bluuebunny/crossref_metadata_2025 huggingface dataset:
Program of All‐inclusive Care for the Elderly (PACE): An Innovative Model of Integrated Geriatric Care and Financing
Authors: Eng Catherine , Pedulla James , Eleazer G. Paul , McCann Robert , Fox Norris
Published: April 2015

OBJECTIVES: The Program of All‐inclusive Care for the Elderly (PACE) is a long‐term care delivery and financing innovation. A major goal of PACE is prevention of unnecessary use of hospital and nursing home care.

SETTING: PACE serves enrollees in day centers and clinics, their homes, hospitals and nursing homes. Beginning at On Lok in San Francisco, the PACE model has been successfully replicated across the country. In 1995, PACE was fully operational in 11 cities in nine states.

PARTICIPANTS: To enroll in PACE, a person must be 55 years of age or older, be certified by the state as eligible for care in a nursing home and live in the program's defined geographical catchment area. PACE participants are ethnically diverse. In 1995, the average PACE enrollee was 80.0 years old and had an average of 7.8 medical conditions and 2.7 dependencies in Activities of Daily Living. A significant number have bladder incontinence (55%). Many enrollees (39%) live alone in the community, and 14% have no means of informal support.

INTERVENTION: Medicare and Medicaid waivers allow delivery of services beyond the usual Medicare and Medicaid benefits. The PACE service delivery system is comprehensive, uses an interdisciplinary team for care management, and integrates primary and specialty medical care. PACE receives monthly capitation payments from Medicare and Medicaid. Patients ineligible for Medicaid pay privately.

RESULTS: Outcomes of PACE programs have been positive. There has been steady census growth, good consumer satisfaction, reduction in use of institutional care, controlled utilization of medical services, and cost savings to public and private payers of care, including Medicare and Medicaid.

CONCLUSION: The growing number of older people in the United States challenges healthcare providers and policy makers alike to provide high quality care in an environment of shrinking resources. The PACE model's comprehensiveness of health and social services, its cost‐effective coordinated system of care delivery, and its method of integrated financing have wide applicability and appeal.
Elevated Fasting Plasma Insulin in a General Aged Population: An Innocent Companion of Cardiovascular Diseases
Authors: Lindberg Otto , Tilvis Reijo S. , Strandberg Timo E. , Valvanne Jaakko , Sairanen Sirpa , Ehnholm Christian , Tuomilehto Jaakko
Published: April 2015

OBJECTIVE: Although high insulin levels have been linked to cardiovascular disease, the role of insulin as an independent risk factor has been questioned. Our objective was to examine the association of fasting plasma insulin with cardiovascular disease as well as to investigate the prognostic value of insulin with respect to survival.

DESIGN: A 5‐year follow‐up of random samples from four birth cohorts aged 65 (n = 660), 75 (n = 194), 80 (n = 179), and 85 (n = 162) years at baseline.

SETTING: Two urban communities in southern Finland.

MEASUREMENTS: Clinical and laboratory investigation at base line with collection of date and cause of death information during follow‐up.

RESULTS: Subjects with cardiovascular disease generally had higher levels of fasting plasma insulin than did subjects without cardiovascular disease (13.9 mU/L vs 11.2 mU/L, P < .001). Heart failure and hypertension were associated with significant 30 to 80% elevations of insulin levels in all but the oldest group. In the 65‐year‐old group, all vascular diseases were associated with significantly elevated insulin. The associations were generally not explained by body mass index or by use of diuretics or beta‐blockers. During the follow‐up, insulin was generally not associated with an impaired survival. On the contrary, in subjects with manifest cardiovascular disease, high insulin was associated with a rather favorable 5‐year survival prognosis. Exclusion of subjects who died during the first 500 days of follow‐up did not change these associations.

CONCLUSION: Albeit fasting plasma insulin appeared to be secondarily associated with cardiovascular disease in this general aged population, it was related to a fair or favorable survival prognosis.
Association of Postprandial Hypotension With Incidence of Falls, Syncope, Coronary Events, Stroke, and Total Mortality at 29‐Month Follow‐Up in 499 Older Nursing Home Residents
Authors: Aronow Wilbert S. , Ahn Chul
Published: April 2015

OBJECTIVE: To investigate whether a marked decrease in postprandial systolic blood pressure correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality at long‐term follow‐up in older nursing home residents.

DESIGN: In a prospective study of 499 nursing home residents aged 62 years or older, at 29‐month mean follow‐up, the maximal reduction in postprandial systolic blood pressure was correlated with the incidence of falls, syncope, new coronary events, new stroke, and total mortality.

SETTING: A large long‐term health care facility. PATIENTS: The 499 ambulatory or wheelchair‐bound residents included 354 women and 145 men, mean age 80 ± 9 years (range 62–100).

MEASUREMENTS AND MAIN RESULTS: The mean follow‐up was 29 ± 10 months (range 1–36). At follow‐up, falls had occurred in 199 persons (40%), syncope in 72 persons (14%), new coronary events in 139 persons (28%), new stroke in 61 persons (12%), and total mortality in 199 persons (40%). The mean maximal decrease in postprandial systolic blood pressure was 20 ± 5 mm Hg for persons with falls and 12 ± 4 mm Hg in persons without falls (P < 0.001); 23 ± 5 mm Hg in persons with syncope and 14 ± 5 mm Hg in persons without syncope (P < 0.001); 18 ± 6 mm Hg in persons with coronary events and 14 ± 5 mm Hg in persons without coronary events (P < 0.001); 21 ± 6 mm Hg in persons with stroke and 15 ± 5 mm Hg in persons without stroke (P < 0.001); and 17 ± 6 mm Hg in persons who died and 15 ± 5 mm Hg in persons who did not die (P < 0.001). Maximal decrease in postprandial systolic blood pressure was an independent risk factor for falls, syncope, new coronary events, new stroke, and total mortality. Age was an independent risk factor for new coronary events and for total mortality. Male sex was an independent risk factor for syncope, new coronary events, stroke, and total mortality. Prior falls was an independent risk factor for new falls. Prior syncope was an independent risk factor for new syncope. Prior stroke was an independent risk factor for new stroke.

CONCLUSIONS: A marked reduction in postprandial systolic blood pressure in older nursing home residents was associated at long‐term follow‐up with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.
A Survey of Grief and Bereavement in Nursing Homes: The Importance of Hospice Grief and Bereavement for the End‐Stage Alzheimer's Disease Patient and Family
Authors: Murphy Kathleen , Hanrahan Patricia , Luchins Daniel
Published: April 2015

OBJECTIVES: To determine the prevalence of grief and bereavement services in nursing homes. To highlight the importance of grief and bereavement as provided in the Medicare hospice benefit for the end‐stage Alzheimer's Disease (AD) patient and family residing in long‐term care facilities.

DESIGN: Telephone survey of nursing homes.

PARTICIPANTS: One hundred twenty‐one nursing homes in the Lower Peninsula of the state of Michigan.

MEASUREMENTS: The facilities were asked questions about on‐site grief and bereavement services, services routinely offered by licensed hospice agencies. RESULTS: Fifty‐five percent of the homes sent sympathy cards after the patients death. Ninety‐nine percent of the facilities surveyed did not provide materials to the family or primary caregiver on the grieving process or bereavement after the death. None of the facilities sent a letter after the patients death informing them of local, community or on‐site bereavement support group meetings. Seventy‐six percent of the homes were not able to offer a referral to a counseling or psychiatric professional when bereavement intervention was deemed appropriate. Fifty‐four percent of the homes usually went to the funeral home or the funeral of a patient who died at their facility. Ninety‐eight percent of the nursing homes neither visited, made phone calls, nor provided written communication (i.e., bereavement newsletter) to the family members after the patients death.

CONCLUSION: The study demonstrated few grief and bereavement services for families of patients residing in long‐ term care facilities. Because grief and bereavement is part of the career of most Alzheimer's caregivers, access to the Medicare hospice benefit should be encouraged for families of patients with end‐stage Alzheimer's Disease residing in nursing facilities. J Am Geriatr Soc 45:1104–1107, 1997.
Identification of Medications That Cause Cognitive Impairment in Older People: The Case of Oxybutynin Chloride
Authors: Katz Ira R. , Sands Laura Prouty , Bilker Warren , DiFilippo Suzanne , Boyce Alice , D'Angelo Kristina
Published: April 2015

OBJECTIVES: To evaluate the cognitive effects of acute challenges with the antispasmodic agent oxybutynin hydrochloride in normal older volunteers and to compare these effects with those attributable to diphenhydramine, another commonly used medication with anticholinergic (muscarinicblocking) activity.

DESIGN: A double‐blind, placebo‐controlled cross‐over study.

SETTING: Laboratory evaluations of community subjects.

PARTICIPANTS: A convenience sample of 12 volunteers, average age 69.17 years.

INTERVENTION: Baseline assessment was followed by randomized administration of a placebo, oxybutynin hydrochloride (5 and 10 mg), and diphenhydramine hydrochloride (50 mg) in test sessions separated by 1 week.

MEASUREMENTS: Evaluation of cognitive performance with a 1‐hour battery of pencil and paper, interviewer‐administered, and computer‐administered tests beginning 90 minutes after drug (or placebo) administration.

RESULTS: Random regression analyses demonstrated that oxybutynin caused significant cognitive decrements on seven of 15 cognitive measures, and diphenhydramine caused decrements on five measures. The most sensitive measures for detecting the effects of oxybutynin hydrochloride were the Buschke Selective Reminding Test and Reaction Time.

CONCLUSIONS: These findings demonstrate that oxybutynin can cause cognitive impairment and suggest that physicians prescribing it should monitor their patients to facilitate the early recognition of those who experience drug‐related cognitive deficits. More generally, the findings demonstrate that systematic research with normal volunteers can identify cognitive toxicity not recognized during the process of drug development or postmarketing surveillance.
Strength, Physical Activity, and Body Mass Index: Relationship to Performance‐Based Measures and Activities of Daily Living Among Older Japanese Women in Hawaii
Authors: Davis James W. , Ross Philip D. , Preston Steven D. , Nevitt Michael C. , Wasnich Richard D.
Published: April 2015

OBJECTIVES: Remaining strong, lean, and physically active may contribute to successful aging, both by maintaining function and by enabling more independent living. The study objective was to investigate this hypothesis among a long‐lived population of older Japanese women.

DESIGN: A cross‐sectional study.

SETTING: The island of Oahu, Hawaii.

PARTICIPANTS: A total of 705 community‐dwelling women (mean age, 74; range, 55–93).

MEASUREMENTS: As outcomes, 7 physical performance measures including walking speed, the Get Up and Go test, chair stands, functional reach, and hand and foot reaction times, and 8 questions regarding activities of daily living (ADL). As possible predictors, physical activity, body mass index, and quadriceps, grip, and triceps strength.

RESULTS: In multivariable models, one or more of the strength tests was associated positively with six of the seven performance‐based measures. Among the significant associations, 1‐SD increases in strength were associated with 2 to 4% increases in performance compared with the sample mean. Physical activity was independently, and positively associated with the most complex of the tests, the Get Up and Go test. Body mass index (BMI), in contrast to strength and physical activity, was negatively associated with five of the seven performance tests. Among the significant associations, 1‐SD increases in BMI were associated with 3 to 8% reductions in performance. In multivariable models strength was also associated positively with seven of the eight ADLs. In the same models, physical activity was positively associated with five and BMI was negatively associated with six of the ADLs.

CONCLUSION: The results suggest that remaining strong, lean, and physically active provided wide‐ranging benefits for this population of older Japanese women.
Ethnicity and Decision‐Makers in a Group of Frail Older People
Authors: Hornung Carlton A. , Eleazer G. Paul , III Harry S. Strothers , Wieland G. Darryl , Eng Catherine , McCann Robert , Sapir Marc
Published: April 2015

OBJECTIVE: To assess the relationship between ethnicity and decision‐makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All‐inclusive Care for the Elderly (PACE).

DESIGN: A retrospective chart review of 1193 participants in the PACE program.

SETTING: Program of All‐inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation.

PARTICIPANTS: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non‐Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian.

MEASUREMENTS: Demographic characteristics of the patients and the presence or absence of an alternative decision‐maker; the characteristics of alternative decision‐makers included the relationship to the participant as recorded in the patient's medical record.

RESULTS: Ninety‐one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision‐maker was identified for about 15% of Asians and Hispanics and for one‐third of blacks, but only about 8% of whites had an alternative decision‐maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision‐maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision‐maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision‐maker.

CONCLUSIONS: In this population, we found significant ethnic variation in the person identified to be the decision‐maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross‐cultural patterns in identified or de facto decision‐makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.
Screening for Dementia in the Outpatient Setting: The Time and Change Test
Authors: Froehlich Tanya E. , Robison Julie T. , Inouye Sharon K.
Published: April 2015

OBJECTIVE: To develop and validate the Time and Change (T&C) test, a simple, standardized method for detecting dementia in a diverse older outpatient population with varying levels of education.

DESIGN: A prospective cohort validation study.

SETTING: Two outpatient clinics at an urban teaching hospital.

PARTICIPANTS: The concurrent validation sample consisted of 100 consecutive outpatients 70 years of age or older who were 58% non‐white and had a 16% dementia prevalence rate and educational levels ranging from 0 to 17+ years. Reliability was tested in a sample of 42 consecutive outpatients 75 years of age or older with a 36% dementia prevalence rate.

MEASUREMENTS: T&C ratings were validated against a reference standard based on the Blessed Dementia Rating Scale and the Mini‐Mental State Examination. Reliability, contribution to physician recognition of dementia, and ease of use were assessed.

RESULTS: In the outpatient setting, the T&C had a sensitivity of 63%, specificity of 96%, a negative predictive value of 93%, a positive predictive value of 77%, and test‐retest and inter‐observer reliability agreement rates of 95% and 100%, respectively. When T&C results were added to the physician's documentation of dementia, the number of missed cases decreased from 44% to 19%, and the number of overcalled cases decreased by 100%. When timed cut points were added, the T&C test had a sensitivity of 94 to 100%, specificity of 37 to 46%, negative predictive value of 98 to 100%, positive predictive value of 23 to 25%, and test‐retest and inter‐observer agreement rates of 82% and 70 to 75%, respectively.

CONCLUSION: The T&C test is a simple, accurate, reliable, performance‐based tool that can improve physician ability to recognize dementia in diverse outpatient populations.
Equivalence of Two Screens of Cognitive Functioning: The Short Portable Mental Status Questionnaire and the Orientation‐Memory‐Concentration Test
Authors: Fillenbaum Gerda G. , Landerman Lawrence R. , Simonsick Eleanor M.
Published: April 2015

OBJECTIVE: To determine the equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire (SPMSQ) and the Orientation‐Memory‐Concentration (OMC) test.

DESIGN: The design was cross‐sectional and longitudinal.

SETTING: Four rural and one urban county in the Piedmont region of North Carolina (n = 3210).

PARTICIPANTS: A stratified random cluster sample (n = 3210) of people 68 years of age and older.

MEASUREMENTS: SPMSQ and OMC at the fourth wave of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE); disability, depression, and death measurements from the fourth through seventh waves of EPESE; demographic characteristics.

RESULTS: On the SPMSQ and the OMC (r = .80), 15.3% and 38.4%, respectively, of those tested were rated cognitively impaired. Poorer scores were associated with older age, black race, and less education. These associations were attenuated on the dichotomized SPMSQ but not on the OMC. Both measures predicted disability and depressive symptomatology currently and 3 years hence and death.

CONCLUSIONS: The SPMSQ and OMC, although highly correlated, are not equivalent. Association with race and education are greater for the OMC, whereas an association with age exists for both measures. The milder level of impairment identified by the OMC increases predictive capacity.
Functional Outcomes of Posthospital Care for Stroke and Hip Fracture Patients Under Medicare
Authors: Kane Robert L. , Chen Qing , Finch Michael , Blewett Lynn , Burns Risa , Moskowitz Mark
Published: April 2015

BACKGROUND: Medicare's introduction of the Prospective Payment System for hospitals has led to tremendous growth in ways of providing posthospital care. Despite substantial differences in costs per episode of care, the type of posthospital care that produces the best results for specific types of patients is not clear. This study analyzed the outcomes of different types of posthospital care for a cohort of older Medicare patients (who had diagnoses associated with the use of a range of posthospital care modalities) for up to a year after hospital discharge.

METHODS: Medicare patients hospitalized with strokes and hip fractures were enrolled consecutively just before discharge from 52 hospitals in three cities in 1988–1989. These diagnosis‐related groups were chosen because patients were discharged to all three major types of Medicare‐supported posthospital care. Patients were interviewed in‐person before discharge and again at 6 weeks, 6 months, and 1 year after discharge. The functional outcomes of posthospital care were evaluated by the instrumental variables estimation approach to correct for selection bias caused by nonrandom treatment assignment The impacts of discharge locations on the functional outcomes were examined by one‐way analyses of variance (ANOVA).

RESULTS: In general, the more disabled patients went to nursing homes and rehabilitation, but the overlap in distribution was sufficient to conduct the analyses. Stroke patients discharged to nursing homes had the highest mortality rate (P < .01). Stroke patients discharged to home health had the lowest rehospitalization rates (P < .05) Hip fracture discharged to home health care had the highest adjusted rehospitalization rate, whereas those discharged to nursing homes had the lowest adjusted rehospitalization rate (P < .05). For stroke patients, posthospital care in rehabilitation facilities or home health care was associated with significantly better functional improvement compared with stroke patients discharged elsewhere. However, functional outcomes deteriorated by 1 year posthospitalization among stroke patients who received their posthospital care at nursing homes or received no formal posthospital care. For hip fracture patients, all four types of posthospital care were associated with functional improvement, but patients discharged to rehabilitation facilities experienced the most functional improvement.

CONCLUSIONS: The choice of posthospital care can influence the course of Medicare patients. Careful attention should be paid to how hospital discharge decisions are made and to the financial incentives for different types of posthospital care provided under the current payment system. The current supply of nursing homes is not well suited to the demands of posthospital care.
Detecting Balance Deficits in Frequent Fallers Using Clinical and Quantitative Evaluation Tools
Authors: Cho Chiung‐Yu , Kamen Gary
Published: April 2015

OBJECTIVE: This investigation sought to determine whether older idiopathic frequent fallers could be distinguished from healthy older adults on the basis of balance and movement coordination tests. A secondary objective was to determine the relationships among clinical balance test scores, balance performance data obtained by accelerometry, and quantitative motor coordination tests.

DESIGN: Two group comparison designs.

SETTING: A motor control research laboratory in a university setting.

PARTICIPANTS: The 16 subjects recruited for this study included eight healthy older subjects and eight age‐matched idiopathic fallers.

MEASUREMENTS: Each participant's balance performance was assessed by accelerometry, as well as by coordination and clinical tests. Accelerometry scores, obtained by 1g accelerometers placed at the hip and on the head, were made with eyes open or closed, either standing on the floor or on a wedge of compliant foam. Clinical balance scores were obtained using variants of Romberg's test and the functional reach test. Motor coordination tests obtained included the heel‐to‐toe transition and rapid stepping tests.

MAIN RESULTS: Statistically significant differences were obtained between groups for all accelerometry variables except root mean square. All accelerometry variables were successful in discriminating between head and hip sites. Moreover, the amplitude of sway obtained from accelerometry data identified significant differences among the four test conditions. The Romberg test, using right leg alone with eyes open, showed a significant difference between fallers and healthy older subjects. Walking velocity was significantly faster for normal older subjects than for fallers (1.10 m/sec vs 0.80 m/sec). No significant between‐group differences were obtained using the functional reach test. Coordination skills yielded significant between‐group differences using the rapid stepping test but no significant differences between groups with the heel‐toe transition test.

CONCLUSION: Accelerometry is an inexpensive and clinically useful technique that can distinguish between healthy older people and idiopathic frequent fallers. In conjunction with clinical procedures and commercially available tests to assess motor coordination, these techniques can identify older individuals susceptible to frequent falls.
Assessing the Impact of Neuropsychiatric Symptoms in Alzheimer's Disease: The Neuropsychiatric Inventory Caregiver Distress Scale
Authors: Kaufer Daniel I. , Cummings Jeffrey L. , Christine Dianne , Bray Tim , Castellon Steve , Masterman Donna , MacMillan Audrey , Ketchel Patrick , DeKosky Steven T.
Published: April 2015

OBJECTIVES: To develop an adjunct scale to the Neuropsychiatric Inventory (NPI) for assessing the impact of neuropsychiatric symptoms in Alzheimer's disease (AD) patients on caregiver distress.

DESIGN: Cross‐sectional descriptive and correlational study.

SETTING: University out‐patient memory disorders clinics.

PARTICIPANTS: Eighty‐five AD subjects and their caregivers (54 spouses, 31 children).

MEASUREMENTS: The NPI and NPI Caregiver Distress Scale (NPI‐D) were used to assess neuropsychiatric symptoms in AD patients and related caregiver distress, respectively. Criterion validity of the NPI‐D was examined (N = 69) by comparison with an abridged version of the Relatives' Stress Scale (RSS'), a general measure of caregiver stress, using item clusters that had previously been correlated to behavioral disturbances in demented patients. Test‐retest (n = 20) and inter‐rater reliability (n = 16) of the NPI‐D were also assessed.

RESULTS: Test‐retest and interrater reliability of the NPI‐D were both adequate. Overall, caregiver NPI‐D distress ratings were correlated significantly with the RSS' (r = .60, P < .001). RSS' ratings correlated strongly with NPI scores (r = .64, P < .001), even after controlling for degree of cognitive impairment based on the Mini‐Mental State Exam (MMSE) score (r = .61). MMSE scores showed a moderate correlation to RSS' ratings (‐.30, P = .02), but this association was markedly attenuated when controlling for the degree of neuropsychiatric disturbance based on the NPI score (r = −.14). NPI‐D ratings for 9 of 10 NPI symptom domains correlated most strongly with either NPI symptom severity or total (frequency × severity) scores. Agitation, dysphoria, irritability, delusions, and apathy were the symptoms most often reported to be severely distressing to caregivers.

CONCLUSIONS: The NPI‐D provides a reliable and valid measure of subjective caregiver distress in relation to neuropsychiatric symptoms measured by the NPI. Neuropsychiatric alterations are more strongly associated than cognitive symptoms to caregiver distress. The NPI‐D may be useful in both clinical and research settings for assessing the contribution to caregiver distress of neuropsychiatric symptoms in AD patients.
Risk Factors for Colonization with Yeast Species in a Veterans Affairs Long‐term Care Facility
Authors: Hedderwick Sara A. , Wan Jim Y. , Bradley Suzanne F. , Sangeorzan Jon A. , Terpenning Margaret S. , Kauffman Carol A.
Published: April 2015

OBJECTIVES: To assess colonization and serious infection with yeasts and the risk factors that are associated with colonization by these organisms.

DESIGN: Monthly surveillance for colonization and infection over a period of 2 years.

SETTING: A long‐term‐care facility (LTCF) attached to an acute‐care Veterans Affairs Medical Center.

PARTICIPANTS: The 543 men and 10 women in the facility.

MEASUREMENTS: Colonization and serious infection rates with yeasts. Analysis of risk factors associated with yeast colonization of residents.

RESULTS: Colonization rates were relatively stable during the 2‐year period (53 ± 1.8% patients colonized per month). Candida albicans was the most common colonizer, found in 35 ±.9% of patients colonized per month. The pharynx was the most commonly colonized site, with 41 ± 1.4% of patients per month with pharyngeal colonization. Eighty‐four percent of patients remaining in the facility for 3 or more months were colonized by yeast at some time during their stay. Presence of neurogenic bladder, leg amputation, or a low serum albumin were independently associated with yeast colonization; neither diabetes mellitus nor functional status was a risk factor for colonization by yeasts. Only four serious yeast infections in four patients (esophagitis and three urinary tract infections) were found during the 2‐year period; all infections occurred in patients who were colonized by yeasts previously.

CONCLUSION: In our LTCF, colonization of patients by yeasts occurred commonly in those residents remaining in the facility for 3 or more months. However, serious yeast infections occurred infrequently. It is likely that colonization of residents of LTCFs by yeasts may only become clinically important when the patient is transferred to an acute‐care hospital where additional risk factors may allow the development of serious yeast infection.
Environmental Correlates of Resident Agitation in Alzheimer's Disease Special Care Units
Authors: Sloane Philip D. , Mitchell C. Madeline , Preisser John S. , Phillips Charles , Commander Charlotte , Burker Eileen
Published: April 2015

OBJECTIVE: To determine the point prevalence of agitated behaviors in a representative sample of Alzheimer's disease Special Care Units, and to determine the extent to which agitation is associated with aspects of the treatment environment.

DESIGN: A cross‐sectional study in which nonparticipant observers recorded 3723 observations of resident behaviors in 53 Alzheimer's disease Special Care Units. Observational data were gathered on the physical environment and staff treatment in these settings, and resident characteristics were extracted from a data base developed in the study states by the Health Care Financing Agency. Analyses studied the association between aspects of the staff and physical environment and resident agitation levels, controlling for resident cognitive and functional status.

SETTING: Special Care Units in nursing homes in Kansas, Maine, Mississippi, and South Dakota.

PARTICIPANTS: All residents and staff of the participating units.

MAIN OUTCOME MEASURES: Eight specific agitated behaviors and two indexes of resident agitation were measured by direct observation by research assistants on three to four data collection walk‐throughs in each of the study facilities.

RESULTS: The most common agitated behaviors noted were repetitive mannerisms (4.5% of resident observations) and non‐loud verbal excess (3.8%). Wandering, which frequently reflects agitation, was noted in 6.5% of resident observations. The proportion of residents exhibiting an agitated behavior varied from none in some units to 38% in one unit. Independent correlates of low unit agitation levels included favorable scores on measures of the physical environment and of staff treatment activities, low rates of physical restraint use, a high proportion of residents in bed during the day, small unit size, low levels of resident functional dependency, and fewer numbers of comorbid conditions.

CONCLUSIONS: While the prevalence of agitation tends to increase as Alzheimer's disease progresses, modifiable treatment factors appear to have a strong influence on the prevalence of agitation. Both physical design and staff treatment appear to influence agitation rates, as do some measures consistent with a low stimulus approach to Alzheimer's care.
Perceived Efficacy in Patient‐Physician Interactions (PEPPI): Validation of an Instrument in Older Persons
Authors: Maly Rose C. , Frank Janet C. , Marshall Grant N. , DiMatteo M. Robin , Reuben David B.
Published: April 2015

OBJECTIVE: To develop and validate a brief instrument – the Perceived Efficacy in Patient‐Physician Interactions Questionnaire (PEPPI) – to measure older patients' self‐efficacy in obtaining medical information and attention to their medical concerns from physicians.

DESIGN: Two consecutive validation surveys.

SETTING: Eleven senior multipurpose centers in Los Angeles County California.

POPULATION: A convenience sample of 163 community‐dwelling older persons (Survey 1: n = 59, mean age = 77.1 years, 76.3% female; Survey 2: n = 104, mean age = 77.4 years, 57.7% female).

MEASURES: The 10‐item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self‐reported health and restricted activity days items.

RESULTS: The full 10‐item and a 5‐item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r = ‐.27, P =.001) and positively with active coping (r =.17, P =.03) and with patient satisfaction with physician interpersonal manner (r =.49, P <.0001) and communication (r =.51, P <.0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self‐reported health (r =.42, P <.0001), education (r =.24, P =.01) and self‐mastery (r =.29, P =.01) and negatively with restricted activity days (r = ‐.25, P =.01). PEPPI‐5 demonstrated correlations similar in magnitude, direction, and statistical significance.

CONCLUSION: In either the 5‐ or 10‐item version, PEPPI is a valid and reliable measure of older patients' perceived self‐efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.
A Nonpharmacologic Sleep Protocol for Hospitalized Older Patients
Authors: McDowell Jane A. , Mion Lorraine C. , Lydon Thomas J. , Inouye Sharon K.
Published: April 2015

OBJECTIVES: To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative‐hypnotic drug (SHD) use.

DESIGN: Prospective cohort study.

SETTING: A 34‐bed general medical unit in a university‐affiliated teaching hospital.

PARTICIPANTS: A total of 175 consecutive admissions aged 70 years or older.

INTERVENTION: A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD.

MEASUREMENTS: The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction.

RESULTS: A cohort of 111 patients, mean age 79.3 (± 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients‐days. The overall adherence rate was 400/539 (74%) patient‐days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose‐response relationship, with the highest correlation for receiving two to three parts (ρ = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (ρ = .75, P = .001) than did SHDs (ρ = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001).

CONCLUSION: The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.
Apolipoprotein E Phenotypes, Dementia and Mortality in a Prospective Population Sample
Authors: Tilvis Reijo S , Strandberg Timo E , Juva Kati
Published: April 2015

OBJECTIVE: To study the relationships between apoE phenotypes, dementia, and mortality.

SETTING: A population‐based study in Helsinki, Finland (the Helsinki Ageing Study).

DESIGN: A prospective birth cohort study with 5‐year follow‐up.

PARTICIPANTS: A total of 550 subjects of three birth cohorts of 75 (n = 182), 80 (n = 185), and 85 (n = 183) years of age.

MEASUREMENTS: ApoE phenotype was determined from baseline blood samples. The cognitive function of the subjects was tested at baseline and at a 5‐year follow‐up using the Mini‐Mental State Examination (MMSE) and the Clinical Dementia Rating (CDR). Diagnosis and type of dementia were determined by a neurologist. The cohorts were followed for 5 years, and causes of death were determined. Cox proportional hazards model was used for survival analyses. Analyses were performed comparing the apoE e4 allele and others.

RESULTS: At baseline, the apoE e4 allele was found in 148 of 550 subjects (27%), in 24% of nondemented persons, in 51% of patients with probable or uncertain Alzheimer's disease (AD), and in 34% patients with vascular dementia. The CDR score was worse among subjects with an e4 allele compared with others at baseline (P < .001) and after a 5‐year follow‐up (P = .007). The crude mortality rates of subjects with and without an e4 allele were 48% (n = 71) and 37% (n = 148), respectively. After controlling for age and gender, the hazard ratio of an e4 allele was 1.61 (95% CI, 1.21–2.14) for all‐cause mortality, deaths caused by dementia 2.20 (95% CI, 1.03–4.72), and presence of AD 3.24 (95% CI, 1.67–6.25).

CONCLUSIONS: In a population aged 75 to 85 years, the presence of an apoE e4 allele is associated with impaired cognitive function, clinical dementia, AD, and excess 5‐year mortality resulting from dementia and all causes.
The Association of Weight Change in Alzheimer's Disease with Severity of Disease and Mortality: A Longitudinal Analysis
Authors: White Heidi , Pieper Carl , Schmader Ken
Published: April 2015

OBJECTIVE: To describe weight loss in relation to the severity of Alzheimer's disease (AD), to identify confounders that might account for weight loss, and to investigate the association of weight change with mortality.

METHODS: This study included 666 subjects with AD from the Consortium to Establish a Registry for Alzheimer's Disease, a longitudinal study of subjects with AD studied for ≤6 years. Body weight was measured on entry and at annual follow‐up examinations as part of standardized clinical assessments. Hierarchical linear models were used to estimate weight change per change in stage of AD, as measured by the Clinical Dementia Rating scale, and to assess the impact of possible confounders on the tendency for weight loss. Linear correlation of the trajectories of weight and CDR over time were used to determine the association between weight change and stage change. The association between weight change and mortality was modeled using the Cox proportional hazards model.

RESULTS: Each change in stage of AD was associated with an estimated average weight loss of nearly 2 lb (P = .0001). The correlation between change in stage of AD and weight change was statistically significant (r = −0.09, P = .005), which indicates a greater tendency toward weight loss with progression of AD. Weight loss of 2:5% in any year before death was a significant predictor of mortality. When weight loss in the year before death or censoring was analyzed as a continuous variable, it was a significant predictor of mortality. Additionally, the relative risk of death increased as weight loss increased. In contrast, weight gain decreased the risk of mortality.

CONCLUSION: The risk of weight loss tends to increase with severity and progression of AD. Weight loss is a predictor of mortality among subjects with AD, whereas weight gain appears to have a protective effect.
Discussions About End‐of‐Life Care in Nursing Homes
Authors: Bradley Elizabeth H. , Peiris Vasum , Wetle Terrie
Published: April 2015

OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the resident's wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions.

DESIGN: Retrospective cohort study of residents admitted to nursing homes before and after the PSDA.

SETTING: Six large (at least 120 licensed chronic care beds), randomly selected nursing homes in Connecticut.

PARTICIPANTS: Six hundred randomly selected nursing home residents admitted during 1990 and 1994 to one of the six study nursing homes.

MEASUREMENTS: Documented discussions concerning future treatment wishes were abstracted from residents' nursing home medical records. Participants in the discussion, as well as the timing (i.e., date) and content of the documented discussions were recorded. Sociodemographic and health status factors were also obtained from the medical record.

RESULTS: A large majority of residents (71.5%) had no discussion of future treatment wishes documented in their medical record. However, the percentage of residents with documented discussions had increased since the implementation of the PSDA (36.7% post‐PSDA vs 20.3% pre‐PSDA). Of those in the post‐PSDA cohort who had had discussions, 90% had only one discussion within the first year of admission, and more than half (58.1%) of those who had discussions discussed only life‐support systems (cardiopulmonary resuscitation, artificial nutrition and hydration, and ventilation) rather than broader preferences for future treatment, including proxy decision‐making.

CONCLUSIONS: Despite the increased prevalence of discussions about future treatment wishes since the enactment of the PSDA, no discussions were documented for most residents. For those with documented discussions, such conversations occurred rarely and were narrow in scope, suggesting that residents' and families' roles in medical decision‐making in nursing homes may be limited.
Influence of Patient Preferences and Local Health System Characteristics on the Place of Death
Authors: Pritchard Robert S. , Fisher Elliott S. , Teno Joan M. , Sharp Sandra M. , Reding Douglas J. , Knaus William A. , Wennberg John E. , Lynn Joanne ,   SUPPORT Investigators
Published: April 2015

OBJECTIVE: To examine the degree to which variation in place of death is explained by differences in the characteristics of patients, including preferences for dying at home, and by differences in the characteristics of local health systems.

DESIGN: We drew on a clinically rich database to carry out a prospective study using data from the observational phase of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT component). We used administrative databases for the Medicare program to carry out a national cross‐sectional analysis of Medicare enrollees place of death (Medicare component).

SETTING: Five teaching hospitals (SUPPORT); All U.S. Hospital Referral Regions (Medicare).

STUDY POPULATIONS: Patients dying after the enrollment hospitalization in the observational phase of SUPPORT for whom place of death and preferences were known. Medicare beneficiaries who died in 1992 or 1993.

MAIN OUTCOME MEASURES: Place of death (hospital vs non‐hospital).

RESULTS: In SUPPORT, most patients expressed a preference for dying at home, yet most died in the hospital. The percent of SUPPORT patients dying in‐hospital varied by greater than 2‐fold across the five SUPPORT sites (29 to 66%). For Medicare beneficiaries, the percent dying in‐hospital varied from 23 to 54% across U.S. Hospital Referral Regions (HRRs). In SUPPORT, variations in place of death across site were not explained by sociodemographic or clinical characteristics or patient preferences. Patient level (SUPPORT) and national cross‐sectional (Medicare) multivariate models gave consistent results. The risk of in‐hospital death was increased for residents of regions with greater hospital bed availability and use; the risk of in‐hospital death was decreased in regions with greater nursing home and hospice availability and use. Measures of hospital bed availability and use were the most powerful predictors of place of death across HRRs.

CONCLUSIONS: Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics. These findings may explain the failure of the SUPPORT intervention to alter care patterns for seriously ill and dying patients. Reforming the care of dying patients may require modification of local resource availability and provider routines.
Differences Among Geriatricians, General Internists, and Cardiologists in the Care of Patients with Heart Failure: A Cautionary Tale of Quality Assessment
Authors: Chin Marshall H. , Wang John C. , Zhang James X. , Sachs Greg A. , Lang Roberto M.
Published: April 2015

OBJECTIVES: To describe differences in the characteristics, processes of care, and resource utilization of patients with heart failure cared for by geriatricians, general internists, cardiologists, and combinations of physicians.

DESIGN: A retrospective cohort study.

SETTING: An urban academic medical center.

PARTICIPANTS: A total of 439 outpatients with a billing diagnosis of heart failure or cardiomyopathy who were treated by geriatricians, general internists, cardiologists, and combinations of physicians.

MEASUREMENTS: Demographic and clinical characteristics, medication use, diagnostic testing, hospitalizations, and inpatient and outpatient costs were measured.

RESULTS: Compared with patients of cardiologists, patients cared for by geriatricians were older, more likely to have hypertension, diastolic dysfunction, and high comorbidity, and less likely to undergo echocardiography, cardiac catheterization, and electrocardiography. Use of angiotensin‐converting enzyme inhibitors was similar among patients with reduced systolic function. Patients cared for by geriatricians had the same costs, rates of hospitalization, and likelihood of being symptomatic as patients of cardiologists.

CONCLUSIONS: The processes of care for patients with heart failure seen solely by geriatricians differ from those for patients seen by other physicians, but the case‐mix also varies. Assessment of left ventricular function by geriatricians probably needs to be increased. However, although they were older and had more comorbidity, patients of geriatricians had total costs and symptomatology similar to those of patients of cardiologists. Future work is needed to identify those patients most likely to benefit from treatment by geriatricians and to determine how care can be optimally coordinated among different types of physicians and health providers.