bluuebunny/crossref_metadata_2025 huggingface dataset:
Temporal Order of Cognitive and Functional Loss in a Nursing Home Population
Authors: Cohen‐Mansfield Jiska , Werner Perla , Reisberg Barry
Published: April 2015

OBJECTIVE: The order in which cognition and the ability to perform activities of daily living (ADLs) are lost in an institutionalized aged population was examined. Understanding the order of loss of function is important for preparing caregivers and planning of care.

METHOD: The conditional probabilities of the inability to perform activity A when there exists the inability to perform activity B were explored in secondary analyses of cross‐sectional data describing 408 nursing home residents. Residents' abilities to perform ADLs were rated by nursing staff using Linn and Linn's Rapid Disability Rating Scale (RDRS‐2); cognitive functioning was rated by social workers and nursing staff using a modified version of Reisberg et al.'s Brief Cognitive Rating Scale (BCRS, with 4 axes: orientation, concentration, recent memory, and past memory).

RESULTS: The results regarding ADLs confirm previous findings of a natural order of loss of ability (from the one lost first to last): bathing, dressing, grooming, toileting, walking, and eating. The examination of order in the loss of concentration, recent memory, past memory, and orientation revealed that these seem to be lost concurrently when the cutpoint was 3 (i.e., relatively normal functioning vs. moderate and severe dementia). When the cutpoint was 6 (i.e., severe dementia vs. higher levels of functioning), the order that emerged was: recent memory, past memory, concentration, and orientation.

CONCLUSIONS: Although there is a significant relationship between loss of ability to perform ADLs and stage of cognitive impairment, the loss of any specific ADL is not uniquely related to any one stage of cognitive deterioration in this diverse population. This may be explained by the high prevalence of disease in this institutionalized population, as exemplified by the 60% suffering from arthritis and the 17% suffering from neurological disorders other than dementia.
A Follow‐Up Study of Age‐Associated Memory Impairment: Neuropsychological Predictors of Dementia
Authors: Hänninen Tuomo , Hallikainen Merja , Koivisto Keijo , Helkala Eeva‐Liisa , Reinikainen Kari J. , Soininen Hilkka , Mykkänen Leena , Laakso Markku , Pyörälä Kalevi , Riekkinen Paavo J.
Published: April 2015

OBJECTIVE: To examine the clinical course of age‐associated memory impairment (AAMI) and to evaluate the value of neuropsychological tests in predicting cognitive decline in AAMI subjects in a follow‐up period of more than 3 years.

DESIGN: Prospective cohort study.

SETTING: The outpatient Memory Research Unit of the Department of Neurology at the University of Kuopio in Eastern Finland.

PARTICIPANTS: A sample of 229 subjects (mean age 71.7 years) identified in two screening studies as having AAMI.

MEASUREMENTS: A battery of neuropsychological tests and a structured inquiry for health status and subjective memory complaints were performed at baseline and follow‐up to diagnose AAMI according to the criteria proposed by a National Institute of Mental Health work group.

RESULTS: Of the 229 subjects, 176 (76.9%) participated in the follow‐up for, on average, 3.6 years after the baseline. Of the participants, 104 (59.1%) still met the AAMI criteria. Other subjects were classified into five subgroups: (1) subjects showing decline in cognition meeting dementia diagnosis (16, 9.1% (13 of them AD)); (2) subjects with mild cognitive decline meeting neither dementia nor AAMI criteria (13, 7.4%); (3) subjects with memory performance now superior to AAMI criteria (17, 9.7%); (4) subjects having a disease classified as exclusion in the criteria (15, 8.5%); (5) subjects not now reporting subjective memory loss in everyday life (9, 5.1%). Two subjects (1.1%) were not classified because of incomplete data. Neuropsychological tests predicted which subjects would develop dementia during the follow‐up period. The best discriminators between these subjects and those who remained AAMI were memory and verbal fluency tests.

CONCLUSION: The study suggests that, in general, AAMI is nonprogressive, but the AAMI population also includes subjects with early dementia and subjects without genuine memory loss. However, these subjects can be differentiated with a more detailed neuropsychological evaluation. J Am Geriatr Soc 43:1007–1015, 1995.
Community Physicians' Cooperation with a Program of In‐Home Comprehensive Geriatric Assessment
Authors: Büla Christophe J. , Alessi Cathy A. , Aronow Harriet U. , Yuhas Karen , Gold Marcia , Nisenbaum Rosane , Beck John C. , Rubenstein Laurence Z.
Published: April 2015

OBJECTIVES: To study the cooperation of primary care physicians with a community‐based prevention and health promotion program for older persons, to study physician factors related to cooperation, and to determine any relationship between physician cooperation and patient adherence to program recommendations and patient satisfaction with health care.

DESIGN AND SETTING: A survey administered in subjects' homes and physicians' offices in Santa Monica, California.

PARTICIPANTS: Patients (n = 81) were intervention group subjects in a 3‐year, randomized, controlled trial of in‐home comprehensive geriatric assessment paired with prevention and health promotion. Physicians (n = 50) were selected if they had been contacted at least once by a study nurse practitioner about one of these patients.

MEASUREMENTS: Physician cooperation was rated by study nurse practitioners. Physicians were interviewed to identify factors associated with cooperation. Patients' satisfaction with health care and adherence were measured prospectively throughout the 3‐year program.

MAIN RESULTS: Physicians exhibiting better cooperation had fewer years in practice (P = .03) and were more likely to discuss the program with their patients (P = .005), see benefit for their patients from the program (P = .02), and rate program information as useful (P = .002). Higher physician cooperation did not predict higher patient satisfaction (P = .23) but did predict higher patient adherence to program recommendations (P = .02).

CONCLUSIONS: Physicians rated as cooperative were more likely to have a positive appraisal of the program, and their patients had higher adherence to program recommendations. These findings suggest that strategies for increasing primary care physician cooperation might improve effectiveness of similar community‐based prevention and health promotion programs.
Assessment of Capacity to Comply with Medication Regimens in Older Patients
Authors: Fitten L. Jaime , Coleman Lenore , Siembieda Douglas W. , Yu Marian , Ganzell Steven
Published: April 2015

OBJECTIVE: To develop an instrument that will facilitate and focus the assessment of a patient's capacity to adhere to a medication regimen before its initiation.

DESIGN: This is a crossectional study that compares medical inpatients and outpatients to an age‐matched, community‐living, independent and relatively healthy group on their ability to adequately understand and implement hypothetical but realistic medication regimens.

SETTING: Department of Veterans Affairs Medical Center, Sepulveda, California.

PARTICIPANTS: Fifty‐five older subjects (65 years or older) were divided into three groups: (1) generally healthy comparisons (standard group) (n = 20); (2) medical outpatients (n = 15); and (3) medical inpatients ready for discharge (n = 20).

MEASUREMENTS: Older subjects were first tested on their capacity to comply with a difficult medication regimen presented in scenario form. If scores on the first scenario did not meet a standard group‐derived cutoff point, further testing was conducted with a simpler scenario to identify greater levels of impairment.

RESULTS: The outpatient group had significantly lower scenario scores than did the healthy comparison group (P < .03). The simpler scenario also showed a trend toward outpatient impairment (P = .06). In the comparison group, only 5% failed Scenario 1, and none failed Scenario 2. The outpatient group had the most difficulty, with 40% failing Scenario 1 and one‐third of those failing Scenario 2. This differed significantly from the comparison groups (Fisher's Exact P < .03). In the inpatient group 20% failed Scenario 1 and 75% of those failing Scenario 2. The sensitivity and specificity of the Folstein Mini‐Mental State Examination in identifying scenario‐impaired subjects were 73% and 80%, respectively. Question types were analyzed to determine which questions were most frequently missed. Memory and judgment questions were found overall to be the most frequently missed. Healthy controls missed some judgment questions; however, the outpatient group was significantly worse in this category (X2 = 5.08; P = .01). All three groups improved their scenario performance significantly with question cueing.

CONCLUSION: A significant number of medically ill outpatients encountered difficulty in understanding or remembering correctly hypothetical but realistic medication regimens. This suggests that an older medical patient's cognitive and functional capacity to comply with medication regimens of differing complexity can be specifically assessed before the start of the regimen and probably should be assessed in patients whose compliance capacity is in question. The assessment instrument under development in this study may be helpful in detecting those who need assistance with medications, thus identifying the need for intervention before poor compliance can lead to increased morbidity, rehospitalization, and increased medical costs.
Understanding the Biology of Aging: The Key To Prevention and Therapy
Authors: Vijg Jan , Wei Jeanne Y.
Published: April 2015

OBJECTIVE: To review recent progress and consider future approaches for basic research on aging with clinical applicability.

DATA SOURCES: Peer‐reviewed publications on experimental gerontology and geriatrics.

STUDY SELECTION AND DATA EXTRACTION: Studies were selected that described experimental approaches in gerontology and geriatrics, starting with the evolutionary basis of aging, through theories trying to explain its major causes, to novel experimental approaches, e.g., computer informatics, protein chemistry and genetics.

DATA SYNTHESIS: Our increased understanding of the evolutionary basis of aging has made it possible to consider a number of experimental strategies more rationally. Most theories on the causes of aging involve some kind of somatic damage that accumulates with age, the rate of which is determined by environmental, genetic, and behavioral factors. The recent emergence of more powerful methodology offers new possibilities for identifying basic mechanisms of aging, which would increase our understanding of biologically based susceptibility to age‐related health problems.

CONCLUSIONS: There is a growing awareness that age‐related deterioration will affect an ever growing number of people, in both absolute and relative terms. It can be expected that this will further increase the resources that will be made available for research on aging. Although ultimately unavoidable, aging is a process that appears to be experimentally accessible. Therefore, the mechanisms of senescence and death may eventually be more completely understood, with the promise of preventing and/or delaying many of the adverse effects associated with aging, including most of the common diseases, and possibly also of extending lifespan.
Lessons Learned from a Prospective Meta‐analysis
Authors: Margitić Susan E. , Morgan Timothy M. , Sager Mark A. , Furberg Curt D.
Published: April 2015

OBJECTIVE: To describe the unique aspects of and the lessons learned in planning and conducting a pooled analysis of multiple trials evaluating interventions to reduce functional decline in hospitalized older persons. Specific examples from the Hospital Outcomes Project for the Elderly (HOPE) meta‐analysis are discussed.

DESIGN: A prospective meta‐analysis (PMA) that compiled and pooled data from concurrently conducted clinical trials testing related but distinct interventions.

SETTING: The Data Coordinating Center for the prospective meta‐analysis coordinated the collection and analysis of common outcome data from five university‐affiliated hospitals and one community hospital conducting the clinical trials.

PARTICIPANTS: Acutely ill hospitalized elderly participants at least 65 to 75 years old.

INTERVENTIONS: Treatments being evaluated included exercise, physical therapy, a multidisciplinary geriatric care unit, a multidisciplinary in‐hospital intervention with post‐discharge care, a nursing‐based geriatric care program, and a program to improve detection and evaluation of delirious patients.

CONCLUSION: The prospective meta‐analysis provides selected advantages over independently conducted clinical trials and retrospective meta‐analyses. It does, however, pose special design and operational challenges that must be addressed well before initiation of the individual trials. Specific issues of concern include: maintaining scientific integrity of both the individual trials and the PMA; reaching consensus on PMA goals, what data to collect, how and when to collect them and how to maintain uniformly high quality data across all sites; defining the role of the Data Coordinating Center in a multicenter project that utilizes different trials and protocols; and establishing policies concerning analyses of the pooled data, publication of pooled analyses, and ownership of the pooled database.
Malnutrition, Tube Feeding and Pressure Sores: Data Are Incomplete
Authors: Finucane Thomas E.
Published: April 2015

PURPOSE: To review data about the relationship between pressure sores and (1) nutritional status, (2) nutrient intake, and (3) tube feeding.

DATA SOURCES: Medline search of terms associated with “decubitus ulcer” combined with terms associated with “pressure sore” from 1985 through August 1994. Hand review of all issues of the journal Decubitus (now Advances in Wound Care) through June 1994 and the Journal of Parenteral and Enteral Nutrition from January 1987 through May‐June 1994. Review of bibliography of pertinent articles. A small survey of experts.

STUDY SELECTION: Articles where the title, Me SH terms, or abstract suggested an examination of the relationship between nutrition and pressure sores, and those suggested by the experts, were reviewed.

DATA EXTRACTION: Study designs were disparate. Results were simply tabulated.

RESULTS: In seven studies, low serum albumin was associated with development or presence of pressure sores; in five it was not. Most measures of nutritional status were not associated with pressure sore outcomes. Poor nutritional intake was associated with poor pressure sore outcome in four of seven studies. Tube feeding was positively associated with presence of pressure sores in one study. Special nutrition support was ineffective in improving pressure sore outcome in a second. Two studies showed better healing in patients receiving high‐protein formula: in one, all patients were tube fed; in the other, route of feeding was not stated.

CONCLUSION: Data about the relationship between malnutrition and pressure sores are incomplete and contradictory. No randomized trials of tube feeding as prevention or treatment of pressure sores has been done. Routine use of tube feeding to prevent or treat pressure sores is not clearly supported by data.
Assessing Diagnostic Approaches to Depression in Medically Ill Older Adults: How Reliably Can Mental Health Professionals Make Judgments About the Cause of Symptoms?
Authors: Koenig Harold G. , Pappas Pamela , Holsinger Tracy , Bachar James R.
Published: April 2015

OBJECTIVE: To evaluate the reliability of the DSM‐IV approach and five other schemes for counting symptoms toward the diagnosis of depression in hospitalized medically ill older patients and to examine whether mental health professionals can reliably make judgments about the etiology (medical or psychological) of depressive symptoms.

METHOD: A sample of 38 patients aged 60 years or older admitted to the general medicine, cardiology, or neurology services at Duke University Medical Center were evaluated for depression using a structured psychiatric interview and the Hamilton Depression Scale. Interrater reliability for the diagnostic schemes, for unstructured clinical diagnoses, and for determinations of the causes of individual depressive symptoms was assessed by three pairs of mental health professionals.

RESULTS: Agreement between raters for structured diagnoses was high regardless of diagnostic strategy, with the DSM‐IV approach being only slightly less reliable than the strict inclusive approach (Kappa 0.88 vs Kappa 1.0, respectively). For all diagnostic approaches, there was perfect agreement between raters for eight cases of major depression. Agreement for unstructured clinical diagnoses of depression (K = 0.50) was much lower than for the structured diagnoses. Agreement between raters on the etiology of individual depression criterion symptoms assessed by structured interview was greater than 80% for 14 of 19 symptoms. Correlation between raters' depression severity ratings on the Hamilton Scale using the DSM‐IV etiologic approach was equivalent to that using the strict inclusive approach (0.98 vs 0.95, respectively).

CONCLUSIONS: Mental health professionals can be trained to make judgments reliably about the cause (medical or psychological) of symptoms in hospitalized older medical patients. The “strict inclusive” and other diagnostic schemes for counting symptoms toward the diagnosis of depression have only marginal, if any, benefit compared with the the current DSM‐IV approach.
Serum Anticholinergic Activity in Hospitalized Older Persons with Delirium: A Preliminary Study
Authors: Mach John R. , Dysken Maurice W. , Kuskowski Mike , Richelson Elliott , Holden Lori , Jilk Kris M.
Published: April 2015

OBJECTIVE: To evaluate the relationship between total serum anticholinergic activity (SAA) and the presence or absence of delirium in older hospitalized persons on general medical wards.

DESIGN: Case‐control study and within‐subjects repeated‐measures in recovered delirious patients.

SETTING: Minneapolis Veterans Affairs Medical Center medical wards.

PARTICIPANTS: Eleven male delirious patients (DSM‐III‐R criteria) aged 60 or older and 11 comparably aged male nondelirious controls.

MEASUREMENTS: Radioreceptor bioassay of total SAA using tritiated quinuclidinyl benzilate (QNB) binding to muscarinic receptors. Results are expressed in terms of atropine equivalents (nm).

MAIN RESULTS: Mean SAA was significantly elevated in the delirious group (mean ± SD = 6.05 ± 2.97 nm atropine equivalents) compared with the controls (3.38 ± 2.49; t(20) = 2.28, P < .05). At study entry, mean SAA was significantly higher in delirious subjects whose symptoms eventually resolved completely (mean ± SD = 7.77 ± 2.37) compared with subjects whose delirious symptoms persisted (3.99 ± 2.30; t(9) = 2.68, P < .05). All six patients in whom delirium resolved completely had a decrease in serum anticholinergic activity when measured during delirium (7.77 ± 2.37) and after symptom resolution (3.92 ± 2.61; t(5) = 3.29, P < .05).

CONCLUSIONS: Our findings suggest that serum anticholinergic activity may play a role in delirium in medical inpatients. The relationships between SAA and delirium in medical patients and between total SAA and medication use warrant further study.
Functional and Mobility Impairments Associated with Paget's Disease of Bone
Authors: Lyles Kenneth W. , Lammers J. Eugene , Shipp Kathy M. , Sherman Lawrence , Pieper Carl F. , Martinez Salutario , Gold Deborah T.
Published: April 2015

OBJECTIVE: To determine if patients with Paget's disease of bone involving the tibia, femur, and/or acetabular portion of the ilium had more impairments in function and mobility than age‐ and sex‐matched control subjects.

PATIENTS AND METHODS: A case control study with Paget's disease patients selected from a center for bone disease at a tertiary medical center; control subjects were volunteers from the Duke University Aging Center subject registry. Demographic characteristics, physical examination and serum alkaline phosphatase levels were obtained. Radiographs of the pelvis and lower extremities were evaluated by a radiologist. All participants completed a Functional Status Questionnaire (FSQ). Mobility measures included mobility skills protocol, 10‐foot walk time, 360‐degree turn left (number of steps), and 6‐minute walk distance.

RESULTSThe 12 Paget's disease patients were no different in age (70.7 ± 6.2 years) than the 12 control subjects (69.5 ± 6.2 years). Serum alkaline phosphatase levels were elevated in Paget's patients (539 ± 530 IU/L), and normal in control subjects (85 ± 17 IU/L). In addition to Paget's disease, radiographs showed joint space loss in joints proximate to the diseased bone. On the FSQ scales Paget's disease patients had significantly lower scores in basic activities of daily living (P < .05), instrumental activities of daily living (P < .001), and social activity than control subjects (P < .05). There was no difference between the groups on scales measuring mental health and quality of social interaction. On mobility measurements, Paget's disease patients showed significant impairments when compared with control subjects: mobility skills protocol score (22.5 ± 2.5 vs 25.6 ± 0.7, P < .001); 10‐foot walk (3.96 ± 1.3 vs 2.55 ± 0.5 seconds, P < .001); 360 degree turn left (8.0 ± 1.0 vs 5.9 ± 0.6 steps, P < .001); and 6‐minute walk (342.0 ± 108.5 vs 519.4 ± 100 meters, P < .001).

CONCLUSION: When compared with control subjects, patients who have Paget's disease of bone involving the tibia, femur, or acetabular portion of the ilium have clinically and statistically significant functional and mobility impairments compared to age‐ and gender‐matched controls.
Do Surgical Brain Lesions Present as Isolated Dementia? A Population‐Based Study
Authors: Alexander Elizabeth M. , Wagner Edward H. , Buchner David M. , Cain Kevin C. , Larson Eric B.
Published: April 2015

OBJECTIVE: To determine the incidence of clinically important subdural hematoma (SDH), hydrocephalus not associated with a recent intracranial bleed, and intracranial tumor that is not obviously metastatic, and to test the sensitivity of a promising decision rule for computerized tomography (CT) in dementia.

DESIGN: Population‐based, retrospective, sequential case series.

SETTING: Staff model health maintenance organization (HMO).

PATIENTS: Patients aged 65 years and older with one of the three lesions, diagnosed over a 4.5‐year period, identified mainly through computerized databases of hospital discharge diagnoses and a registry of malignant tumors.

MEASUREMENTS: Clinical data were based on chart review. The decision rule, based on one that had been previously proposed and tested, stated that CT would be required if any one of 11 clinical criteria were met by a patient with cognitive impairment. Rule sensitivity was evaluated using clinical information recorded before CT.

MAIN RESULTS: One hundred forty‐five clinically important lesions were identified among 137,100 person‐years at risk. Average annual incidence per 100,000 was 46.7 (95% CI 36.0, 59.6) for SDH, 5.8 (95% CI 2.5, 11.5) for hydrocephalus not associated with a recent intracranial bleed, and 53.2 (95% CI 41.7, 66.9) for intracranial tumors that were not obviously metastatic. Using the 65 to 74‐ year age strata as a reference, the relative risk for SDH was 4.8 (95% CI 2.7, 8.5) in 75 to 84‐year‐olds and 13.1 (95% CI 7.7, 22.5) in the 85 and older strata. Among 59 patients who presented with cognitive impairment, without altered sensorium or physical evidence of trauma, decision rule sensitivity was 93.2% (95% CI 83.5%, 98.1%). Sensitivity was 90.7% (95% CI 77.9%, 97.4%) in the subgroup that presented to an ambulatory care clinic rather than to an emergency department.

CONCLUSIONS: These three lesions, which are the most common surgical lesions that may present as dementia, are rare. Most cases have presentations that easily distinguish them from typical Alzheimer's disease. This case series indicates that it may be feasible to develop a decision rule for the selective use of CT in dementia. Disease spectrum will influence measures of decision rule performance such as sensitivity and specificity.
Weight Gain Impacts Morbidity and Mortality in Institutionalized Older Persons
Authors: Keller Heather H.
Published: April 2015

OBJECTIVE: To determine if a significant weight change in previously undernourished older persons is associated with mortality and morbidity.

DESIGN: Retrospective survey.

SETTING: A chronic care hospital in Canada.

SUBJECTS: Follow‐up survey from an original data set (Time 1) on 88 previously diagnosed undernourished and 60 adequately nourished. Average age was 78 years; average length of residence was 40 months. Of the 148 subjects, 120 were male.

MEASUREMENTS: Average time to follow‐up (Time 2) was 319 days from Time 1. Data was collected on weight change, reported incidence of infection, use of antibiotics, number of falls, and admissions to acute centers, as well as incidence and cause of death. Three‐day diet intake records were available on 15% of subjects within 1 month of Time 2. Five nutritional groups existed within this follow‐up population: those previously undernourished who gained at least 5% of Time 1 weight (Group 1), those undernourished who lost at least 5% of Time 1 weight (Group 2), those undernourished who maintained their weight (Group 3), those adequately nourished who lost at least 5% of original weight (Group 4), and those who remained adequately nourished (Group 5).

RESULTS: Forty‐one of the 148 patients died; this was significantly associated with nutrition group (X2 = 11.23, P = 0.02), with fewer deaths in Groups 1, 3, and 5. As well, primary diagnosis (x2 = 32.6, P = 0.001), length of residence (X2 = 25.6, P = 0.01), and time to death (X2 = 26.4, P = 0.009) were significantly associated with nutrition group. Diet intake records indicated an improvement in energy and protein intake in Group 1 during the follow‐up. Energy and protein change, whether increased or decreased from the original study, was significantly associated with nutrition group. Total number of feeding impairments and presence of dysphagia were significantly associated with nutrition group. Other morbidity events were not significantly associated with nutrition group, but trends suggest a positive effect of weight gain on incidence of falls, incidence of more than two infections, and incidence of recurring infections.

CONCLUSIONS: A weight increase of at least 5% of body weight in previously undernourished patients is associated with a decreased incidence of death and may reduce morbidity events. Feeding impairments may affect ability of patients to gain weight, but dysphagia is associated with weight increase. Other nonnutritional variables of diagnosis, number of medications, and declining medical status also affect mortality and morbidity outcomes.
A Simple Model for Predicting Postoperative Delirium in Older Patients Undergoing Elective Orthopedic Surgery
Authors: Fisher Bruce W. , Flowerdew Gordon
Published: April 2015

OBJECTIVE: To determine the incidence, and severity of postoperative delirium (POD) in older patients undergoing elective orthopedic procedures and to identify potential preoperative risk factors.

DESIGN: A prospectively studied cohort of elective orthopedic surgery patients.

SETTING: A University teaching hospital.

PATIENTS: Eighty patients who attended a preadmission clinic and, subsequently, underwent elective orthopedic surgery. All patients were aged 60 years or older, and all spoke English.

MEASUREMENTS: Patients underwent preoperative medical, cognitive, and activities of daily living assessment with standardized instruments and were followed postoperatively with daily visits, telephone interviews with attending nurses using a modified confusion assessment model (CAM), and repeated cognitive testing. Suspected delirium was verified by direct physician assessment.

RESULTS: The elective group had 14 (17.5%) cases of POD, of which six (7.5%) were severe. These incidences are low compared with those of nonelective surgery groups reported elsewhere in the literature. Stepwise multiple logistic regression identified two POD risk factors: clock‐drawing scores ≤ 6 (OR = 9.0, CI, 2.8 to 45.6) and male gender (OR = 5.6, CI 1.9 to 33.8).

CONCLUSION: A simple model using clock‐drawing scores and male gender for preoperative identification of elective patients at greatest risk for POD appears sensitive, predictive, and practical for the preadmission clinic setting, but it should be validated in a prospective trial.
Functional Incidental Training, Mobility Performance, and Incontinence Care with Nursing Home Residents
Authors: Schnelle John F. , MacRae Priscilla G. , Ouslander Joseph G. , Simmons Sandra F. , Nitta Misty
Published: April 2015

OBJECTIVE: To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents.

DESIGN: Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols.

PARTICIPANTS: Seventy‐six incontinent nursing home residents completed all phases of the trial.

MEASURES: The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8‐week intervention.

RESULTS: The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group × time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56,2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group X time interaction.

CONCLUSION: The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.
Dental, Visual, Auditory and Olfactory Complications in Paget's Disease of Bone
Authors: Wheeler Timothy T. , Alberts Marco A. M. , Dolan Teresa A. , McGorray Susan P.
Published: April 2015

OBJECTIVE: To determine the prevalence of dental problems in Paget's patients and in a control population without Paget's disease. The relationship of localization of bony involvement of Paget's disease with the prevalence of dental, auditory, visual, and smell changes is examined.

DESIGN: Cross‐sectional national survey

PARTICIPANTS: Four hundred ninty‐eight subjects with Paget's disease were generated randomly from the mailing list of the Paget Foundation.

INTERVENTION: Each subject was sent a cover letter, two questionnaires, and a stamped, addressed return envelope. One questionnaire contained questions specific for the individual with Paget's disease. Subjects were asked to give the other questionnaire, which contained the same questions except for those asking about the specifics of Paget's disease, to an unaffected spouse or a similar aged friend.

MEASUREMENTS: All subjects were asked about their age, gender, race, educational level, income, living situation, chronic medical conditions, self‐rating of their general physical and dental health, the number of teeth present, and the presence of dental, auditory, visual, and olfactory problems. Paget's subjects were also asked to indicate which bones were affected.

RESULTS: Paget's disease subjects assessed their oral health to be poorer than the controls. Paget's subjects were more likely to report pain when opening the mouth and were more likely to have had dental extractions. A significantly higher percentage of Paget's individuals with facial or maxillo‐mandibular involvement reported having heart trouble. Paget's individuals with skull, facial or maxillo‐mandibular involvement were more likely to report a change in their hearing, sight, and smell than Paget's subjects without involvement of the craniofacial complex. Dental problems were reported by 93% of those Paget's subjects with maxillomandibular involvement, compared with only 10% for those with skull involvement only or involvement at sites distant to the craniofacial complex.

CONCLUSIONS: Patients with Paget's disease of bone involving facial or maxillo‐mandibular parts of the skeleton have a higher prevalence of change in hearing, sight, smell, and dental problems. We also have found an association of heart disease in patients who have involvement of facial or maxillo‐mandibular bones.
Weight Change and Physical Function in Older Women: Findings from the Nun Study
Authors: Tully Christine L. , Snowdon David A.
Published: April 2015

OBJECTIVE: To investigate the association between change in weight and decline in physical function in older women.

DESIGN: Longitudinal study of a defined population of Catholic sisters (nuns) whose weight and function were assessed twice, an average of 584 days apart.

SETTING: Unique life communities (convents) located throughout the United States.

PARTICIPANTS: 475 Catholic sisters who were 75 to 99 years of age (M = 82.1, SD = 4.8) and were independent in at least one Activity of Daily Living (ADL) at the first assessment of weight and function.

INTERVENTIONS: None.

MEASUREMENTS: At each assessment, weight, ADLs, and cognitive function were evaluated as part of the Nun Study‐a longitudinal study of aging and Alzheimer's disease. Annual percent weight change was calculated using weights from the two assessments, as well as the number of days that elapsed between assessments.

RESULTS: Mean weight at first assessment was 140 pounds (range 78 to 232, SD = 27). The mean annual percent weight change was 0.1% (range 22% loss to 16% gain, SD = 3.8). Age‐ and initial weight‐adjusted findings indicated that those participants with an annual percent weight loss of 3% or greater had 2.7 to 3.9 times the risk of becoming dependent in each ADL, compared to the sisters with no weight change. The elevated risk persisted in those who were mentally intact or were independent in their eating habits.

CONCLUSION: Monitoring of weight may be an easy and inexpensive method of identifying older individuals at increased risk of disability.
Psychotropic Use Among Older Residents of Board and Care Facilities
Authors: Spore Diana , Mor Vincent , Hiris Jeffrey , Larrat E. Paul , Hawes Catherine
Published: April 2015

OBJECTIVE: To describe patterns of psychotropic use as well as clinically relevant and concurrent nonpsychotropic use among older residents of board and care facilities in 10 states.

METHODS: Weighted use rates were based on data from a sample of 2054 residents aged 65 and older from 410 facilities in 10 states, drawn via a complex, multistage sampling design. Data, including drug name, use frequency, and PRN use, were collected on all drugs taken by the resident during a 7‐day period. During face‐to‐face interviews with residents and/or proxies, data were also collected on resident characteristics.

SUBJECTS: The majority of subjects were female, white, and widowed. Average age was 82 years. Approximately 25% had a current mental or emotional condition, and 8% had been hospitalized for a psychiatric condition during the year before admission. More than half needed help with at least one activity of daily living. Forty percent had moderate or severe cognitive impairment, and 18% had received mental health care during the previous year.

ANALYSES: Weighted descriptive analyses were performed with Software for Survey Data Analysis (SUDAAN), which accounts for the complex, multistage sampling design.

RESULTS: Approximately 35% of the older residents used at least one psychoactive agent, with 30% of psychotropic users receiving two to four different psychotropic medications. Use rates decline with age, for psychotropics overall and for therapeutic classes. Results revealed potentially problematic polypharmacy in relation to drug duplication within therapeutic classes, use of multiple psychotropics across classes, and concurrent nonpsychotropic use.

CONCLUSIONS: Compared with community‐dwelling older adults, this study revealed high psychotropic use rates among older board and care facility residents. Overall, our results suggest that serious consideration be given to the apparent need for systematic drug utilization review, a potentially useful program that is mandated in other settings.
Effects of Resistance Training on Strength, Power, and Selected Functional Abilities of Women Aged 75 and Older
Authors: Skelton Dawn A. , Young Archie , Greig Carolyn A. , Malbut Katie E.
Published: April 2015

OBJECTIVE:To determine the effects of 12 weeks of progressive resistance strength training on the isometric strength, explosive power, and selected functional abilities of healthy women aged 75 and over.

DESIGN:Subjects were matched for age and habitual physical activity and then randomly assigned into either a control or an exercise group.

SETTING:The Muscle Function Laboratory, Royal Free Hospital School of Medicine, London.

PARTICIPANTS:Fifty‐two healthy women were recruited through local and national newspapers. Five dropped out before and seven (4 exercisers and 3 controls) during the study. Pre‐ and posttraining measurements were obtained from 20 exercisers (median age 79.5, range 76 to 93 years) and 20 controls (median age 79.5, range 75 to 90 years).

INTERVENTIONS:Training comprised one supervised session (1 hour) at the Medical School and two unsupervised home sessions (supported by an exercise tape and booklet) per week for 12 weeks. The training stimulus was three sets of four to eight repetitions of each exercise, using rice bags (1–1.5 kg) or elastic tubing for resistance. The exercises were intended specifically to strengthen the muscles considered relevant for the functional tasks, but were not to mimic the functional measurements. No intervention was prescribed for the controls.

MEASUREMENTS:Pre‐ and posttraining measurements were made for isometric knee extensor strength (IKES), isometric elbow flexor strength (IEFS), handgrip strength (HGS), leg extensor power (LEP), and anthropometric indices (Body impedance analysis, arm muscle circumference, and body weight). Functional ability tests were chair rise, kneel rise, rise from lying on the floor, 118‐m self‐paced corridor walk, stair climbing, functional reach, stepping up, stepping down, and lifting weights onto a shelf. Pre‐ and posttraining comparisons were made using analysis of variance or analysis of covariance (using weight as a covariate) for normally distributed continuous data and one‐sided Fishers exact test (2times2 table) for discontinuous data.

RESULTS:Improvements in IKES (mean change 27%,P= .03), IEFS (22%,P= .05), HGS (4%,P= .05), LEP/kg (18%,P= .05) were associated with training, but the improvement in LEP (18%,P= .11) did not reach statistical significance. There was an association between training and a reduction in normal pace kneel rise time (median change 21%,P= .02) and a small improvement in step up height (median 5%,P= .005). The other functional tests did not improve.

CONCLUSIONS:Progressive resistance exercise can produce substantial increases in muscle strength and in power standardized for body weight in healthy, very old women. However, isolated increases in strength and LEP/kg may confer only limited functional benefit in healthy, independent, very old women.
Admission Health Status Differences of Black and White Indigent Nursing Home Residents
Authors: Stegbauer Cheryl Cummings , Engle Veronica F. , Graney Marshall J.
Published: April 2015

OBJECTIVE: To compare the health status of newly admitted lower socioeconomic status (SES) southern black (n = 81) and white (n = 53) nursing home residents.

DESIGN: The study data were part of a larger prospective study on the health of newly admitted nursing home residents.

SETTING: A 575‐bed, government‐funded nursing home providing care for indigent residents in a large southern city.

PARTICIPANTS: Newly admitted black and white nursing home residents aged 60 and older.

MEASUREMENTS: Mental status was measured using the Short Portable Mental Status Questionnaire, activities of daily living by Scaled Outcome Criteria, and medical status by medical diagnoses and medications.

MAIN RESULTS: Blacks entering the nursing home were more cognitively and functionally impaired and had 3.7 years less education than white residents, but average age was not significantly different for black and white residents.

CONCLUSIONS: Many common health status measures showed no significant black‐white differences for institutionalized older adults when region and SES were constants. However, mental status, self‐care activities, and marital status were significantly different. These findings indicate a possible impact of lifelong poverty or low educational attainment on the increased disability of indigent black older adults. Black residents in our study had less spousal support to remain in the community.
A Cost and Value Analysis of Two Interventions with Incontinent Nursing Home Residents
Authors: Schnelle John F. , Keeler Emmett , Hays Ron D. , Simmons Sandra , Ouslander Joseph G. , Siu Albert L.
Published: April 2015

OBJECTIVE: More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences.

DESIGN: The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance.

PARTICIPANTS: Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value.

MEASUREMENT: The staff‐time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room).

RESULTS: Both interventions had labor costs that were greater than “usual care” costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers,

CONCLUSION: Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.
Falls Among Older People: Relationship to Medication Use and Orthostatic Hypotension
Authors: Liu Barbara A. , Topper Anne K. , Reeves Richard A. , Gryfe Cyril , Maki Brian E.
Published: April 2015

OBJECTIVE: To assess the risk of falls attributable to medication use and orthostatic hypotension.

DESIGN: Prospective cohort study.

SETTING: Two self‐care, apartment‐style residential facilities in the Toronto area.

PARTICIPANTS: A total of 100 consecutive older volunteers (mean age = 83, range 62–96) who were independent in activities of daily living and able to stand unaided.

MEASUREMENTS: Prescription medications used by each subject were documented at baseline. Blood pressure measurements were performed supine, immediately after standing, and after 5 minutes. Subjects reported falls weekly, by postcard, for a period of 1 year; nonreporters were contacted by telephone.

RESULTS: Fifty‐nine percent of subjects fell at least once during the 1‐year follow‐up. Antidepressant use was associated with an increase in the risk of experiencing one or more falls (RR = 1.6, P = .02). The use of other drug classes examined, including diuretics and sedative‐hypnotics, was not associated with an increased risk of falling. Orthostatic hypotension was not predictive of falls. Surprisingly, there was an increase in the diastolic blood pressure of fallers, after 5 minutes, that was not seen in the nonfallers (3.3 vs −0.2 mm Hg, P = .05). Possible explanations for this previously unreported observation are explored.

CONCLUSION: Patients using antidepressants should be followed closely because the risk of falls is increased. Previously reported relationships between benzodiazepines and diuretics and falls are not supported by the present findings. Clinical detection of orthostatic hypotension is unlikely to be useful in predicting future risk of falling.
Risk Factors For Motor Vehicle Crashes Among Older Drivers in a Rural Community
Authors: Foley Daniel J. , Wallace Robert B. , Eberhard John
Published: April 2015

OBJECTIVE: To estimate the motor vehicle crash rate in a cohort of older drivers from a rural community and to identify health‐related conditions that increase their risk for crash involvement.

DESIGN: Cohort study with 5 years of crash‐record surveillance.

SETTING: The Iowa 65+ Rural Health Study, one of four Established Populations for Epidemiologic Studies of the Elderly (EPESE).

PARTICIPANTS: A total of 1791 drivers aged 68 years and older.

MAIN MEASURES: Exposure measures of physical, mental, and sensory well‐being from a health interview survey; outcome measure of police‐reported crashes maintained by the Iowa Department of Motor Vehicles.

RESULTS: Between 1985 and 1989, 206 drivers were involved in 245 state‐recorded crashes. The estimated annual crash involvement rate for these rural older drivers (28 per 1000 driving‐years) was about 20% less than the national average for drivers aged 65 years and over (36 per 1,000). An increased risk for motor vehicle crashes was associated with episodes of back pain (Relative Risk = 1.4, P < .05), use of nonsteroidal anti‐inflammatory drugs (RR = 1.7, P < .01), and poor performance on a free‐recall memory test (RR = 1.4, P < .05).

CONCLUSIONS: If these and other geriatric conditions are confirmed as risk factors for motor vehicle crashes, medical guidelines for license renewal may need updating and health professionals may need new instruments to detect older patients at high risk for unsafe driving.