnic differences in access to care as reflected by insurance in addition to Medicare, ethnic differences in survival, especially among males, or ethnic differences in medication preferences.
Beliefs Concerning Death, Dying, and Hastening Death Among Older, Functionally Impaired Dutch Adults: A One‐Year Longitudinal Study
Authors: Sullivan Mark , Ormel Johan , Kempen G.I.J.M. , Tymstra Tj.
Published: April 2015

OBJECTIVES: Population surveys have documented increasing public support for euthanasia and assisted suicide but have not focused on the population of chronically ill older persons, obtained detailed sociocultural or health status information, or performed repeat assessments. This study seeks to describe the views of functionally‐impaired Dutch elders on death, dying, and hastened death and to relate these to sociocultural and health status.

DESIGN: One‐year prospective epidemiologic survey.

SETTING AND PARTICIPANTS: Community‐dwelling participants in the longitudinal component of the Groningen Longitudinal Aging Study were assessed at home by interview and questionnaire in 1994 (n=632) and again in 1995 (n=575).

MEASUREMENTS: Independent variables were sociocultural characteristics (eg, age, sex, income, education, religious affiliation, strength of religious belief), physical health status (number of chronic medical conditions, functional impairments), and mental health status (life satisfaction, self‐efficacy, anxiety, depression, and neuroticism). Dependent variables were preoccupation with and fear of death, fears of the dying process, and attitudes toward hastened death.

RESULTS: Low and stable rates of preoccupation with death and fear of death were found. Occasional but not persistent fears about the dying process were common. Fears of death and dying were most closely related to health status, especially mental health status. Views concerning hastening death were most strongly related to sociocultural variables, especially religious belief and affiliation. There was little change over the 1‐year follow‐up, with a trend toward less fears of death and dying and less support for hastened death. Significant changes in fears of death and dying and attitudes toward hastened death were not seen even in the 25% of subjects with the greatest deterioration in activities of daily living or greatest increase in anxiety and depression during the 1‐year follow‐up.

CONCLUSION: Beliefs about death, dying, and hastened death are stable over 1‐year follow‐up. Fears of death and dying are most strongly related to mental health in this community sample. Attitudes about hastening death are primarily related to religious belief and secondarily to mental health. Mental health factors may determine the distress associated with the prospect of death and dying, whereas religion may dictate the actions considered proper when dying.
An Operation Under General Anesthesia as a Risk Factor for Age‐Related Cognitive Decline: Results from a Large Cross‐Sectional Population Study
Authors: Dijkstra Jeanette B. , Van Boxtel Martin P.J. , Houx Peter J. , Jolles Jellemer
Published: April 2015

OBJECTIVE: To evaluate the factor ‘operation under general anesthesia’ as a possible risk factor for age‐related cognitive decline.

DESIGN: A retrospective, population‐based, cross‐sectional study.

SETTING: Maastricht Aging Study (MAAS), Maastricht, The Netherlands.

PARTICIPANTS: 1257 normal healthy subjects aged 24 to 86 years. Of the 1257 healthy subjects, 946 subjects appeared to have undergone at least one operation under general anesthesia.

MEASUREMENTS: The history of an operation under general anesthesia, number of operations, duration of anesthesia, cognitive performance, subjective health, and subjective memory were measured.

RESULTS: A history of an operation under general anesthesia, the number of operations, and the total duration of anesthesia significantly contributed to the number of subjective health‐related complaints but did not predict cognitive performance or memory complaints. Subjects with a history of an operation under general anesthesia felt less healthy than subjects who had never undergone an operation under general anesthesia. No interactions with age were found.

CONCLUSION: The present study found no support for the notion that a history of an operation under general anesthesia is a determinant or risk factor for accelerated age‐related cognitive decline.
The Relationship Between Insomnia and Mortality Among Community‐Dwelling Older Women
Authors: Althuis Michelle D. , Fredman Lisa , Langenberg Patricia W. , Magaziner Jay
Published: April 2015

OBJECTIVES: To investigate the relationship between insomnia and 6‐year survival among older, community‐dwelling, white women.

DESIGN: Longitudinal study.

SETTING: The sample was selected randomly from a 20‐census tract area of Baltimore, Maryland.

PARTICIPANTS: In 1984, 778 women aged 65 years and older participated in the baseline survey; 613 were re‐interviewed in 1985; 596 were reinterviewed in 1986.

MEASUREMENTS: Insomnia was measured as self‐report of at least one of three sleep complaints: trouble initiating sleep, waking at night and trouble falling back to sleep, and waking too early. Cox proportional hazards models were used to assess the relationship between insomnia, as reported at the most recent of three interviews, and mortality.

RESULTS: Twenty‐nine percent of the sample reported trouble initiating sleep, 22.4% reported waking at night and having trouble falling back to sleep, and 26.6% reported waking too early. Of the sample, 43.2% had insomnia at the baseline interview; 23.2% percent of respondents with insomnia at baseline died during the follow‐up period compared with 22.0% of those without insomnia at baseline. Recent insomnia was not associated significantly with mortality in either crude analyses (Hazards Ratio (HR)=1.11, 95% CI, 0.78–1.60) or analyses adjusted for age, prescription medication use, functional limitations, self‐rated health, and number of chronic conditions (HR=0.74, 95% CI, 0.50–1.09).

CONCLUSION: Our results, combined with the results from previous studies, suggest strongly that insomnia is not an indicator of approaching mortality in older community‐dwelling populations.
Arginine Vasopressin Levels in Nursing Home Residents with Nighttime Urinary Incontinence
Authors: Ouslander Joseph G. , Nasr Samer Z. , Miller Myron , Withington Wendy , Lee Carol S. , Wiltshire‐Clement Michelle , Cruise Patrice , Schnelle John F.
Published: April 2015

OBJECTIVES: To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents.

DESIGN: Case series.

SETTING: Four nursing homes and two board and care facilities.

PARTICIPANTS: Sixty‐two nursing home residents and 27 board and care residents.

MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay.

RESULTS: Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios ± 50%. Forty‐nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios ± 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences.

CONCLUSION: Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.
Congestive Heart Failure and Cognitive Impairment in an Older Population
Authors: Cacciatore Francesco , Abete Pasquale , Ferrara Nicola , Calabrese Claudio , Napoli Claudio , Maggi Stefania , Varricchio Michele , Rengo Franco ,   Osservatorio Geriatrico Campano Study Group
Published: April 2015

OBJECTIVE: Congestive heart failure (CHF) is potentially preventable, and the identification of modifiable risk factors for cognitive impairment (CI) for older persons is a very important issue. We examined the cross‐sectional relationship between CHF and CI in an older population.

DESIGN: A cross‐sectional survey.

SETTING AND PARTICIPANTS: A total of 1339 subjects aged 65 and older were selected from the electoral rolls of Campania, a region of southern Italy.

MEASUREMENTS: Sociodemographic characteristics were recorded, as was the presence of cardiovascular diseases, including CHF classified according to the New York Heart Association (NYHA) guidelines for disease severity; CI evaluated by means of the Mini‐Mental State Examination (MMSE), with a score of <24 indicating impairment; geriatric depression scale (GDS) rating; blood pressure (BP); and heart rate (HR).

RESULTS: The final sample numbered 1075; 172 subjects were excluded because of neurological disorders and psychotropic therapy, and 92 were excluded because their BP, HR, or cognitive examination was not recorded. Prevalence of CHF was 8.2%, and 23.0% of subjects scored <24 on the MMSE. The prevalence of CHF in subjects with an MMSE score of <24 and ≥24 was 20.2% and 4.6%, respectively (P < .001). Logistic regression analysis showed that CHF was associated independently with CI by sex, age, educational level, GDS, diabetes, hypertension, alcohol consumption, smoking, atrial fibrillation, systolic and diastolic BP, and HR. The risk of CI was 1.96‐fold greater in subjects with CHF (odds ratio: 1.96; 95% confidence interval: 1.07–3.58; P < .028). Systolic BP decrease was correlated negatively with NYHA classes only in subjects with CI (r = −0.981; P < .020), whereas HR increase was correlated positively with NYHA classes only in subjects without CI (r = 0.985; P < .015).

CONCLUSIONS: In our population, CHF is associated with CI in subjects aged 65 years and older. Systolic BP reduction and the lack of HR increase, related to NYHA classes, might characterize cognitively impaired subjects with CHF.
Improving Balance
Authors: Robbins Steven , Waked Edward , Krouglicof Nicholas
Published: April 2015

OBJECTIVE: To test the hypothesis that shoes made with a sole material that retains compressed thickness between steps (low resiliency) provide balance better than and comfort equal to shoes composed of high resiliency sole material.

SETTING: Older subjects were recruited from a medical clinic population, and younger subjects came from a recreational sports population.

DESIGN: A randomized‐order, cross‐over, controlled comparison design.

PARTICIPANTS: Groups comprised random samples of 30 older (mean age 66 years, SD ± 3.0), and 30 younger (mean age 34 years, SD ± 6.0) healthy men who met age selection criteria.

MEASUREMENTS: Stability was inferred by sway measures: sway velocity (cms−1), X‐Y area (cm2), and radial area (cm2). Comfort was measured by direct scaling and magnitude estimation using an 11‐point ratio scale.

RESULTS: Stability inferred by sway velocity was 311% (P < .001) and 31 % (P < .001) poorer for younger and older groups, respectively, for high and low resiliency interfaces. Sway velocity with low resiliency interface was lower than bare platform, the lowest ever recorded under equivalent conditions (P < .001). All interfaces were equally comfortable.

CONCLUSIONS: Stability rises with low resiliency interfaces and declines with high resiliency interfaces: sway velocity in older people wearing hard‐soled footwear incorporating low resiliency technology would be 20% lower than in younger people wearing most current athletic and walking shoes. Inasmuch as existing theory can not account for improved balance with interfaces, we propose that when humans are supported by rigid support surfaces, elastic biologic tissues store energy from postural adjustments and locomotion, which is returned as a reaction force causing overshoot. This amplifies frontal plane foot movement and attenuates foot position awareness, causing less precise postural adjustments and instability. Low resiliency interfaces dissipate energy and thereby moderate overshoot. Low resiliency interface technology is capable of improving stability, which portends improved health for unstable older people in particular.
Cost of Health Care for a Community of Older Adults in an Urban Academic Healthcare System
Authors: Callahan Christopher M. , Stump Timothy E. , Stroupe Kevin T. , Tierney William M.
Published: April 2015

BACKGROUND: Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs.

OBJECTIVE: To describe the distribution and content of total healthcare costs accrued over a 4‐year period by a community of older adults cared for in an urban academic healthcare system and to describe high‐cost patients and utilization patterns.

DESIGN: A cohort study.

SETTING: A tax‐supported public healthcare system consisting of a 450‐bed hospital and seven community‐based ambulatory care centers.

PATIENTS: 12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995.

MEASUREMENTS: Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios.

MAIN RESULTS: The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (± 7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4‐year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high‐cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs.

CONCLUSIONS: Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4‐year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self‐care behaviors are an important target for interventions to reduce costs.
Final‐Year‐of‐Life Pacemaker Recipients
Authors: Hefflin Brockton J.
Published: April 2015

BACKGROUND: Older persons who have initial cardiac pacemakers implanted during their final year of life have not been characterized as a group, which makes it difficult to evaluate the suitability of some of their health services utilizations.

OBJECTIVE: To help determine how prudently pacemakers are used in this group, we assessed its pacemaker candidates from the perspective of health and ability to perform physical activities of daily living.

DESIGN: A retrospective, population‐based, cross‐sectional study.

SETTING: The 1993 National Mortality Followback Survey.

PARTICIPANTS: An estimated 1,647,955 persons aged 65 years or older who died in the US in 1993.

MEASUREMENTS: Demographic and cause‐of‐death frequencies obtained by analyzing age, sex, race, and underlying cause‐of‐death variables in the survey. For persons who had initial pacemakers implanted during their last year of life, we determined the percent of persons, within 10‐year age groups, who had no difficulty at any time during their final year of life performing 11 specific physical activities of daily living (e.g., climbing stairs, preparing meals, bathing). These data were obtained from negative responses to questions that asked if the decedents, at any time during their last year of life, had difficulty performing the specific activities.

RESULTS: Of the estimated 78,941 persons aged 65 years or older with a pacemaker who died in the US in 1993, 14,158 (18%) had their first pacemaker implanted during their last year of life. Estimated median survival of the final‐year‐of‐life recipients of pacemakers after pacemaker implantation was 5 months. Compared with the general older population that died in 1993, the final‐year‐of‐life recipients of pacemakers group had higher percentages of persons who died of acute disorders (49% vs 19%) and who lived alone in a private home (47% vs 20%), and a lower percentage of persons with Alzheimer's disease (1% vs 7%). The age‐stratified means of the percentages of final‐year‐of‐life recipients of pacemakers who had no difficulty performing each physical activity of daily living were all greater than 50.

CONCLUSION: Our results suggest that older persons who had initial pacemakers implanted during their final year of life and who died in 1993 were not terminally ill, inactive pacemaker candidates, in general, but relatively independent, physically functional candidates who frequently died abruptly. The physical, mental, and life expectancy factors recommended for consideration by expert guidelines for the implantation of cardiac pacemakers were generally applied to persons in this subgroup.
High Levels of Hopelessness Persist in Geriatric Patients with Remitted Depression and a History of Attempted Suicide
Authors: Szanto Katalin , Reynolds Charles F. , Conwell Yeates , Begley Amy E. , Houck Patricia
Published: April 2015

OBJECTIVE: To determine whether a high level of hopelessness after treatment of a depressive episode is an indicator of a history of lifetime suicide attempts in older people.

DESIGN: Groups of suicide attempters, suicidal ideators, and nonsuicidal patients were compared via analysis of variance with respect to levels of hopelessness, depression, anxiety, and global functioning before and after treatment of depression.

SETTING: An outpatient research clinic providing two treatment protocols of late‐life mood disorders.

PARTICIPANTS: A total of 107 consecutive outpatients (mean age 67) with major depression who responded to treatment.

MEASUREMENTS: Levels of hopelessness, severity of depression, anxiety, and global functioning were compared across the three groups at the beginning of treatment and at remission.

RESULTS: After remission there were no differences between the three groups in depression severity, anxiety, and global functioning. Hopelessness remained significantly higher in the attempter group than among ideators or nonsuicidal patients.

CONCLUSIONS: Suicide attempts, the most important risk factor for subsequent suicide, are associated with persistent, high levels of hopelessness following remission of depression in late‐life patients. These findings suggest that treatments designed specifically to lower hopelessness (such as cognitive, behavioral or interpersonal therapy) may be effective in reducing suicide risk.
Underutilization of Warfarin in Older Persons with Chronic Nonvalvular Atrial Fibrillation at High Risk for Developing Stroke
Authors: Mendelson Gad , Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of the use of warfarin to maintain an international normalized ratio (INR) between 2.0 and 3.0 in older persons with chronic nonvalvular atrial fibrillation (AF), and without contraindications to warfarin, who are at high risk for developing new thromboembolic (TE) stroke.

DESIGN: A retrospective analysis of charts from all older persons seen during 1997 at an academic hospital‐based geriatrics practice.

SETTING: An academic hospital‐based geriatrics practice staffed by fellows in a geriatrics training program and full‐time faculty geriatricians.

PATIENTS: Three hundred eighty men and 1183 women, mean age 80 ± 8 years (range 59 to 103 years), were included in the study.

MEASUREMENTS AND MAIN RESULTS: Of 1563 persons studied, 141 (9%) had chronic nonvalvular AF. Of 141 persons with AF, 127 (90%) were at high risk for developing TE stroke because they had either a previous thromboembolism, congestive heart failure, or echocardiographic evidence of abnormal left ventricular systolic function; a systolic blood pressure >160 mm Hg; or they were women older than 75 years of age. Of the 127 persons with AF at high risk for developing TE stroke, three (2%) had contraindications to warfarin. Of the 124 persons with AF at high risk for developing TE stroke and no contraindications to warfarin, 61 (49%) were treated with warfarin to maintain an INR between 2.0 and 3.0, and 45 (36%) were treated with 325 mg aspirin daily. Of 14 persons with AF at low risk for developing TE stroke, one (7%) was treated with warfarin to maintain an INR between 2.0 and 3.0, and six (43%) were treated with 325 mg aspirin daily.

CONCLUSIONS: Warfarin is underutilized as a treatment to maintain an INR between 2.0 and 3.0 in older persons with chronic nonvalvular AF at high risk for developing TE stroke.