bluuebunny/crossref_metadata_2025 huggingface dataset:
Infectious disease outbreaks and increased complexity of care
Authors: Musau J. , Baumann A. , Kolotylo C. , O'Shea T. , Bialachowski A.
Published: April 2015

Aim

This study examined the effects of healthcare‐associated infectious disease outbreaks on nurses' work in a large acute care hospital in Ontario, Canada.

Background

The incidence of healthcare‐associated infections has increased. Previous research focuses on epidemiology, healthcare systems, and the economic burden of outbreaks. Few published studies focus on the impact of outbreaks on nurses' work in acute care facilities.

Introduction

Since the severe acute respiratory syndrome epidemic in 2003, combating infectious diseases has become a key issue. Hospitals have implemented measures related to healthcare‐associated infections. However, nurses experience challenges in preventing, controlling, and contending with outbreaks.

Methods

A retrospective exploratory case study approach was used. Data were collected over a 4‐month period in 2012. The incidence rates of site‐specific HAIs were analysed, and individual interviews were held with 23 bedside nurses and five nurse managers.

Findings

Five themes emerged from the interviews: comparison of healthcare‐associated infections outbreaks; the nature of nurses' work; impact of outbreaks on patient care; innovation and quality control in clinical practice; and increased and expanded IPAC measures. The incidence rates of methicillin‐resistant Staphylococcus aureus, Clostridium difficile and vancomycin‐resistant enterococci at the study site decreased, but remained above provincial benchmarks. Nurses experienced workload challenges, time pressures and psychological effects stemming from outbreaks and developed various innovations in response. Patient care was also affected.

Conclusion

Nurses' work has been impacted by healthcare‐associated infectious disease outbreaks. Nursing workloads should be quantified to facilitate the development of guidelines for optimum nurse–patient ratio during outbreaks.

Implications for Nursing and/or Health Policy

A strong evidence‐based policy framework is required to address healthcare‐associated infectious disease outbreaks. Infection prevention and control guidelines and procedures should be established provincially and nationally. An interdisciplinary approach is essential for the creation of comprehensive and innovative strategies. Nursing research has increased understanding of the implications of infectious diseases in hospitals. Building on the literature, findings from this study can be used to influence policies on the care of patients who have secondary infections. Nurse‐driven protocols are important and can lead to the creation of best practice guidelines that can be implemented across settings.
Gametogenesis and reproductive periodicity of the “biologically vulnerable” giant Caribbean sea anemone, Condylactis gigantea, in Florida
Authors: Sheridan Nancy E. , Fautin Daphne Gail , Garrett Matt J.
Published: April 2015

The giant Caribbean sea anemone, Condylactis gigantea, is an ecologically important member of the benthic community. It provides habitat for many species, including symbiotic cleaner shrimps, and is recognized by reef fishes as a cleaning station cue. Numbers of C. gigantea in Florida have recently declined, possibly due to deteriorating environmental conditions and increasing harvest pressure. A previous research finding indicating that C. gigantea spawns in the late spring has been questioned by fishers for the aquarium trade industry. We therefore examined specimens of C. gigantea collected monthly from October 2011 to September 2012 in the Florida Keys to characterize the reproductive cycle, also measuring several physical and chemical parameters of concurrently collected water samples. We ascertained that the anemone is gonochoric and has a 1:1 sex ratio. Within and between individuals, at the same time and place, spermatogenesis was synchronous, whereas oocyte development was asynchronous. Low‐level spawning occurred between October and April with a peak in May, in good agreement with earlier research. Water quality at both sites showed no discernible change over the study period. Conservation efforts directed at population management could benefit this anemone.
Age, Race, and Gender Variation in the Utilization of Coronary Artery Bypass Surgery and Angioplasty in SHEP
Authors: Bearden Donna , Allman Richard , McDonald Robert , Miller Stephen , Presse Sara , Petrovitch Helen ,   SHEP Cooperative Research Group
Published: April 2015

OBJECTIVE: To assess variability in the use of coronary artery bypass grafting (CABG) and percutaneous transluminal angioplasty (PTCA) in the Systolic Hypertension in the Elderly Program (SHEP) cohort with incident coronary heart disease (CHD) by age, sex, and race.

DESIGN: Retrospective analysis of a multicenter prospective cohort study.

PATIENTS: Among 4736 subjects initially enrolled in SHEP, there were 432 incident cases of CHD, excluding those patients who experienced rapid or sudden cardiac death.

SETTING: Community‐based ambulatory population in academic centers.

MAIN OUTCOME MEASURE: Incident cases of CHD who underwent CABG or PTCA.

RESULTS: Of those participants ≤ 60 and <75 years of age, 7.3% underwent PTCA, compared with 3.9% of those >75 years (P = 0.14). 15.4% of those lt75 underwent CABG surgery, compared with 7.8% of those 75 and older (P = 0.018). When both of these endpoints, CABG and PTCA, were combined, 22.4% of those lt75 underwent a procedure, while only 11.7% of the older cohort did (P = 0.005).

Twenty‐six percent of men underwent either CABG or PTCA, while only 9.1% of women did (P < 0.001). Of those <75 years of age, 31.1% of men and 12.3% of women underwent CABG or PTCA (P < 0.001). In the 75 and older age category, 19.5% of men underwent these interventions, compared with 5.9% of women (P = 0.005).

Active treatment group was significantly associated with decreased use of procedures in participants <75 year old with CHD. Race, activity limitations, number of comorbid conditions, education level, marital status, employment status, and social support were not significantly associated with CABG or PTCA use. When the variables studied were ntered into a logistic regression model, increased age and female sex remained independently associated with decreased CABG and PTCA use.

CONCLUSION: In the SHEP trial older patients and women, regardless of comorbid conditions, socioeconomic status, and social support, underwent less intensive cardiovascular interventions than did younger patients and men when they developed CHD.
The Application of Health Care Surrogate Laws to Older Populations: How Good a Match?
Authors: Hayley Deon Cox , Stern Roya , Stocking Carol , Sachs Greg A.
Published: April 2015

OBJECTIVE: The Health Care Surrogate Act (HCSA) in Illinois has been proposed as a model for state laws naming surrogate medical decision‐makers for those without advance directives (ADs). Our objective was to determine if the HCSA identifies the same surrogate as older persons would choose for themselves. If not, is the discrepancy between legally identified surrogate and preferred surrogate troublesome to respondents? Because it is documented that black Americans have a variety of family structures, some of which may not be reflected in the HCSA list, we also wished to determine if discrepancies between surrogates named by the law and those desired by patients are associated with black or white race.

DESIGN, SETTING AND PARTICIPANTS: A convenience sample of 144 patients aged 65 and older, without cognitive impairment, was interviewed at the geriatrics clinic of an academic medical center.

MAIN OUTCOME MEASURES: Respondents without ADs who had a different stated choice for surrogate medical decision‐maker than the surrogate defined by the Illinois HCSA, based on their existing family.

RESULTS: Twenty‐six percent of respondents without ADs chose a surrogate that differed from the surrogate defined by the HCSA. However, 67% of those with a different choice for surrogate than defined by law were not troubled by the discrepancy. The proportion of black subjects (25%) and white subjects (31%) who had surrogate discrepancies was not significantly different (P = .6).

CONCLUSION: Because the Illinois HCSA named surrogates who would be agreeable to the majority of our respondents, it appears that it may be a useful model for state surrogacy laws. J Am Geriatr Soc 44:185–188, 1996.
Seriously Ill Hospitalized Adults: Do We Spend Less on Older Patients?
Authors: Hamel Mary Beth , Phillips Russell S. , Teno Joan M. , Lynn Joanne , Galanos Anthony N. , Davis Roger B. , Connors Alfred F. , Oye Robert K. , Desbiens Norman , Reding Douglas J. , Goldman Lee ,   for the SUPPORT Investigators
Published: April 2015

OBJECTIVE

To determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age‐related differences in resource use are explained by patients' severity of illness and preferences for life‐extending care.

STUDY DESIGN

Prospective cohort study.

SETTING

Five geographically diverse academic acute care medical centers participating in the SUPPORT Project.

PATIENTS

A total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6‐month mortality of 50%.

MEASUREMENTS

Resource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs.

RESULTS

The median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $7161 lower, respectively. These differences persisted after further adjustment for patients' preferences for life‐extending care.

CONCLUSIONS

Compared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource‐intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life‐extending care.
Memory Complaints and Memory Impairment in Older Individuals
Authors: Jonker Cees , Launer Lenore J. , Hooijer Chris , Lindeboom Jaap
Published: April 2015

OBJECTIVE: To examine whether subjective memory complaints, measured with a series of four questions, are associated with performance on cognitive tests.

DESIGN: Cross‐sectional study of individuals, 65 to 85 years of age, who lived in the community of Amsterdam.

PARTICIPANTS: Individuals were selected randomly within 5‐year age strata from the patient lists of 30 general practitioners. Of the 4051 participants, 2537 nondepressed and nondemented respondents were included in the analysis.

MEASURES: Four categories of subjective memory complaints were developed on the basis of answers to questions about the presence or absence of memory complaints and memory‐related problems in daily functioning. Tests of cognitive function were derived from the subscales of the CAMCOG.

MAIN RESULTS: Individuals with complaints and memory‐related problems performed more poorly on tests of memory and memory‐related functions. This relationship was strengthened after adjusting for age, sex, and premorbid verbal intelligence, all of which were related to complaint status and to performance on cognitive tests.

CONCLUSION: Simple questions about memory function are related to memory performance in nondepressed, nondemented community‐dwelling older people. Subjective memory complaints may be a promising indicator of memory impairment that signals the need for follow‐up. J Am Geriatr Soc 44:44–49, 1996.
Differences in the Signs and Symptoms of Hyperthyroidism in Older and Younger Patients
Authors: Trivalle Christophe , Doucet Jean , Chassagne Philippe , Landrin Isabelle , Kadri Nadir , Menard Jean‐François , Bercoff Eric
Published: April 2015

OBJECTIVES: To determine if aging modifies the clinical presentation of hyperthyroidism and the signs of thyrotoxicosis in older people.

DESIGN: Prospective cohort study.

SETTING: A French university hospital.

SUBJECTS: Eighty‐four new patients with overt hyperthyroidism confirmed chemically between January 1992 and January 1993. Controls were 68 older euthyroid patients matched to the older hyperthyroid patients.

MEASUREMENTS: Comparison of 19 classical signs of hyperthyroidism between 34 older patients (≥70 years; mean age 80.2) and 50 younger patients (≤50 years; mean age 37.4). Older patients were also compared with controls (mean age 81.3).

RESULTS: Three signs were found in more than 50% of older patients: tachycardia, fatigue, and weight loss. Seven signs were found significantly less frequently in older patients (P < .001): hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, polydipsia, and increased appetite. Only anorexia (32% vs 4%) and atrial fibrillation (35% vs 2%) were more found frequently in older people (P < .001). A goiter was present in 94% of the younger and in 50% of the older patients (P < .001). The mean number of clinical signs found in the older subjects was significantly smaller than the number found in younger patients (6 vs 10.8; P < .001). Comparison with older controls showed three signs that were highly associated with thyrotoxicosis in older people: apathy (Odd ratio (OR): 14.8), tachycardia (OR: 11.2), and weight loss (OR: 8.7).

CONCLUSION: This study confirms the paucity of clinical signs of hyperthyroidism in older adults. These results suggest the necessity of routine screening for thyroid disease in this age group. J Am Geriatr Soc 44:50–53, 1996.
Frailty and Hospitalization of Long‐Term Stay Nursing Home Residents
Authors: Fried Terri R. , Mor Vincent
Published: April 2015

OBJECTIVE: To determine the relationship between characteristics of older, long‐term stay nursing home patients and hospitalization.

DESIGN: A cohort study.

SETTING: One hundred three proprietary nursing homes.

PARTICIPANTS: All residents of these nursing homes aged 65 or older admitted between January 1, 1991, and December 30, 1993, who had no transitions out of the nursing home during the first 6 months of their stay.

MEASUREMENTS AND MAIN RESULTS: Among the cohort of 3782 residents, 931 (25%) were hospitalized at least once during the second 6 months of their nursing home stay. In a logistic regression model, severe functional impairment (adjusted odds ratio (AOR) 1.20, 95% confidence interval (CI) 1.01, 1.43), worsening ADL self‐performance (AOR 1.22, 95% CI 1.04, 1.43), presence of a decubitus ulcer (AOR 1.62, 95% CI 1.17, 2.24), presence of a feeding tube (AOR 2.03, 95% CI 1.54, 2.67), primary diagnosis of congestive heart failure (AOR 1.61, 95% CI 1.11, 2.34), and primary diagnosis of respiratory disease (AOR 1.77, 95% CI 1.24, 2.54) were associated with hospitalization. No form of advance directive was associated with a lower rate of hospitalization.

CONCLUSIONS: Physically frail patients, who may be the least likely to benefit from hospitalization, are the most likely to be hospitalized. The lack of an association between “Do‐not‐hospitalize” orders and lower rates of hospitalization suggests that there are substantial barriers to providing acute care in the nursing home. The association between recent functional decline, primary diagnoses of congestive heart failure and respiratory disease, and hospitalization indicates, however, that certain patient groups may be targeted successfully to reduce hospitalization rates.
National Trends in the Initial Hospitalization for Heart Failure
Authors: Croft Janet B. , Giles Wayne H. , Pollard Robert A. , Casper Michele L. , Anda Robert F. , Livengood John R.
Published: April 2015

OBJECTIVES: Heart failure is a major health care burden among older adults, but information on recent trends has not been available. We compare rates, sociodemographic characteristics, and discharge outcomes of the initial hospitalization for heart failure in the Medicare populations of 1986 and 1993.

DESIGN: Information reported on the Medicare hospital claims record during initial hospitalization for heart failure was compared for patients aged 65 and older hospitalized in 1986 (N = 631,306) and those aged 65 and older hospitalized in 1993 (N = 803,506).

RESULTS: Age‐standardized hospitalization rates (per 1000 person‐years) for any diagnosis of heart failure were higher in 1993 than in 1986 (white: 24.6 vs 22.4, black: 26.1 vs 22.4, respectively). Age‐specific results suggested an earlier onset of heart failure in black adults. In 1993, compared with 1986, higher proportions of heart failure patients were discharged to another care facility (white: 23.9% vs 16.8%, black: 17.6% vs 10.5%, respectively) or to health service care at home (white: 11.3% vs 6.0%, black: 12.4% vs 6.5%, respectively). In contrast, in‐hospital mortality was lower in 1993 than in 1986 (white: 10.4% vs 13.3%, black: 8.9% vs 11.1%, respectively).

CONCLUSION: The increased numbers of hospitalizations for heart failure and the likelihood that these patients will require advanced nursing care after discharge have important implications for future national health care expenditures and resources.
Depression and Mortality in Medically Ill Older Adults
Authors: Ganzini Linda , Smith David M. , Fenn Darien S. , Lee Melinda A.
Published: April 2015

OBJECTIVE: To determine if major depressive disorder influences the survival of older, medically ill veterans.

DESIGN: Thirty month follow‐up of an inception cohort.

SETTING: An academically‐affiliated Veterans Affairs Medical Center.

PARTICIPANTS: One hundred veterans, half of whom have a depressive disorder, recruited from inpatient medical and surgical units in 1990–1991. At initial evaluation all participants were older than age 65, cognitively intact, and medically but not terminally ill.

MEASUREMENTS: Severity of medical illness, functional status, social support and presence of depression were measured at initial evaluation, presence of depression was measured 4 to 6 months after initial evaluation, and survival status was determined at 30 months. Retrospective medical record review was used to determine if patients received depression treatment and to explore whether depressed persons received life‐sustaining medical treatment less often than nondepressed persons.

RESULTS: At 30 months, 36 of the 100 subjects had died. Only two factors predicted mortality: severity of medical illness and depression. The survival of subjects who had recovered from depression at 4 to 6 months was intermediate to never depressed and continuously depressed subjects. Somatic treatment of depression did not alter outcome. There was no significant difference between depressed and nondepressed in how often life‐sustaining medical treatments were withheld or withdrawn.

CONCLUSION: Presence of major depression in medically‐ill older hospitalized veterans continues to be a risk factor for death 30 months after diagnosis.
Questionable Dementia: Clinical Course and Predictors of Outcome
Authors: Devanand D.P. , Folz Mara , Gorlyn Marianne , Moeller James R. , Stern Yaakov
Published: April 2015

OBJECTIVE: To evaluate the clinical course and predictors of outcome in outpatients with cognitive impairment who do not meet criteria for dementia at initial evaluation.

DESIGN: Naturalistic longitudinal study.

METHODS: Cognitively impaired patients in a memory disorders clinic who fell between the “normal” and “dementia” categories were defined broadly as “questionable dementia” (QD). Of 127 consecutive QD patients, 75 were followed for a minimum of 1 year (mean 2.5 years, SD 1.7). Baseline neuropsychological testing was conducted in 62 of these 75 QD patients.

RESULTS:: At the final follow‐up time‐point, 41.3% met diagnostic criteria for dementia (27 of 31 patients with dementia had possible or probable Alzheimer's Disease, AD), 44% were rated as not demented, and 14.7% remained as “uncertain” dementia. Increased age was associated with the final diagnosis of dementia, but duration of follow‐up, Clinical Dementia Rating, and modified Mini Mental State (mMMS) scores were not predictive. Low scores on the mMMS delayed recall subtest, consistent long‐term retrieval on the Selective Reminding Test, category naming for animals, and the WAIS‐R digit symbol, picture arrangement, and block design subtests were predictive of the final diagnosis of dementia (all P ≤.01). mMMS delayed recall showed 66.7% sensitivity and 71.4% specificity, the other five neuropsychological subtests together showed 66.7% sensitivity and 66.7% specificity, and the six tests together showed 81% sensitivity and 76.9% specificity. Similar predictive accuracy was obtained for the final diagnosis of AD.

CONCLUSIONS: In QD patients, poor performance on the mMMS delayed recall item may be a useful predictor of the diagnosis of dementia (and AD) on follow‐up. Combining a screening instrument like the mMMS with specific neuropsychological tests may provide good predictive accuracy. In QD patients, the observed heterogeneity in diagnostic outcome, with most patients in the “dementia” and “no dementia” categories at follow‐up, enhances the feasibility of evaluating early markers with predictive accuracy for dementia and AD.
HM‐PAO (CERETEC) SPECT Brain Scanning in the Diagnosis of Alzheimer's Disease
Authors: Bergman H. , Chertkow H. , Wolfson C. , Stern J. , Rush C. , Whitehead V. , Dixon R.
Published: April 2015

OBJECTIVE: To evaluate the accuracy of Single Photon Emission Computed Tomography (SPECT) scanning in the diagnosis of Alzheimer's Disease (AD) and its capacity to improve the diagnostic accuracy of conventional clinical evaluation.

DESIGN: Comparison of SPECT scanning of AD and normal subjects with the criterion standard of clinical diagnosis confirmed by 1‐year repeated evaluation.

SETTING: A memory clinic in a tertiary care university hospital.

PATIENTS: One hundred twenty patients were evaluated upon entering the Jewish General Hospital (McGill University) Memory Clinic. Fifty‐eight patients were diagnosed as having AD and 17 as having vascular dementia. Twenty unmatched controls (recruited mainly through newspaper advertisements) were normal, and 25 had cognitive impairment without dementia (not included in the statistical analysis).

MAIN OUTCOME MEASURES: Comparison of visual inspection of SPECT, based on the system of classification developed by Holman et al., using B pattern alone as positive or B (bilateral posterior temporal and/or parietal cortex deficits) or C (bilateral posterior temporal and/or parietal deficits with additional defects) pattern and B or C or D (unilateral posterior temporal and/or parietal defects with or without additional defects) as positive compared with clinical diagnosis after repeated evaluations. Sensitivity and specificity, as well as positive predictive value (PPV) and negative predictive value (NPV) based on the prevalence of AD in a memory clinic setting of 30% or 50%, were calculated.

RESULTS: With B pattern as positive, the sensitivity of SPECT was 21% whereas the specificity was 80%. With B or C as positive, the sensitivity was 29% and the specificity was 75%. With B or C or D as positive, the sensitivity was 55% and the specificity was 65%. With a 30% prevalence, the PPV with B pattern as positive was 31% whereas the NPV was 30%. The PPV with B or C as positive was 33% while the NPV was 29%, and the PPV with B or C or D as positive was 40% whereas the NPV was 23%. With a 50% prevalence, the PPV with B pattern as positive was 51% and the NPV 49.6%; the PPV with B or C as positive was 54% and the NPV 48.6%; the PPV with B or C or D as positive was 61% while NPV was 41%.

CONCLUSION: The sensitivity and specificity were too low for SPECT to be useful as a diagnostic test for AD. The poor positive and negative predictive values in our tertiary care clinic mean that SPECT is not useful in “ruling‐in” or “ruling‐out” AD in that setting. In fact, clinical evaluation is more accurate.
Implementation of the Patient Self‐Determination Act (PSDA) in Nursing Homes in New York City
Authors: Mezey Mathy , Mitty Ethel , Rappaport Michael , Ramsey Gloria
Published: April 2015

OBJECTIVE: To examine implementation of the Patient Self Determination Act (PSDA), verbal directives, procedures for determination of resident' decision‐making capacity, and role of ethics committees in nursing homes in New York City.

DESIGN: Telephone survey.

PARTICIPANTS: Social workers in 109 (69%) nursing homes in New York City.

MEASUREMENT: An 80‐item instrument addressing: (1) social worker knowledge of the PSDA; (2) informing residents about advance directives (living wills and durable power of attorney for health care [health care proxies]); (3) determination of decision‐making capacity to be informed about advance directives; (4) estimates of advance directives executed; (5) perceptions of PSDA effect; (6) ethics committees; (7) follow‐up and documentation; and (8) staff and community education.

MAIN RESULTS: Virtually all social workers in nursing homes stated that they made what they perceived to be a “serious effort” to inform residents about advance directives and to have residents execute directives (preferentially a health care proxy). More residents were thought to have executed a directive pursuant to the PSDA law than before the Act went into effect. Social workers in most homes informed residents about directives through face‐to‐face discussions. Most homes, however, did not inform residents who were thought to lack decision‐making capacity about their right to execute a directive. Only 37% of homes had written procedures to determine a resident's decision‐making capacity to be informed about directives; most homes relied on physician and social work assessments. Voluntary homes differed significantly from proprietary homes in that they were larger, more likely to have an ethics committee, and more aggressive in their implementation of the PSDA. Forty‐five percent of homes with an ethics committee had written procedures for determination of resident decision‐making capacity compared with 26% of homes without a committee. Overall, 24% of residents were thought to have executed an advance directive. The number of directives per bed did not vary significantly by facility size, ownership, religious affiliation, or whether they did or did not have an ethics committee.

CONCLUSIONS: The fact that social workers in nursing homes speak with most residents about advance directives has the potential to improve resident understanding around end of life decisions. The practice of not informing residents about advance directives when they are perceived to lack decision‐making capacity is problematic given that most homes have no clear procedures for determining residents' cognitive capacity to execute a directive. There is a need to replicate the benefits achieved by homes with ethics committees in implementing the PSDA in other homes.
Sexual Violence, Post‐traumatic Stress Disorder and Dementia
Authors: McCartney James R. , Severson Karen
Published: April 2015

Little is known of Post‐Traumatic Stress Disorder (PTSD) in older people. No literature exists on this disorder in older women exposed to sexual assault. A case of apparent PTSD in a demented woman raises questions of the anatomy and phenomenology of this disorder. Difficulties in diagnosis in a demented population may cloud the issues or prevent a proper therapeutic outcome.
Assessing Capacity to Participate in Discussions of Advance Directives in Nursing Homes: Findings from a Study of the Patient Self Determination Act
Authors: Bradley Elizabeth , Walker Leslie , Blechner Barbara , Wetle Terrie
Published: April 2015

OBJECTIVE: To better understand the implementation of the Patient Self‐Determination Act (PSDA) in long‐term care, with a focus on the informing process as it affects advance directives.

DESIGN: Retrospective cohort study of nursing home admissions, using medical record reviews, and a companion qualitative survey using key informant interviews.

SETTING: Eleven nursing homes in Connecticut.

PARTICIPANTS: A total of 600 residents randomly selected from six randomly chosen nursing homes and 19 key informants selected from five purposely sampled nursing homes in Connecticut.

MEASURES: Institutional compliance with the PSDA requirement to provide written information about advance directives at admission and aspects of the informing process, including to whom the information is given.

RESULTS: Compliance with the PSDA requirement to provide information at admission is high (90.7 of admissions in the post‐PSDA cohort received information within 1 week of admission). However, in nearly 70% of admissions in which information was provided, someone other than the residents received the information. Staff often cited the resident's cognitive impairment as a reason for excluding residents from this informing process. However, even among those residents judged to be alert and oriented at admission, someone other than the resident received the information 47.7% of the time.

CONCLUSIONS: Substantial numbers of residents may be inappropriately excluded from participating in discussions because of difficulties in determining decisional capacity to discuss future treatment wishes. The research highlights the difficulties of enhancing resident participation and autonomy in long‐term care through procedural regulations such as the PSDA. More reliable methods of determining resident decisional capacity are needed to integrate the full intent of the PSDA into clinical practice in long‐term care.
Disability in Older Adults: Evidence Regarding Significance, Etiology, and Risk
Authors: Fried Linda P. , Guralnik Jack M.
Published: April 2015

OBJECTIVES: This article synthesizes and assesses current evidence about the importance of physical disability to older adults. It then considers the applications of research findings to clinical geriatrics practice.

RESULTS: Physical disability is a major adverse health outcome associated with aging. Certain subgroups of older adults, including individuals with mobility difficulty, with preclinical functional changes, and persons who are hospitalized, are at particularly high risk of becoming disabled or experiencing disability progression. The major underlying causes of physical disability are chronic diseases, including both acute events, such as hip fracture and stroke and slowly progressive diseases such as arthritis and heart disease. These diseases appear to have task‐specific effects; understanding this may assist in setting treatment and prevention goals. Comorbidity, particularly certain combinations of chronic diseases, is a strong risk factor for disability in itself. Recent trials indicate that clinical interventions may be able to prevent onset or progression of disability.

CONCLUSIONS: Available evidence now suggests clinical approaches to both treatment and prevention of disability and directions for defining optimal clinical care for the future.
Correlates of Kyphosis in Older Women
Authors: Ensrud Kristine E. , Black Dennis M. , Harris Fran , Ettinger Bruce , Cummings Steven R. ,   For the Fracture Intervention Trial Research Group
Published: April 2015

OBJECTIVE: To determine the association between kyphosis (degree of forward curvature of the thoracic spine) and measures of spinal osteoporosis (height loss and vertebral fractures) and chronic back pain and disability in older women.

DESIGN: A cross‐sectional study.

SETTING: Eleven clinical centers in the United States.

PARTICIPANTS: A total of 6439 community‐dwelling osteoporotic women aged 55–80 enrolled in the Fracture Intervention Trial (FIT), a multicenter clinical trial of alendronate.

MEASUREMENTS: Thoracic curvature was measured at baseline using a Debreuner Kyphometer. Height loss was determined by subtracting current height measured with a Harpenden stadiometer from self‐reported height at age 25. Vertebral fractures were defined by morphometry and semiquantitative reading of lateral thoracic and lumbar spine radiographs, and chronic back pain and back‐related disability were assessed by questionnaire.

RESULTS: After adjustment for age, a 15° increase in kyphosis was associated with losing more than 4 cm of height (OR, 1.88; 95% CI, 1.79–2.03) and having a vertebral fracture (OR, 1.57; 95% CI, 1.46–1.69). Kyphosis was more strongly related to thoracic fractures than to lumbar fractures, and kyphosis was most prominent in women with multiple thoracic wedge fractures. Kyphosis was also associated with upper back pain (OR per 15° increase, 1.62; 95% CI 1.47–1.79) and middle back pain (OR per 15° increase, 1.24; 95% CI 1.12–1.36), but it was not related to lower back pain (OR per 15° increase, 0.98; 95% CI 0.90–1.05). Women with greater degrees of kyphosis were only slightly more likely to report back‐ related disability (OR per 15° increase, 1.18; 95% CI 1.03–1.35) and poorer health status (OR per 15° increase, 1.19; 95% CI 1.03–1.37).

CONCLUSIONS: Older women with greater degrees of kyphosis are likely to have other manifestations of spinal osteoporosis such as height loss and thoracic fractures and to suffer chronic upper and middle back pain. Measurement of kyphosis may be useful in assessing the severity of spinal osteoporosis.
Older Medicare Enrolees' Choices for Insured Services
Authors: Danis Marion , Biddle Andrea K. , Henderson Gail , Garrett Joanne M. , DeVellis Robert F.
Published: April 2015

OBJECTIVES: The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program.

DESIGN: A cross‐sectional survey using anonymous, in‐person interviews and an innovative instrument to elicit choices.

SETTING: General Internal Medicine outpatient clinic at a university teaching hospital.

PARTICIPANTS: One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995.

MEASUREMENTS: Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits.

RESULTS: Subjects of various educational and economic backgrounds were able to carry out the selection process with relative ease, and four‐fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made.

CONCLUSION: These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.
Clinical Correlates of Low Blood Pressure in Very Old People: The Importance of Cognitive Impairment
Authors: Guo Zhenchao , Viitanen Matti , Winblad Bengt
Published: April 2015

OBJECTIVE: To identify the medical conditions associated with low blood pressure in very old people.

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

SETTING: Two neighboring communities in Stockholm, Sweden.

SUBJECTS: Participants were 319 male and 1070 female participants, with the mean age of 85.0 years (SD = 5.8).

MEASUREMENTS: Blood pressure recording, pulse rate counting, and Mini‐Mental State Examination (MMSE) were conducted by trained nurses. Information on illness condition and activities of daily living (ADL) status was self‐reported or gathered from proxy respondents. The computerized inpatient register system was also used for collecting the data of illness condition. Systolic pressure less than 130 mm Hg and diastolic pressure less than 70 mm Hg were defined as low systolic and diastolic pressure, respectively. MMSE score less than 24 was considered to indicate cognitive impairment.

MAIN RESULTS: In multiple logistic regression analyses, low systolic pressure was related to slower pulse rate (≤60 per minute), heart failure, ADL limitation, and cognitive impairment, and low diastolic pressure was related to increasing age, slower pulse rate, cardiac dysrhythmia, ADL limitation, and cognitive impairment. People with diabetes mellitus were less likely to be in the low systolic pressure group. 34.9% of the prevalence of low systolic pressure, and 17.9% of the prevalence of low diastolic pressure was associated with cognitive impairment.

CONCLUSIONS: Low blood pressure in the very old may be associated with poor functional status, cardiac insufficiency and, more importantly, cognitive impairment. It would be expected that low blood pressure is associated with increased mortality in this age group.
The “Common Cold” in Frail Older Persons: Impact of Rhinovirus and Coronavirus in a Senior Daycare Center
Authors: Falsey Ann R. , McCann Robert M. , Hall William J. , Criddle Mary M. , Formica Maria A. , Wycoff Dennis , Kolassa John E.
Published: April 2015

OBJECTIVE: To evaluate the incidence and impact of rhino‐virus and Coronavirus infections in older persons attending daycare.

DESIGN: Prospective descriptive study.

SETTING: Three senior daycare centers in Rochester, New York.

PATIENTS: Frail older persons and staff members of the daycare centers who developed signs or symptoms of an acute respiratory illness

MEASUREMENTS: Demographic, medical, and physical findings were recorded on subjects at baseline and during respiratory illness. Nasopharyngeal specimens for viral culture as well as acute and convalescent sera for Coronavirus 229E enzyme immunoassay (EIA) were obtained for all illnesses.

RESULTS: During the 44 months of study, 352 older persons experienced 522 illnesses. Thirty‐five (7%) of 522 cultures were positive for rhinovirus and 37 (8%) of 451 serologies were positive for Coronavirus 229E infection. The clinical syndromes associated with rhinovirus and Coronavirus infection were similar and characterized by nasal congestion, cough, and constitutional symptoms. No patient died or was hospitalized, but approximately 50% had evidence of lower respiratory tract involvement. The average illness lasted 14 days. During the same period, 113 staff developed 338 respiratory illnesses. Eight percent were identified as Coronavirus and 9% as rhinovirus. Cough, sputum production, and constitutional symptoms were significantly more common among older persons.

CONCLUSIONS: Rhinovirus and Coronavirus 229E are common causes of moderately debilitating acute respiratory illnesses among older persons attending daycare.
The Relation Between Antioxidants and Memory Performance in the Old and Very Old
Authors: Perrig Walter J. , Perrig Pasqualina , Stähelin Hannes B.
Published: April 2015

OBJECTIVES: Aging processes, and among them brain aging, are thought to be associated with free radical action. It is hypothesized that plasma antioxidant vitamin levels correlate with cognitive performance in healthy older subjects.

DESIGN: Longitudinal and cross‐sectional comparisons.

SETTING: The city of Basle, considered representative of the older urban population in Switzerland.

PARTICIPANTS: A total of 442 subjects aged 65 to 94 years (mean: 75 years; 312 male, 132 female) was selected from a random sample.

MEASUREMENTS: In 1993, participants were tested for memory, and plasma vitamin levels were measured for the three antioxidants α‐tocopherol, ascorbic acid, and β‐caro‐tene. These vitamin parameters, measured previously in 1971 in the same sample, were integrated in our analyses. In addition, plasma cholesterol, ferritin, and systolic blood pressure were taken into account. Memory variables were priming, working‐memory, free recall, recognition and the WAIS‐R vocabulary test (semantic memory).

RESULTS: Correlations showed significant stability of the plasma antioxidants over the time lag of 22 years (a‐tocopherol: r = .47, P ≥ .001; β‐carotene: r = .43, P < .001; ascorbic acid: r = .22, P < .001). Free recall, recognition, and vocabulary (but not priming and working‐memory) correlated significantly with ascorbic acid and β‐carotene in the cross‐sectional 1993 data as well as in the longitudinal 1971–1993 analysis. These two antioxidants remained significant predictors, especially of semantic memory, after controlling for possible confounding variables like age, education, and gender using multiple regression analyses and ANOVAs.

CONCLUSION: Among people aged 65 and older, higher ascorbic acid and β‐carotene plasma level are associated with better memory performance. These results indicate the important role played by antioxidants in brain aging and may have implications for prevention of progressive cognitive impairments.
One‐Leg Balance Is an Important Predictor of Injurious Falls in Older Persons
Authors: Vellas Bruno J. , Wayne Sharon J. , Romero Linda , Baumgartner Richard N. , Rubenstein Laurence Z. , Garry Philip J.
Published: April 2015

OBJECTIVE: To test the hypothesis that one‐leg balance is a significant predictor of falls and injurious falls.

DESIGN: Analysis of data from a longitudinal cohort study.

SUBJECTS: Healthy, community‐living volunteers older than age 60 enrolled in the Albuquerque Falls Study and followed for 3 years (N = 316; mean age 73 years).

MAIN OUTCOME MEASURES: Falls and injurious falls detected via reports every other month.

INDEPENDENT VARIABLES: Baseline measures of demographics, history, physical examination, Iowa Self Assessment Inventory, balance and gait assesessment, and one‐leg balance (ability to stand unassisted for 5 seconds on one leg).

RESULTS: At baseline, 84.5% of subjects could perform one‐leg balance. (Impairment was associated with older age and gait abnormalities.) Over the 3‐year follow‐up, 71% experienced a fall and 22% an injurious fall. The only independent significant predictor of all falls using logistic regression was age greater than 73. However, impaired one‐leg balance was the only significant independent predictor of injurious falls (relative risk: 2.13; 95% CI: 1.04, 4.34; P = .03).

CONCLUSION: One‐leg balance appears to be a significant and easy‐to‐administer predictor of injurious falls, but not of all falls. In our study, it was the strongest individual predictor. However, no single factor seems to be accurate enough to be relied on as a sole predictor of fall risk or fall injury risk because so many diverse factors are involved in falling.
Chronic Medical Conditions and Risk of Fall Injury Events at Home in Older Adults
Authors: Herndon James G. , Helmick Charles G. , Sattin Richard W. , Stevens Judy A. , DeVito Carolee , Wingo Phyllis A.
Published: April 2015

OBJECTIVE: To evaluate the association between selected chronic medical conditions (CMCs) and fall injury events at home among community‐dwelling older persons.

DESIGN: Population‐based case‐control study.

SETTING: The general community.

PARTICIPANTS: Persons aged 65 and older living at home, excluding those using a wheelchair; 467 cases and 691 control subjects were studied.

MEASUREMENTS: The main independent variables were self‐reported histories of 10 CMCs: diabetes, high blood pressure, anemia, heart attack, Parkinson's disease, stroke, emphysema, cancer (other than skin), cataracts, and glaucoma.

RESULTS: The final multivariate model included variables for age, sex, body mass, dependency in activities of daily living, current exercise (three or more times per week), mental status scores, and three CMCs. Persons with a history of stroke or anemia had an increased risk of a fall injury event: for stroke the adjusted odds ratio (aOR) equalled 1.7 (95% confidence interval (CI), 1.0–3.0); for anemia the aOR equalled 1.5 (95% CI, 1.0–2.2). Those with a history of high blood pressure had decreased risk (aOR = .7, 95% CI 0.5–0.9).

CONCLUSIONS: Persons 65 and older with a self‐reported history of anemia or stroke are at increased risk of a fall injury event in the home, whereas those with a self‐reported history of high blood pressure are at decreased risk.
Surrogate and Physician Understanding of Patients' Preferences for Living Permanently in a Nursing Home
Authors: Mattimore Thomas J. , Wenger Neil S. , Desbiens Norman A. , Teno Joan M. , Hamel Mary Beth , Liu Honghu , Califf Robert , Connors Alfred F. , Lynn Joanne , Oye Robert K.
Published: April 2015

OBJECTIVE: To evaluate patients' willingness to live permanently in a nursing home and surrogate and physician understanding of that preference.

DESIGN: Evaluation of cross‐sectional interview data from a cohort study.

SETTING: Five academic medical centers.

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

MEASUREMENTS: Patients' willingness to live permanently in a nursing home was measured on a 5‐point scale ranging from “very willing” to “rather die.” Ordinal logistic regression was used to identify patient demographic and clinical characteristics associated with this preference. Surrogate and physician perceptions of patient preferences were compared with patients' responses, and factors associated independently with surrogate and physician understanding of patient preference were identified.

RESULTS: Of 9105 patients, 3262 (36%) provided responses to the study question: 7% were “very willing” to live permanently in a nursing home, 19% “somewhat willing,” 11% “somewhat unwilling,” 26% “very unwilling,” and 30% would “rather die.” Older age was associated independently with less willingness to live permanently in a nursing home (odds ratio [OR]= .90 per decade; 95% confidence interval [CI]: 0.85, 0.96). Patients with more education (OR = 1.03 per year; 95% CI:1.00,1.05) and more disabilities (OR = 1.05 per disability; 95% CI:1.01,1.09), and black patients (OR = 1.46 compared with white patients; 95% 0:1.20,1.76) were more willing to live in a nursing home. Surrogates understood 61% of patients' nursing home preferences but identified only 35% of patients who were willing to live permanently in a nursing home. Physicians identified 18% of patients willing to live permanently in a nursing home.

CONCLUSION: Patient attitudes about living permanently in a nursing home can be elicited, cannot be reliably predicted from demographic and clinical variables, and are frequently misunderstood by surrogates and physicians. Elicitation of patient preferences regarding permanent nursing home placement should be explored before patients become unable to participate in decision making in order to enhance the concordance of patient preference with the way they spend the end of their lives.