bluuebunny/crossref_metadata_2025 huggingface dataset:
Validating the GDS Depression Screen in the Nursing Home
Authors: McGivney Shawn A. , Mulvihill Michael , Taylor Brian
Published: April 2015

Objective: The GDS (Geriatric Depression Scale) has demonstrated validity among ambulatory elderly but is less useful in nursing home (NH) populations, probably because of high rates of cognitive impairment. We, therefore, sought the lowest level of Mini‐Mental Status Exam (MMSE) score for which the GDS would remain valid.

Design: Validation Study.

Setting: Nursing Homes in New York City.

Participants: A total of 66 of 168 newly admitted residents to the NH were able to complete psychiatric assessment, undergo an MMSE, and complete the GDS. The psychiatrists and testers (all non‐MDs) were blinded to each others' results. Using a cutoff of 10 or greater on the GDS to indicate depression, the GDS's validity (when compared with the psychiatric diagnoses) was sought at ever decreasing levels of cognitive function as measured by the MMSE.

Results: The results of all participants (n = 66) revealed a sensitivity of 63% and a specificity of 83%. When only those with an MMSE score ≥15 (the best cutoff score) were included, 44 (64%) participants were selected, with a sensitivity and specificity of 84% and 91%, respectively.

Conclusions: The two‐step procedure of first selecting those with MMSE scores ≥15 and then giving the GDS significantly increases the utility of the GDS in detecting depression in NH residents and should improve the diagnostic process for this widely underdetected problem.
Age‐Related Therapeutic Response to Antithyroid Drug in Patients with Hyperthyroid Graves' Disease
Authors: Yamada Takashi , Aizawa Toru , Koizumi Yoichi , Komiya Ichiro , Ichikawa Kazuo , Hashizume Kiyoshi
Published: April 2015

Objective: To determine whether there is an age‐related difference in the therapeutic response to antithyroid drugs in hyperthyroid Graves' disease.

Design: Retrospective analysis of treatment duration and recurrence rate.

Patients: Two hundred and twenty‐two patients who have triiodothyronine‐suppressible thyroids within 4 years of methimazole treatment.

Measurements: Serum thyroid hormone levels, serum thyrotropin receptor antibody titer, and thyroidal radioiodine uptake.

Main results: A longer period of methimazole treatment was needed to normalize serum thyroid hormone levels and to restore normal thyroidal triiodothyronine suppressibility in young than in aged patients. There was an average 10‐month lag between normalization of thyrotropin receptor antibody titer and restoration of thyroidal triiodothyronine suppressibility in both young and aged patients. Recurrence after discontinuation of methimazole was more frequent in young than in aged patients.

Conclusions: Aged patients with hyperthyroid Graves' disease show a more favorable response to antithyroid drugs than young counterparts.
Case Managers and Physicians: Communication and Perceived Problems
Authors: Feltes Michael , Wetle Terrie , Clemens Elizabeth , Crabtree Benjamin , Dubitzky Deborah , Kerr Myra
Published: April 2015

Objective: To describe case managers' perceptions of the physician‐case manager relationship.

Design: A qualitative field study using in‐depth open‐ended interviews was used to elicit case managers' experiences and practices. A muladisciplinary team analyzed transcripts using an adaptation of the “grounded theory” approach of Glaser and Strauss.

Participants/Setting: Case managers were selected for interview using a maximum variation sampling strategy within an established state‐wide case management agency.

Main Outcome Measures: Transcript analysis allowed for the organization of observations into themes, which were merged across interviews to generate theses.

Results: Case managers report that: (1) The case manager role is poorly understood by physicians. (2) Physicians lack insight into the social and environmental aspects of home‐bound elderly people. (3) Access to physician services is often difficult to obtain. (4) Power struggles occasionally surface in care planning. (5) Decisions by physicians and case managers regarding the care of frail elderly are often made from different agenda.

Conclusions: From the perspective of case managers, gaps in interprofessional communication may hinder the optimal care of frail elderly individuals. J Am Geriatr Soc 42:5–10, 1994
Influence of Diagnostic Classification on Outcomes and Charges in Geriatric Assessment and Rehabilitation
Authors: Miller Stephen T. , Applegate William B. , Elam Janet T. , Graney Marshall J.
Published: April 2015

Objective: To determine if diagnostic classification is associated with different outcomes from treatment on a geriatric assessment unit (GAU) compared with usual care for elderly patients with acute illnesses.

Study Design: Reanalysis after post‐hoc diagnostic classification of a randomized clinical trial with one year follow up.

Setting: Community hospital with rehabilitation facility.

Subjects: A total of 155 subjects, mean age 78 years and 78% female, of whom 58 subjects had a rehabilitation classification of their diagnoses and 97 had a medical or surgical classification.

Outcome Measures: Mortality, nursing home use, activities of daily living, and charges for subsequent medical services.

Results: Mortality was decreased in persons with a rehabilitation classification who had received the GAU intervention. The GAU increased point‐prevalence residence in the community for persons with a rehabilitation classification. For persons with a medical‐surgical classification, the GAU intervention was associated with decreased cumulative use of nursing homes. However, GAU intervention was also associated with trends for increased charges in both diagnostic classification groups, even when adjusted for differential survival.

Conclusion: Greater benefit from the GAU intervention on mortality and maintenance of residence in the community was observed in a group with a rehabilitation classification when compared with a group with a medical‐surgical classification. These improved outcomes in the rehabilitation group were not accompanied by decreased charges for later medical services that could compensate for initial rehabilitation charges. J Am Geriatr Soc 42:11–15, 1994
Longitudinal Study on Oral Health in Subjects with Alzheimer's Disease
Authors: Ship Jonathan A. , Puckett Scott A.
Published: April 2015

Objective: To examine longitudinal oral health changes in unmedicated, generally healthy subjects with Alzheimer's disease (AD) and compare them to age‐ and gender‐matched healthy, unmedicated control subjects.

Design: Oral health parameters were evaluated over 2 to 3 years and the results compared between subjects with AD and controls.

Setting: Clinical Center of the National Institutes of Health, Bethesda, Maryland.

Participants: Twenty‐one community‐dwelling subjects with a clinical diagnosis of AD and 21 age‐ and gender‐matched control subjects. Neither population was being treated for any other systemic condition nor taking any prescription medications.

Measurements: Unstimulated and stimulated major salivary gland flow rates were measured, and gingival, periodontal, dental, and oral mucosal tissues assessed.

Main Results: In general, subjects with AD demonstrated decreased salivary flow rates and diminished oral health, but most longitudinal changes in oral health status were not significantly different than controls.

Conclusions: Patients with AD are susceptible to a variety of oral health problems, and progression of AD can lead to a deterioration in oral health and function. These patients require aggressive preventive care to maintain function for as long as possible, which necessitates close cooperation among numerous health care professionals. J Am Geriatr Soc 42:57–63, 1994
Performance of Case‐Finding Tools for Depression in the Nursing Home: Influence of Clinical and Functional Characteristics and Selection of Optimal Threshold Scores
Authors: Gerety Meghan B. , Williams John W. , Mulrow Cynthia D. , Cornell John E. , Kadri Abdulhay A. , Rosenberg Jeff , Chiodo Laura K. , Long Marci
Published: April 2015

OBJECTIVE: To compare case‐finding tools for depression in the nursing home setting and to evaluate effects of subject function, cognition, and disease number on test performance.

DESIGN: Cross‐sectional survey.

SETTING: One academic and four community homes.

SUBJECTS: One hundred thirty‐four randomly selected, mildly cognitively impaired, functionally dependent residents.

METHODS AND MEASURES: The Geriatric Depression Scale (GDS), Short Geriatric Depression Scale (SGDS), Center for Epidemiologic Studies Depression Scale (CES‐D), and Brief Carrol Depression Rating Scale (BCDRS) were administered. The Structured Clinical Interview for DSM‐III‐R diagnoses was administered independently. Operating characteristics and the effects of subject characteristics on test performance were evaluated using McNemar's test and logistic regression. Selection of “optimal” threshold scores was guided by Kraemer's quality indices and clinical judgment.

RESULTS: Thirty‐five subjects (26%) had major depression. No differences were found among the instruments in sensitivity (range 0.74–0.89), specificity (range 0.62–0.77), or area under the receiver operating curve (ROC) (range 0.85–0.91). Resident characteristics did not affect test performance. Quality indices showed the GDS and BCDRS met criteria for moderate to substantial agreement with the criterion standard, whereas the SGDS and the CES‐D achieved only fair agreement. No change in threshold scores was warranted.

CONCLUSIONS: The GDS and BCDRS performed well in the nursing home. As the GDS can serve as a both a case‐finding and severity instrument, it is preferred. Use of brief, interviewer‐administered tools may improve detection of depression in the nursing home.
Physiological Factors Associated with Falls in Older Community‐Dwelling Women
Authors: Lord Stephen R. , Ward John A. , Williams Philippa , Anstey Kaarin J.
Published: April 2015

OBJECTIVE: To determine the prevalence of impaired vision, peripheral sensation, lower limb muscle strength, reaction time, and balance in a large community‐dwelling population of women aged 65 years and over, and to determine whether impaired performances in these tests are associated with falls.

DESIGN: One‐year prospective study.

SETTING: Conducted as part of the Randwick Falls and Fractures Study, in Sydney, Australia.

PARTICIPANTS: Four hundred fourteen women aged 65 to 99 years (mean age 73.7 years, SD = 6.3) were randomly selected from the community; 341 of these women were included in the 1‐year prospective study.

MAIN RESULTS: The prevalence of impairment in all tests increased with age. In the year following assessment, 207 subjects (60.7%) experienced no falls, 63 subjects (18.5%) fell one time only, and 71 subjects (20.8%) fell on two or more occasions. After controlling for age, multiple falling was associated with low contrast visual acuity and contrast sensitivity, poor vibration sense and proprioception, reduced lower limb strength, slow reaction time, and impaired balance, as indicated by four sway tests and two clinical stability measures. Discriminant function analysis identified visual contrast sensitivity, proprioception in the lower limbs, quadriceps strength, reaction time, and sway on a compliant (foam rubber) surface with the eyes open as the variables that significantly discriminated between subjects who experienced multiple falls and subjects who experienced no falls or one fall only (Wilks' lambda = 0.73 (P < 0.001), canonical correlation = 0.52). This procedure correctly classified 75% of subjects into multiple faller or nonmultiple faller groups.

CONCLUSIONS: These findings support previous results conducted in retirement village and institutional settings and indicate that the test procedure aids in the identification of older community‐dwelling women at risk of falls.
Incidence of Complications After Carotid Sinus Massage in Old er Patients with Syncope
Authors: Munro Neil C. , Mclntosh Shona , Lawson Joanna , Morleyf Chris A. , Sutton Richard , Kenny Rose Anne
Published: April 2015

OBJECTIVE: To review the incidence of neurological complications occurring after carotid sinus massage performed for diagnostic purposes.

DESIGN: Case review and comparison with previously published work.

SETTING: Syncope Clinic, Royal Victoria Infirmary, Newcastle‐upon‐Tyne, and Chelsea and Westminster Hospital, London.

PARTICIPANTS: Patients undergoing investigation of dizziness, syncope, or unexplained falls.

METHODS: Carotid sinus massage performed for 5 seconds in both supine and erect postures, both before and after atropine. Contraindications to carotid sinus massage were the presence of carotid bruits, recent myocardial or cerebral ischemia, or previous ventricular tachyarrhythmias.

RESULTS: Two cases of neurological complications were reported from a total of 500 patients (2000 massage episodes) investigated in one center, giving an incidence of 0.1%. Combining this data with another center performing investigations in a similar fashion, seven neurological complications arose from a total of 5000 massage episodes, an incidence of 0.14%. Reported complications were pyramidal signs in five cases and visual field defects in two. Pyramidal weakness persisted in one case with a pre‐existing stroke on the same side, and a visual field loss was permanent in one.

CONCLUSIONS: Neurological complications following carotid sinus massage for diagnosis of the carotid sinus syndrome are uncommon and usually transient. Contraindications to carotid sinus massage should be respected and the standardized technique used.
Urinary Incontinence Knowledge Among Community‐Dwelling People 65 Years of Age and Older
Authors: Branch Laurence G. , Walker Laura A. , Wetle Terrie T. , DuBeau Catherine E. , Resnick Neil M.
Published: April 2015

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE).

DESIGN: An intact‐group pretest—posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI.

PARTICIPANTS: A random sample of community‐dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140).

MEASUREMENT: A 14‐item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participant answers to the quiz were part of a 20‐minute telephone interview.

RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of “don't know” responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses.

CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.
Prostaglandin E1 as Treatment for Erectile Failure in Elderly Men
Authors: Godschalk Michael F. , Chen Juza , Katz P. Gary , Mulligan Thomas
Published: April 2015

OBJECTIVE: To determine the efficacy of intracavernosal injection of prostaglandin E1(alprostadil) in elderly men with erectile failure.

DESIGN: Prospective study.

SETTING: Outpatients at a university‐affiliated VA Medical Center.

PARTICIPANTS: Ten subjects aged 65 years and older with duration of erectile failure of 6 months or longer.

INTERVENTIONS: Subjects received intracavernosal injections of prostaglandin E1in the office and self‐administered intracavernosal prostaglandin E1at home.

MEASUREMENTS: Penile rigidity was measured by palpation and by the Rigiscan rigidity monitor.

RESULTS: Intracavernosal injection of prostaglandin E1produced erections adequate for intercourse in 9 of the 10 subjects. Attempts at intercourse were rated satisfactory by two‐thirds of the subjects and their spouses.

CONCLUSIONS: Intracavernosal injection of prostaglandin E1is safe and effective for erectile failure in elderly men.
The Neglected Half of Alzheimer Disease: Cognitive and Functional Concomitants of Severe Dementia
Authors: Auer Stefanie R. , Sclan Steven G. , Yaffee Robert A. , Reisberg Barry
Published: April 2015

OBJECTIVE: Traditional mental status and psychometric assessments bottom out in the late stages of Alzheimer disease (AD). A method adapted from cognitive testing in infants, the Ordinal Scales of Psychological Development was modified (M‐OSPD) and applied to a severely demented population. The concurrent validity of this method was tested in comparison with Functional Assessment Staging (FAST). Internal consistency as a measure for reliability was also determined.

DESIGN: Cross sectional study.

SETTING: Subjects were generally evaluated in their residence, usually a nursing home or a private home.

PATIENTS: Severely cognitively impaired subjects who fulfilled criteria for probable AD were studied.

MEASUREMENTS: Evaluation consisted of clinical global, mental status, functional, and cognitive assessments including the Global Deterioration Scale (GDS) and the Mini‐Mental State Examination (MMSE).

RESULTS: Seventy patients were evaluated. Traditional mental status assessments (eg, the MMSE) manifested virtually uniform bottom scores in all GDS stage 7 subjects (n = 46), and GDS stage 6 subjects had MMSE scores within one standard deviation unit of zero. In contrast, the M‐OSPD scale continued to show results in the last stages of the disease. The Spearman correlation coefficient between the M‐OSPD total score and the 11 FAST substages represented in this sample was −0.77 (P < 0.001).

CONCLUSIONS: The results indicate that patients who are functionally more impaired also show continuing increments in cognitive loss. These cognitive and functional assessments for measuring the magnitude of deterioration in AD can be applied to the estimated half‐million nursing home residents presently labeled “untestable” with the goal of optimization of care and residual capacities.
A Multi‐Center Analysis of the Use of Enalapril and Lisinopril in Elderly Hypertensive Patients
Authors: Hawkins David W. , Hall W. Dallas , Douglas Margaret B. , Cotsonis George
Published: April 2015

OBJECTIVE: To evaluate the clinical use and adverse effects of enalapril and lisinopril in elderly hypertensive subjects.

DESIGN: A multi‐center, retrospective, drug use evaluation survey.

SETTING: Ambulatory care clinics at 14 VA and 14 academic medical centers.

PATIENTS: 422 elderly (>60 years of age) patients with hypertension and no clinical evidence of congestive heart failure.

INTERVENTION: At least 3 consecutive months of anti‐hypertensive therapy with either enalapril or lisinopril.

MEASUREMENTS: Blood pressure, serum creatinine, serum potassium, concomitant disease states, concurrent medications, and documentation of any adverse event that might be related to ACE inhibitor therapy.

RESULTS: There were no significant differences in systolic and diastolic blood pressures, serum creatinine, or serum potassium between enalapril‐ and lisinopril‐treated patients at baseline and after 3 months of therapy. Both treatments resulted in a significant reduction in diastolic blood pressure. There was no significant difference in the incidence of adverse effects between the two treatments. Significantly more patients were dosed on a twice daily regimen of enalapril than lisinopril.

CONCLUSION: The data from this retrospective study confirm the safe and effective use of enalapril and lisinopril, two long‐acting ACE inhibitors, in elderly hypertensive patients.
Emergency Triage to Intensive Care: Can We Use Prognosis and Patient Preferences?
Authors: Hanson Laura C. , Danis Marion , Lazorick Suzanne
Published: April 2015

OBJECTIVE: To identify predictors of 6‐month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions.

DESIGN: Historical cohort

SETTING: A 600‐bed university hospital

PATIENTS: 263 consecutive patients triaged in the emergency room to receive intensive care

MEASUREMENTS AND MAIN RESULTS: Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6‐month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described.

Six‐month mortality was 19 percent, and increased with increasing APS, age ≤ 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P ≤ 0.01). In multivariate analysis, APS, age ≤ 80 and performance status were independent predictors of 6‐month mortality. Only APS predicted mortality in hospital.

The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%).

CONCLUSIONS: Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.
Long‐Term Urethral Catheterization Increases Risk of Chronic Pyelonephritis and Renal Inflammation
Authors: Warren John W. , Muncie Herbert L. , Hebel J. Richard , Hall‐Craggs Mary
Published: April 2015

OBJECTIVE: To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors.

DESIGN: Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy.

SETTING: A 240‐bed long‐term care facility.

PARTICIPANTS: All residents ≤ 65 years old who died and were autopsied during a 2‐year period.

MEASUREMENTS: Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti‐inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones.

RESULTS: The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized >90 days during their last year of life and zero (0/65) when catheterized ≤90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized >>90 days and 18 percent (12/65) when ≤90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension.

CONCLUSION: Chronic pyelonephritis and chronic renal inflammation are associated with long‐term catheterization.
Patterns of Predeath Service Use by Dementia Patients with a Family Caregiver
Authors: Collins Clare , Ogle Karen
Published: April 2015

OBJECTIVE: To describe site of death and patterns of predeath service use (hospital, nursing home, and in‐home services) among persons with dementia who have a family caregiver.

DESIGN: Family caregivers who experienced the death of their relative while participating in a 5‐year longitudinal study were surveyed retrospectively about service use patterns in the 90 days before the death of their relative.

SETTING: Community.

SUBJECTS: Eighty‐two family caregivers of a person with dementia who experienced the death of their relative while participating in a longitudinal study (n = 326) were included in this analysis. All participants were providing care to a relative with dementia in the home at entry into the study.

MAIN OUTCOME MEASURES: Survey items were used to identify site of death and measure use of the following services in the 90 days before death: hospital, nursing home, skilled nursing services, home health aides, and physician home visits.

RESULTS: Sixty‐nine percent of the caregivers were spouses, and 28% were adult children. Family caregivers had been providing care for an average of 6 years (SD = 3.9) before the death of their relative. The most frequent setting for patient death was home (42%), followed by nursing home (32%) and hospital (26%). The average number of days spent at home in the 90 days before death by the sample was more than 60 days. Thirty‐four percent of the dementia patients were cared for exclusively in the home in the 90 days before death, and 34% spent more than half of the 90 days before death at home. Hospital stays were brief, and less than one‐fourth of the sample spent all of the 90 days before death in an institutional setting. Twenty‐one percent of the sample used no in‐home services in the 90 days before death, 48% of the sample did not use skilled nursing services, and only 27% received a physician home visit.

CONCLUSIONS: The results of this study suggest that dementia patients who have a family caregiver receive a significant proportion of their care at home in the 90 days before death. A hospice approach may help address the needs for assistance of families who provide terminal care in the home for a relative with dementia.
Causes of Weight Loss in a Community Nursing Home
Authors: Morley John E. , Kraenzle Dale
Published: April 2015

Objective: To determine the causes of weight loss in nursing home residents.

Design: Retrospective chart review of all weights over the previous 6 months and an in‐depth examination of all residents who lost 5 or more pounds over that period.

Setting: A for‐profit community nursing home in an urban area.

Subjects: All residents who had been in the nursing home for 3 or more months. Their mean age was 80.1 years, and 89% were female.

Results: Weight loss of 5 pounds or more occurred in 19% of subjects. Only 15% of subjects had lost 5% of body weight, and 4% had lost more than 10% of their body weight. Depression accounted for 36% of the weight loss. Other causes of anorexia included medications, psychotropic drug reduction, swallowing disorders, paranoia, dementia with apraxia, gallstones, and obsessive‐compulsive disorder. Increased energy utilization as a cause of weight loss was seen in two residents who wandered incessantly, one with tardive dyskinesia and one with chronic obstructive pulmonary disease. Dehydration was the cause of weight loss in two residents, and one resident had intentional weight loss for obesity. Cancer was the cause of weight loss in two residents. Four of 30 residents had more than one cause of weight loss. One of 25 tube‐fed residents displayed weight loss.

Conclusions: A single cause of weight loss can be identified in most nursing home residents. Depression is the most common cause of weight loss. Psychotropic drug reduction may cause weight loss. The majority of causes of weight loss in a community nursing home are potentially treatable.
Caudal Epidural Blocks for Elderly Patients with Lumbar Canal Stenosis
Authors: Ciocon Jerry O. , Galindo‐Ciocon Daisy , Amaranath L. , Galindo Diana
Published: April 2015

Objective: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS).

Design: This study was a descriptive, prospective study with a 10‐month follow‐up.

Participants and Setting: Thirty patients, 76 ± 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone.

Measurements and Interventions: Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo‐Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5‐point pain rating scale was utilized before and at 2‐month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS.

Results: The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 ± 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 ± 0.82 to 1.5 ± 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001).

Conclusion: CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.
Fracture Risk in Patients with Alzheimer's Disease
Authors: Melton L. Joseph , Beard C. Mary , Kokmen Emre , Atkinson Elizabeth J. , O'Fallon W. Michael
Published: April 2015

Objective: To assess the risk of fracture following onset of Alzheimer's disease.

Design: Retrospective (historical) cohort study.

Setting: Population‐based in Rochester, Minnesota.

Participants: All 543 Rochester residents with onset of Alzheimer's disease during the 10‐year period, 1975–84, and an equal number of age‐ and sex‐matched controls from the community.

Measurements: Fractures were assessed through review of each subject's complete (inpatient and outpatient) medical records in the community.

Main Results: Rochester residents with Alzheimer's disease were no more likely to have a history of fracture prior to onset than were matched controls from the same population. During the year of onset, there was a 2‐fold excess of fractures at various sites among those with Alzheimer's disease. The risk ratio for any fracture subsequently was 1.1 (95% CI 0.9, 1.3), and this slight increase was accounted for entirely by a 2.7‐fold increase in the risk of hip fracture (95% CI 1.8, 4.2).

Conclusions: Fracture risk was not increased before the onset of Alzheimer's disease, although there was an excess of fractures around the time that Alzheimer's disease came to clinical attention. Fracture risk was not elevated thereafter except for a substantial increase in the risk of hip fracture. This suggests a link with certain falls rather than generalized disuse osteoporosis.
Voluntary Active Euthanasia and Physician‐Assisted Suicide in Dutch Nursing Homes: Are the Requirements for Prudent Practice Properly Met?
Authors: Muller M. T. , Van der Wal G. , van Eijk J. Th. M. , Ribbe M. W.
Published: April 2015

Objective: To acquire data about and an understanding of the way in which Dutch nursing home physicians (NHPs) who administer voluntary active euthanasia and/or physician‐assisted suicide (EAS) cope with the requirements for prudent practice. These requirements include: the patient must experience his or her suffering as unbearable and hopeless; the wish to die must be well considered and persistent; the request must be voluntary; the NHP must consult at least one other physician; the physician is not allowed to issue a certificate testifying to natural death and is obliged to keep records.

Design, Setting, Participants, Measurements: See preceding paper.

Results: Sixty‐nine NHPs (12%) indicated that they had administered EAS on at least one occasion. The state of the patient was described by the NHP as utterly hopeless in 88% of cases and as utterly unbearable in 64% of the cases. The period of time between the first discussion of the subject and the actual administration varied from less than a day to more than a year. The most frequently given reasons for the request were unbearable suffering (53%) and hopeless suffering (49%). The majority of the NHPs (85%) indicated that it was the patient who first broached the subject of EAS. Eighty‐five percent of the NHPs also requested a consultation with another physician. In the majority of cases this second opinion was given by another NHP (63%); over 50% of these NHPs worked in the same nursing home. Ninety‐one percent of the physicians consulted were convinced that the request was well considered, and 93% found that there was no alternative treatment available. The nurses involved were consulted informally: 94% were questioned about the request for EAS and 93% about the physician's intention to comply. Seventy‐five percent of the respondents said they had made some sort of written notes regarding the last time they had administered EAS. The number of certificates testifying to death by natural causes fell after 1988. In 41% of the cases all requirements were met.

Conclusion: The results of this study indicate that Dutch NHPs observe all the requirements for EAS in 41% of cases. In the remaining cases, shortcomings were found: NHPs allowed too little time between the first discussion and the actual administration; they did not always keep written records; or they signed a death certificate testifying that the patient had died a natural death.
Resident Training in Nursing Home Care: Survey of Successful Educational Strategies
Authors: Counsell Steven R. , Katz Paul R. , Karuza Jurgis , Sullivan Gail M.
Published: April 2015

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs.

DESIGN: A mail survey with three follow‐up mailings.

PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs.

MEASUREMENTS: Open‐ and closed‐ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested.

MAIN RESULTS: Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill‐based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended.

CONCLUSIONS: Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.
The Relationship between Disease and Function and Perceived Health in Very Frail Elders
Authors: Mulrow Cynthia D. , Gerety Meghan B. , Cornell John E. , Lawrence Valerie A. , Kanten Deanna N.
Published: April 2015

Objective: To study associations between disease and observed function and self‐perceived health in very frail elders.

Design and Setting: Cross‐sectional survey of nine nursing homes in San Antonio, TX.

Participants: 194 elderly long‐stay nursing home residents dependent in at least two ADLs and without severe cognitive impairment.

Measures: Burden of disease (BOD) was chart abstracted using a standardized protocol that assessed types and severities of 59 categorizations of chronic and acute medical conditions. Observed function and self‐perceived health status were assessed independently by the Katz Activities of Daily Living scale (ADL) and the Sickness Impact Profile (SIP), respectively.

Results: Summary BOD scores had a low, but statistically significant, univariate correlation with ADL scores (r = 0.21, P = 0.003) and no significant correlation with SIP scores (R = −0.008). Multiple linear regression analyses, including the 24 most frequent disease categories, showed that disease explained significant amounts of ADL (r2 = 0.25, P = 0.001) and borderline significant amounts of SIP (r2 = 0.16, P = 0.11). Models including both disease and sociodemographic, cognitive, and affective variables showed disease added significant incremental explanation beyond the other factors to ADL (incremental r2 = 0.14, P = 0.04), but not to SIP (incremental r2 = 0.08, P > 0.10).

Conclusions: Disease, observed function, and self‐perceived health status are separate, but interrelated entities, with disease having a stronger relationship to observed function than self‐perceived health. Comprehensive assessment of frail elders may need to include all three areas, and studies that focus on one area should take into account the other two as potential important covariates.
A Longitudinal Study of Risk Factors Associated with the Formation of Pressure Ulcers in Nursing Homes
Authors: Brandeis Gary H. , Ooi Wee Lock , Hossain Monir , Morris John N. , Lipsitz Lewis A.
Published: April 2015

Objective: To determine risk factors associated with the formation of stage II—IV pressure ulcers in nursing homes.

Design: Since the incidence rate for pressure ulcer formation varies among nursing homes, the homes were divided into tertiles based on these rates. Pooled logistic regression was used to model which factors are associated with the formation of pressure ulcers in both high and low incidence homes.

Setting: 78 National HealthCorp nursing homes.

Subjects: We studied 4232 nursing home residents free of pressure ulcers on admission to a nursing facility and at 3‐months follow‐up. All remained in the home for at least 3 additional months to a maximum of 21 months.

Measurements: The effects of age, gender, race, antipsychotic drug use, urinary incontinence, fecal incontinence, body mass index, diabetes mellitus, disorientation, ambulation, physical restraints, activities of daily living of bathing, feeding, or transferring, and nursing home bed size on the formation of a stage II—IV pressure ulcer while the subject was a resident in the nursing home were studied.

Main Results: Significant factors associated with the formation of pressure ulcers in high incidence homes (21‐month incidence = 19.3%) were ambulation difficulty (OR = 3.3; CI = 2.0, 5.3), fecal incontinence (OR = 2.5; CI = 1.6, 4.0), diabetes mellitus (OR = 1.7; CI = 1.2, 2.5), and difficulty feeding oneself (OR = 2.2; CI = 1.5, 3.3). In the low incidence homes (21‐month incidence = 6.5%), significant factors associated with pressure ulcer incidence were ambulation difficulty (OR = 3.6; CI = 1.7, 7.4), difficulty feeding oneself (OR = 3.5; CI = 2.0, 6.3), and male gender (OR = 1.9; CI = 1.2, 3.6).

Conclusions: Although low and high incidence homes share similar risk factors, such as ambulation and feeding activities of daily living, the main difference was that diabetes and fecal incontinence played a major role only in high risk homes, while male gender was an important discriminator only in low incidence homes. Yet, it is unclear if these factors explain the three‐fold difference in the incidence rates for pressure ulcers in these facilities. Baseline or resident clinical characteristic differences of any one factor between the high and low incidence homes varied by no more than 5%. While we identified certain conditions which are associated with pressure ulcer formation, there may be unknown or unmeasured facility effects in addition to the characteristics of a given resident in a particular home.
A Prospective Study of Dehydroepiandrosterone Sulfate and Cognitive Function in an Older Population: The Rancho Bernardo Study
Authors: Barrett‐Connor Elizabeth , Edelstein Sharon L.
Published: April 2015

Objective: To determine whether low plasma dehydroepiandrosterone sulfate (DHEAS) levels predict poor cognitive function in the elderly.

Design: A prospective, population‐based study with periodic clinical evaluations and 100% follow‐up for vital status.

Setting: Rancho Bernardo, California

Patients: 270 men and 167 women (80% of surviving, local, age‐eligible subjects) from the Rancho Bernardo cohort who had plasma obtained for DHEAS assays in 1972 to 1974 and screening for dementia in 1988 to 1991.

Measurements: DHEAS levels were measured by radioimmunoassay. There were five interviewer‐administered standard screening tests of cognitive function: Mini‐Mental Status Examination, Buschke selective reminding test, Trails B, category fluency, and Heaton Visual Reproduction test.

Results: DHEAS levels were higher in men than women and decreased with age in both sexes. There were no significant differences in age‐adjusted DHEAS levels in the percent of men or women with categorically impaired performance on any test. When analyzed as a continuous variable, DHEAS levels were significantly correlated with only one test, the Bushke, and only in women. Low baseline DHEAS levels were not associated with any mention of dementia on death certificates or with non‐participation of survivors. Low levels of DHEAS predicted mortality in men more than in women such that men were more likely to have died before cognitive function testing than women.

Conclusion: The single DHEAS‐memory association, restricted to women, is most likely to be spurious, consequent to multiple comparisons. We cannot exclude a true effect of low DHEAS, restricted to women and reflecting their better survival than men.
Hematological and Biochemical Laboratory Values in Older Cardiovascular Health Study Participants
Authors: Robbins John , Wahl Patricia , Savage Peter , Enright Paul , Powe Neil , Lyles Mary
Published: April 2015

OBJECTIVE: To define reference hematologic and biochemical lab values in older individuals.

DESIGN: Randomly selected, age‐ and gender‐stratified participants.

SETTING: Visits by participants to four research clinics.

PATIENTS: A total of 5201 participants in the Cardiovascular Health Study, an observational study of older Medicare‐eligible individuals living at home.

MEASUREMENT: Information about health status, previous illness, and medication use was obtained from participants and/or their MDs. This information was used to define a healthy subset of the population. Blood samples were obtained for Cholesterol, HDL and LDL cholesterol, fasting and 2‐hour postload glucose and insulin, fibrinogen, factors VII and VIII, potassium, creatinine, albumin, uric acid, white blood count, hematocrit, hemoglobin, and platelet count.

RESULTS: Significant differences were found for age group and/or gender for all mean values. Many tests were significantly different from the generally accepted reference ranges used in clinical laboratories.

CONCLUSIONS: In some situations accepted laboratory norms for the general population can not be extrapolated to older adults. There are implications for both research and clinical practice. J Am Geriatr Soc 43:855–859, 1995.
Occult Caffeine as a Source of Sleep Problems in an Older Population
Authors: Brown S. Lori , Salive Marcel E. , Pahor Marco , Foley Daniel J. , Corti M. Chiara , Langlois Jean A. , Wallace Robert B. , Harris Tamara B.
Published: April 2015

OBJECTIVE: To evaluate the impact of caffeine in medication on sleep complaints in a community population of persons aged 67 or older.

DESIGN: Cross‐sectional analysis.

SETTING: Iowa 65+ Rural Health Study

PARTICIPANTS: Those who completed their own interview, including a section on the use of medications, during the third annual in‐person follow‐up in 1984–1985.

MEASUREMENTS: Main outcomes: trouble falling asleep or other sleep complaints. Covariates: use of caffeine‐containing medication, spasmolytic, or sympathomimetic drug; number of drugs used; depressive symptoms; self‐perceived health; comorbidity, hip fracture, arthritis, ulcer of stomach or intestines; and consumption of caffeinated beverages.

RESULTS: The prevalence of caffeinated medication use by participants was 5.4%. Those reporting the use of any caffeine‐containing medication were at an increased risk of having trouble falling asleep (Odds Ratio [OR] = 1.79, 95% confidence interval [CI] = 1.19–2.68). There was no significant risk of other reported nighttime or daytime sleep problems associated with use of caffeine‐containing drugs. Even after adjusting for other factors that could interfere with initiation of sleep, such as painful disease, depressive symptoms, polypharmacy, use of specific medications known to interfere with sleep, and coffee consumption, the use of caffeine‐ containing medication still presented a significantly increased risk of having trouble falling asleep (OR = 1.60, CI = 1.04–2.46). Although those participants using over‐the‐counter analgesic medication containing caffeine had an increased risk of trouble falling asleep (OR = 1.88, CI = 1.22–2.90), there was no significant risk of trouble falling asleep for those who took similar noncaffeinated OTC analgesic drugs (OR = 1.26, CI = 0.87–1.83).

CONCLUSIONS: The use of caffeine‐containing medication is associated with sleep problems. Healthcare providers