bluuebunny/crossref_metadata_2025 huggingface dataset:
Insulin Effects on the Left Ventricle in Older Hypertensive Subjects
Authors: Scuteri Angelo , Di Bernardo Maria Gabriella , De Propris Anna Maria , Marigliano Vincenzo
Published: April 2015

BACKGROUND: To evaluate the effects of hyperinsulinemia on left ventricular (LV) structure and function in older hypertensive subjects

METHODS: Thirty‐seven hypertensive subjects (17 men/20 women) aged 50 to 80, were studied. LV mass were evaluated echocardiographically according to the Penn convention. A 75‐g oral glucose tolerance test (OGTT) was performed after overnight fasting, and both blood glucose and insulin concentrations were assayed at 0, 30, 60, 90, 120, and 180 minutes. Comparison between groups was performed by analysis of variance. A P value of .05 was considered statistically significant.

RESULTS: When the hypertensive patients were divided into two groups according to the median value of 2‐hour post‐loading plasma insulin, there was no difference in blood pressure levels between the groups. However, hyperinsulinemic hypertensive subjects had an increased LV mass (P < .05), mean wall thickness, and interventricular septum thickness (P < .05 for both parameters) and had better systolic function‐ejection and shortening fractions (P < .0001 for both indices).

CONCLUSIONS: Hyperinsulinemia may be associated with increased left ventricular mass and with a better systolic performance in older hypertensive subjects. J Am Geriatr Soc 47:727–729, 1999.
Assessment and Control for Confounding by Indication in Observational Studies
Authors: Psaty Bruce M. , Koepsell Thomas D. , Lin Danyu , Weiss Noel S. , Siscovick David S. , Rosendaal Frits R. , Pahor Marco , Furberg Curt D.
Published: April 2015

In the evaluation of pharmacologic therapies, the controlled clinical trial is the preferred design. When clinical trial results are not available, the alternative designs are observational epidemiologic studies. A traditional concern about the validity of findings from epidemiologic studies is the possibility of bias from uncontrolled confounding. In studies of pharmacologic therapies, confounding by indication may arise when a drug treatment serves as a marker for a clinical characteristic or medical condition that triggers the use of the treatment and that, at the same time, increases the risk of the outcome under study. Confounding by indication is not conceptually different from confounding by other factors, and the approaches to detect and control for confounding — matching, stratification, restriction, and multivariate adjustment — are the same. Even after adjustment for known risk factors, residual confounding may occur because of measurement error or unmeasured or unknown risk factors. Although residual confounding is difficult to exclude in observational studies, there are limits to what this “unknown” confounding can explain. The degree of confounding depends on the prevalence of the putative confounding factor, the level of its association with the disease, and the level of its association with the exposure. For example, a confounding factor with a prevalence of 20% would have to increase the relative odds of both outcome and exposure by factors of 4 to 5 before the relative risk of 1.57 would be reduced to 1.00. Observational studies have provided important scientific evidence about the risks associated with several risk factors, including drug therapies, and they are often the only option for assessing safety. Understanding the methods to detect and control for confounding makes it possible to assess the plausibility of claims that confounding is an alternative explanation for the findings of particular studies. J Am Geriatr Soc 47:749–754, 1999.
Mailed Reminders for Area‐Wide Influenza Immunization: A Randomized Controlled Trial
Authors: Smith David M. , Zhou Xiao‐Hua , Weinberger Morris , Smith Faye , McDonald Robert C.
Published: April 2015

OBJECTIVE: To determine if mailed reminders would increase area‐wide influenza immunization for persons aged 65 and older.

DESIGN: A randomized, controlled trial.

SETTING: Ten counties in Indiana.

PARTICIPANTS: Using a Medicare database, 10,000 subjects were selected randomly from 10 counties in Indiana and randomized for the study. Using pre‐established criteria, 4503 persons in the control group and 4508 in the intervention group were eligible for study.

INTERVENTION: Intervention subjects received mailed reminders during the immunization season of 1995.

MEASUREMENTS: Data from mailed surveys, Medicare claims, and phone calls were used to determine immunization rates.

RESULTS: Of those surveyed who received immunization, only 63.4% filed a Medicare claim. Immunization rates were high in both groups but higher in the intervention group, 69.0% versus 64.2%. Age, presence of lung disease, assignment to the intervention group, presence of heart disease, and an age‐sex interaction term were significantly and independently related to immunization.

CONCLUSIONS: The Healthy People Year 2000 goal (60% immunization for persons 65 and older) was exceeded in this population. Medicare claims data do not reflect immunization rates accurately. Mailed reminders, an inexpensive intervention, increased immunization rates area‐wide and have potential for cost savings.
Mortality, Health Services Use, and Health Behavior in a Cohort of Well Older Adults
Authors: Malmgren Judith A. , Koepsell Thomas D. , Martin Diane P. , Diehr Paula , LaCroix Andrea Z.
Published: April 2015

OBJECTIVES: To construct an evidence‐based Good Health Behavior Score and examine the relationship between aggregate health behaviors, mortality, and health services utilization in the last year of life in a cohort of well older adults.

DESIGN: A prospective cohort.

SETTING: A large health maintenance organization.

PARTICIPANTS: 1867 older enrollees who responded to a health promotion survey.

MEASUREMENTS: A baseline self‐administered questionnaire was used to ascertain health behaviors in 1987–1988, and vital status was determined 48 months later. A Good Health Behavior Score was calculated, and a Cox proportional hazards model was used to compare high, middle, and low score groups regarding risk of death. For those who died, differences in amount and type of health services utilization in relation to the summary score were compared for the year before death.

RESULTS: During the 4 years of follow‐up, the mortality rate for the mid‐level score group was 50% less, and in the highest score group was 70% less, than in the lowest score group. Among decedents, no significant differences were found between high and low Good Health Behavior score groups for inpatient and outpatient utilization, pharmacy use, or total cost during the last year of life.

CONCLUSION: An easily developed and simple health behavior score can predict short term mortality quite strongly. Medical care costs in the last year of life were similar in individuals with higher and lower health behavior scores.
Is Experience as a Prisoner of War a Risk Factor for Accelerated Age‐Related Illness and Disability?
Authors: Creasey Helen , Sulway Mary Rose , Psychol M. , Dent Owen , Broe G. Anthony , Jorm Anthony , Tennant Christopher
Published: April 2015

OBJECTIVE: To determine whether the experience of internment as a Prisoner of War (POW) during World War II was associated with a higher prevalence of chronic disease and diminished functional performance in later life.

DESIGN: A retrospective and prospective cohort design.

SETTING: Concord Repatriation General Hospital, Sydney, Australia.

PARTICIPANTS: A random sample of 101 Australian, male, ex‐prisoners of the Japanese and a comparison group of 107 non‐POW combatants from the same theatre of war.

MEASUREMENTS: Outcome variables were self‐perceived health status, hospital admissions and length of stay, number of prescription medications used, number of somatic symptoms reported, number and types of medical diagnoses, a neurology of aging clinical examination, and the Instrumental Activities of Daily Living (IADL) and Physical Self Maintenance Scales (PSMS).

RESULTS: Prisoners of War reported more somatic symptoms (mean 7.2 vs 5.4, P = .002) than non‐POWs, had more diagnoses (mean 9.4 vs 7.7 P < .001), and used a greater number of different medications (mean 4.5 vs 3.4, P = .001). There were no differences in hospital admissions or length of stay. Among 15 broad categories of diagnosis, differences were confined to gastrointestinal disorders (POWs 63% vs non‐POWs 49%, P = .032), musculoskeletal disorders (POWs 76% vs non‐POWs 60%, P = .011), and cognitive disorders (excluding head injury, dementia, and stroke) (POWs 31% vs non‐POWs 15%, P = .006). Of the 36 signs in the neurology of aging examination, POWs had a significantly higher proportion of seven extrapyramidal signs and six signs relating to ataxia. POWs were more likely to be impaired on the IADL scale than were non‐POWs (33% vs 17%, P = .012) but not significantly more likely to be impaired on the PSMS.

CONCLUSIONS: There were few differences between POWs and controls, and those differences were relatively small. Our findings do not support a major role for a catastrophic life stress in the development of chronic illness and disability in later life. However it is possible that the POW experience played a part in premature, abnormal, or unsuccessful aging in some individuals.
Vaginal Estrogen Creams: Use Patterns Among a Cohort of Women
Authors: Keenan Nora L. , Franks Adele L. , Croft Janet B. , Scholes Delia , Murray E. Taylor
Published: April 2015

OBJECTIVE: To assess the prevalence, amount, and duration of use of vaginal estrogen cream among several birth cohorts of women from 1983 through 1992.

DESIGN: Analyses are based on automated membership, pharmacy, and hospital discharge databases from Group Health Cooperative (GHC) of Puget Sound, a large health maintenance organization in Seattle, Washington.

PARTICIPANTS: A total of 33,822 women, aged 45 years and older as of December 31, 1983, who were enrolled in GHC from 1983 to 1992 or who were enrolled at baseline and died in the following decade.

RESULTS: About 24% of the cohort had filled at least one prescription for vaginal estrogen cream during 1983 through 1992, and about 60% of the users had more than one prescription filled. The annual birth cohort‐specific prevalence of having filled one or more prescriptions for vaginal estrogen creams ranged between 1.6 and 8.2% across birth cohorts, whereas the average annual prevalence for the cohort was between 5.3 and 6.8%. The total amount, duration of use, and proportion of total estrogen exposure from creams increased with age of the birth cohort. Among the 733 women with intact uteri who were long‐term cream users, 60.4% had no progestin prescriptions while averaging 22.1 tubes of estrogen cream.

CONCLUSION: The prescription‐filling patterns for estrogen in this cohort show an increase in the amount, years of use, and proportion of estrogen exposure from creams with the age of the birth cohort and extensive unopposed cream use among a small proportion of women with intact uteri. The systemic effects of vaginal estrogen cream among older postmenopausal women with urogenital atrophy deserve closer scrutiny.
Effects of Long‐Acting Versus Short‐Acting Calcium Channel Blockers Among Older Survivors of Acute Myocardial Infarction
Authors: Gillman Matthew W. , Ross‐Degnan Dennis , McLaughlin Thomas J. , Gao Xiaoming , Spiegelman Donna , Hertzmark Ellen , Goldman Lee , Soumerai Stephen B.
Published: April 2015

OBJECTIVE: Recent studies have highlighted the potentially harmful effects of short‐acting calcium channel blockers, especially of the dihydropyridine type, in patients with coronary heart disease. Some have argued that long‐acting calcium channel blockers are safer, but few outcome data exist. The objective of the study was to compare the occurrence of adverse outcomes among recipients of long‐acting versus short‐acting calcium channel blockers, with dihydropyridines and non‐dihydropyridines compared separately.

SETTING: The New Jersey Medicare population.

DESIGN: A retrospective cohort study using linked Medicare and drug claims data.

PARTICIPANTS: Older survivors of acute myocardial infarction (MI) occurring in 1989 and 1990. Eligible subjects had survived at least 30 days after the MI, participated in Medicare and a drug benefits program, and were prescribed a single type of either a long‐acting or a short‐acting calcium channel blocker within 90 days after the MI.

MEASUREMENTS: The two outcome measures were rates of all‐cause mortality and cardiac rehospitalization. Using separate Cox regression models for dihydropyridines (nifedipine, nicardipine) and non‐dihydropyridines (diltiazem, verapamil), we examined these outcomes for recipients of long‐acting compared with short‐acting calcium channel blockers.

RESULTS: Of the 833 patients eligible for the study, 160 were prescribed long‐acting and 673 short‐acting calcium channel blockers. Clinical characteristics of long‐acting and short‐acting users were comparable. During 2 years of follow‐up, 221 deaths and 300 rehospitalizations occurred. Controlling for age, sex, race, and indicators of disease severity and comorbidity, the relative risk of dying for recipients of long‐acting, compared with short‐acting, dihydropyridines was .42 (95% confidence interval (CI), 0.21‐0.86). For cardiac rehospitalization, the relative risk was 0.57 (95% CI, 0.34‐0.94). For the long‐acting versus short‐acting non‐dihydropyridines, the adjusted relative risk of dying was 1.43 (95% CI, 0.88‐2.32), and for cardiac rehospitalization, .65 (95% CI, 0.40‐1.05).

CONCLUSION: Use of long‐acting dihydropyridine calcium channel blockers after acute MI was associated with substantially lower rates of cardiac rehospitalization and death compared with use of their short‐acting counterparts. More data are needed to address the possibility that long‐acting, compared with short‐acting, non‐dihydropyridines could decrease rehospitalization rates but increase mortality. J Am Geriatr Soc 47:512–517, 1999.
An Analysis of Falls in the Hospital: Can We Do Without Bedrails?
Authors: Hanger H.C. , Ball M.C. , Wood L.A.
Published: April 2015

OBJECTIVES: To determine the effects of introduction of a bedrail policy, and an educational program, on patient falls and fall‐related injuries.

DESIGN: A prospective “Before and After” design.

PARTICIPANTS AND SETTING: All patients admitted during 1 calendar year in an assessment, treatment, and rehabilitation unit for older people.

INTERVENTION: A policy change for the use of bedrails (restricting their use) and an educational program about their effects.

MEASUREMENTS: Patient fall rates ‐ all falls and around the bed falls — and patient and staff injuries.

RESULTS: There was a significant reduction in the number of beds with bedrails attached after the policy introduction (mean of 40/135 vs 18.5/135, respectively, P = .02), but the fall rate (either total or around the bed) did not change significantly. Serious injuries were significantly less common after the bedrail policy was introduced (P = .008), with fewer head injuries.

CONCLUSIONS: Reducing the use of bedrails did not alter patient fall rates significantly, but it was associated with a reduction in serious injuries. Unless it can be shown that bedrails are beneficial, their continued use in older patients must be seriously questioned. J Am Geriatr Soc 47:529–531, 1999.
Drug Treatment of Hypertension in Older Persons in an Academic Hospital‐Based Geriatrics Practice
Authors: Mendelson Gad , Ness Jose , Aronow Wilbert S.
Published: April 2015

OBJECTIVE: To investigate the prevalence of hypertension in older persons, the prevalence of the different antihypertensive drugs used to treat hypertension, the prevalence of the different antihypertensive drugs used to treat hypertension in persons with prior myocardial infarction (MI) or congestive heart failure (CHF), and the prevalence of lowering the blood pressure to < 140/90 mm Hg with therapy.

DESIGN: A retrospective analysis of charts from all older patients seen from December 1, 1997, through August 31, 1998, at an academic, hospital‐based geriatrics practice was performed to investigate the prevalence of hypertension in older persons, the prevalence of different antihypertensive drugs used to treat hypertension, the prevalence of different antihypertensive drugs used to treat hypertension in persons with prior MI or CHF, and the prevalence of lowering the blood pressure to < 140/90 mm Hg with therapy.

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

PATIENTS: A total of 459 men and 1360 women, mean age 80 ± 8 years (range 59 to 101 years), were included in the study.

MEASUREMENTS AND MAIN RESULTS: Hypertension was present in 1051 of the 1819 persons in the study (58%). Target organ damage, clinical cardiovascular disease, or diabetes mellitus was present in 738 (70%) of these 1051 persons. Of the 1051 persons with hypertension, 520 (49%) were treated with diuretics, 297 (28%) with beta‐blockers, 445 (42%) with angiotensin‐converting enzyme (ACE) inhibitors, 171 (16%) with calcium channel blockers, and 13 (1%) with other antihypertensive drugs; 41 (4%) received no antihypertensive therapy. The last blood pressure recorded on the chart was <140/90 mm Hg for 735 of the 1051 persons (70%) with hypertension. Of 306 persons with hypertension and prior MI, 182 (59%) were treated with beta‐blockers, 146 (48%) with ACE inhibitors, 96 (31%) with diuretics, and 29 (9%) with calcium channel blockers. Of 103 persons with hypertension and CHF, 103 (100%) were treated with diuretics, 94 (91%) with ACE inhibitors, 22 (21%) with beta‐blockers, and 3 (3%) with calcium channel blockers.

CONCLUSIONS: The prevalence of hypertension in the 1819 older persons seen in an academic, hospital‐based geriatrics practice was 58%. Educational efforts led to increased use of diuretics and beta‐blockers and decreased use of calcium channel blockers in treating hypertension. The last blood pressure recorded on the chart was <140/90 mm Hg in 70% of older persons with hypertension in the study. J Am Geriatr Soc 47:597–599, 1999.
The Effect of Major Depression on Functional Status in Patients with Coronary Artery Disease
Authors: Steffens David C. , O'Connor Christopher M. , Jiang Wei Jan , Pieper Carl F. , Kuchibhatla Maragatha N. , Arias Rebekka M. , Look Adair , Davenport Chad , Gonzalez Michael B. , Krishnan K. Ranga Rama
Published: April 2015

OBJECTIVE: To examine the effect of major depression on reported functional status in a group of patients with coronary artery disease (CAD).

SETTING: An inpatient cardiology service.

PARTICIPANTS: Three hundred thirty‐five inpatients with coronary artery disease who were free of dementia, Parkinson's disease, and other primary neurological illnesses.

MEASUREMENTS: Duke Depression Evaluation Schedule, a structured psychiatric interview which included the Diagnostic Interview Schedule depression subscale, the Cumulative Illness Rating Scale, and two scales for measuring instrumental and self‐maintenance activities of daily living.

RESULTS: Twenty‐seven subjects met DSM‐IV criteria for major depression. Compared with subjects without major depression, depressed subjects were more than twice as likely to report a self‐maintenance ADL deficit and were significantly more likely to report an IADL deficit than were non‐depressed subjects (93 vs 71%). In regression models, female gender, older age, greater medical illness severity, and presence of major depression were significant predictors of self‐maintenance ADL disability; and female gender, older age, greater medical severity, and presence of major depression significantly predicted greater IADL impairment.

CONCLUSION: The presence of major depression was associated with functional disability in patients with CAD. Further research is needed to clarify whether antidepressant treatment significantly impacts both affective symptoms and functional status in patients with coronary heart disease.
Influence of Companion Animals on the Physical and Psychological Health of Older People: An Analysis of a One‐Year Longitudinal Study
Authors: Raina Parminder , Waltner‐Toews David , Bonnett Brenda , Woodward Christel , Abernathy Tom
Published: April 2015

OBJECTIVE: To examine whether companion animals or attachment to a companion animal was associated with changes in physical and psychological health in older people and whether the relationships between physical and psychological health and human social networks were modified by the presence or absence of a companion animal.

DESIGN: A 1‐year longitudinal study with standardized telephone interview data collected at baseline and repeated at 1‐year

SETTING: Wellington County, Ontario, Canada

PARTICIPANTS: An age‐ and sex stratified random sample (baseline n = 1054; follow‐up n = 995) of noninstitutionalized adults aged 65 and older (mean age = 73, SD ± 6.3)

MEASUREMENTS: Social Network Activity was measured using a family and non‐family social support scale, participation in an organized social group, involvement in the affairs of the social group, the practice of confiding in others, feelings of loneliness, and the perceived presence of support in a crisis situation. Chronic conditions were measured as the current number of selected health problems. Pet ownership was assessed by the report of owning a dog or a cat and the Lexington Attachment to Pets Scale score. Physical health was assessed as the ability to perform Activities of Daily Living (ADLs). Psychological health was measured as a summed score comprising the level of satisfaction regarding one's health, family and friend relationships, job, finances, life in general, overall happiness, and perceived mental health. Sociodemographic variables assessed include subject age, sex, marital status, living arrangements, education, household income, and major life events.

RESULTS: Pet owners were younger, currently married or living with someone, and more physically active than non‐pet owners. The ADL level of respondents who did not currently own pets deteriorated more on average (β = −.270, P = .040) than that of respondents who currently owned pets after adjusting for other variables during the 1‐year period. No statistically significant direct association was observed between pet ownership and change in psychological well‐being (P > .100). However, pet ownership significantly modified the relationship between social support and the change in psychological well‐being (P = .001) over a 1‐year period.

CONCLUSIONS: The results demonstrate the benefits of pet ownership in maintaining or slightly enhancing ADL levels of older people. However, a more complex relationship was observed between pet ownership and an older person's well‐being.
Predictors of Continued Physical Restraint Use in Nursing Home Residents Following Restraint Reduction Efforts
Authors: Sullivan‐Marx Eileen M. , Strumpf Neville E. , Evans Lois K. , Baumgarten Mona , Maislin Greg
Published: April 2015

OBJECTIVES: To examine predictors of continued restraint use in nursing home residents following efforts aimed at restraint reduction.

DESIGN: Secondary analysis of data from a clinical trial using a one‐group, pre‐test post‐test design.

SETTING: Three nonprofit, religion‐affiliated nursing homes in a metropolitan area.

PARTICIPANTS: The sample consisted of 201 physically restrained nursing home residents. Following restraint reduction efforts, 135 of the sample were still restrained. Mean age of participants was 83.9 years.

MEASUREMENTS: Physical restraint use was measured by observation and included any chest/vest, wrist, mitt, belt, crotch, suit, or harness restraint plus any sheet used as restraint or a geriatric chair with fixed tray table. Nursing home residents were subjected to any one of three conditions aimed at restraint reduction, including adherence to the mandate of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87), staff education, and education with consultation from a gerontological clinical nurse specialist. Resident characteristics including dependency, health status, mental status, depression, behavior, fall risk; presence of treatment devices and institutional factors were determined.

RESULTS: Physical dependency, lower cognitive status, behavior, presence of treatment devices, presence of psychiatric disorders, fall risk, and fall risk as staff rationale for restraint were associated (P < .10) with continued restraint use. Nursing hours, staff mix, prevalence of restraint use by unit, and site were also associated (P < .10) with continued use of physical restraints. Following bivariate analysis, associated resident characteristics were subjected to logistic regression. Lower cognitive status (OR = 2.4 (for every 7‐point decrease in MMSE), 95% CI, 1.7, 3.3) and fall risk as staff rationale for restraint (OR = 3.5, 95% CI., 1.5, 8.0) were predictive of continued restraint use. Adding nursing hours, staff mix, and prevalence of restraint use by unit to the logistic regression model was not statistically significant (partial chi‐square = 2.79, df = 6, P = .834). Nursing home site was added to the model without changing the significance (P < .05) of cognitive status or fall risk as a staff rationale for restraint use.

CONCLUSION: Continued restraint use in nursing home residents in this study most often occurred with severe cognitive impairment and/or when fall risk was considered by staff as a rationale for restraint. Efforts to reduce or eliminate physical restraint use with these groups will require greater efforts to educate staff in the assessment and analysis of fall risk, along with targeted interventions, particularly when cognition is also impaired.
The Relation Between Cortisol Excretion and Fractures in Healthy Older People: Results from the MacArthur Studies ‐ Mac
Authors: Greendale Gail A. , Unger Jennifer B. , Rowe John W. , Seeman Teresa E.
Published: April 2015

BACKGROUND: In persons with depression, higher urinary Cortisol is associated with lower bone mineral density.

OBJECTIVE: To examine the relation between urinary free Cortisol (UFC) and fractures.

SETTING: Community‐based samples from Durham, NC, East Boston, MA, and New Haven, CT. PARTICIPANTS: 684 men and women, aged 70 to 79 at baseline, who were part of the MacArthur Study of Successful Aging.

DESIGN: Cohort study. Participants with previous history of fractures at baseline were excluded.

MEASURES: The primary exposure variable was overnight (8: 00 p.m. to 8: 00 a.m.) UFC (μg/g creatinine) at baseline (1988). Outcomes were self‐reported hip, arm, spine, wrist, or other fracture during the follow‐up period (1988–1995). Covariates were baseline age, gender, race, body mass index, current physical activity, lower extremity strength, depression subscale of the Hopkins Symptom Checklist, and current use of cigarettes and alcohol.

ANALYSIS: Logistic regression was used to predict the occurrence of incident fractures (1988–1995) as a function of quartiles of baseline UFC. Models were adjusted for age, gender, and race and were also multiply adjusted for the remaining covariates listed above. Gender‐stratified models and models that excluded corticosteroid users were also run. RESULTS: In multiply adjusted models, higher baseline levels of UFC were significantly associated with incident fractures. Odds of fracture (95% Confidence Intervals) for increasing quartiles of baseline UFC, multiply adjusted, were: 2.28 (.91, 5.77); 3.40 (1.33, 8.69); 5.38 (1.68, 17.21). Results were not materially influenced by exclusion of persons using corticosteroids.

CONCLUSIONS: Higher baseline UFC is an independent predictor of future fracture.
Psychotropic Medication Withdrawal and a Home‐Based Exercise Program to Prevent Falls: A Randomized, Controlled Trial
Authors: Campbell A. John , Robertson M. Clare , Gardner Melinda M. , Norton Robyn N. , Buchner David M.
Published: April 2015

OBJECTIVE: To assess the effectiveness of psychotropic medication withdrawal and a home‐based exercise program in reducing falls in older people.

DESIGN: A randomized controlled trial with a two by two factorial design.

SETTING: Seventeen general practices in Dunedin, New Zealand.

PARTICIPANTS: Women and men aged 65 years registered with a general practitioner and currently taking psychotropic medication (n = 93).

INTERVENTIONS: Two interventions: (1) gradual withdrawal of psychotropic medication versus continuing to take psychotropic medication (double blind) and (2) a home‐ based exercise program versus no exercise program (single blind).

MEASUREMENTS: Number of falls and falls risk during 44 weeks of follow‐up. Analysis was on an intent to treat basis. RESULTS: After 44 weeks, the relative hazard for falls in the medication withdrawal group compared with the group taking their original medication was. 34 (95% CI,. 16–74). The risk of falling for the exercise program group compared with those not receiving the exercise program was not significantly reduced.

CONCLUSIONS: Withdrawal of psychotropic medication significantly reduced the risk of falling, but permanent withdrawal is very difficult to achieve.
Mortality One‐Year Postdischarge from a Veterans Affairs Geriatric Evaluation and Management Unit: Assessing Mortality Risks
Authors: Williams Arthur R. , Meuleman John M. , Shaw Mary M. Conlin
Published: April 2015

OBJECTIVE: To assess at Geriatric Evaluation and Management Unit (GEM) admission factors that affect mortality 12‐months postdischarge and to develop a preliminary risk scoring protocol to guide targeting of GEM care.

SETTING: A 24 bed‐GEM at a Veterans Affairs (VA) Medical Center.

DESIGN: Relative risks (RR) were assessed using prospective data; a risk protocol from 1988–1989 data was tested on 1990–1991 patients.

SUBJECTS: A total of 283 male patients, aged 60 to 102, discharged over 4 years.

RESULTS: Age at GEM admission did not correlate with death (r =. 14; P =. 145), but did correlate with risk scores (r =. 33, P <. 001). The risk protocol had a sensitivity of. 67 and specificity of 1.00. High and low risk patients had mortalities of 51% versus 20%, a Wilcoxon (Gehan) statistic of 15.22, df = 1, and P <. 001. Differences in mortality ceased about 100 days postdischarge. Three univariate RR exceeded 1.00 at a 99% Confidence Interval (CI): IADL score (RR: 1.12; CI, 1.03–1.21); nursing acuity score (RR: 1.78; CI: 1.02–3.11); and a primary diagnosis of pneumonia/sepsis (RR: 3.95; CI, 1.60–9.78). Four RRs exceeded 1.00 at a 90% CI: dementia (RR: 1.78; CI, 1.02–3.09); transfer into the GEM from a medical service (RR: 1.47; CI, 1.02–2.12); deconditioning/functional decline (RR: 1.67; CI, 1.12–2.48); and use of a Foley catheter (RR: 2.22; CI, 1.11–4.45). Thirteen other potential risk factors were found in a multivariate analysis.

CONCLUSIONS: The point estimates of risk factors may help clinicians target GEM care, but the development of a useable risk protocol requires additional work. Causal models may be needed to assess patient conditions related to successful treatment in GEMs.
Use of Physician and Acute Care Services by Persons With and Without Alzheimer's Disease: A Population‐Based Comparison
Authors: Leibson Cynthia , Owens Tomas , O'Brien Peter , Waring Steve , Tangalos Eric , Hanson Virginia , Plevak Matt , Kokmen Emre
Published: April 2015

OBJECTIVE: To estimate differences in use of acute care services between persons with and without Alzheimer's disease (AD).

SETTING/SUBJECTS: All Rochester, Minnesota, residents with AD onset between January 1, 1980, and December 31, 1984 (n = 301), plus one age‐ and sex‐matched nondemented control per case, were identified with a retrospective review of community‐based medical records.

MEASUREMENTS: Cases and controls were followed in their medical records for number of acute care encounters in the year before January 1 of the index year (year of onset for AD case and their matched control) and in the 4 years following December 31 of the index year. Encounters included clinician visits (office or nursing home), emergency room (ER) visits, hospitalizations (inpatient and outpatient), and inpatient days. Multivariate regression analyses were adjusted for age, sex, pre‐index level of illness, and follow‐up time.

RESULTS: In the pre‐index period, cases and controls were similar with respect to level of illness, number of office visits, ER visits, and hospitalizations. In the year before AD onset, 17 cases (7%) had a clinician visit in the nursing home compared with no controls. In the 4 years after the index year, mean length of follow‐up was 3.4 years for both cases and controls. The numbers of ER visits, hospitalizations, and inpatient days were similar for cases and controls. Sixty‐four percent of AD cases had a clinician visit in a nursing home versus 1 % of controls. Controls experienced more office visits than cases (median = 16 vs 10, P <. 001). CONCLUSIONS: The onset of AD is not associated with greater use of acute care services. However, neither is the high use of nursing home care offset by fewer ER or hospital encounters.
Age‐Related Differences in Management of Heart Disease: A Study of Cardiac Medication Use in an Older Cohort
Authors: Ganz David A. , Lamas Gervasio A. , Orav E. John , Goldman Lee , Gutierrez Peter R. , Mangione Carol M.
Published: April 2015

BACKGROUND: Previous studies have suggested suboptimal use of cardiac medications for secondary prevention after myocardial infarction (MI) and atrial fibrillation (AF), especially among older people.

OBJECTIVE: To determine whether patients older than 75 years are less likely than those aged 65 to 74 to be prescribed medications with evidence‐based indications, including angiotensin‐converting enzyme (ACE) inhibitors for left ventricular dysfunction (LVD) and/or diabetes mellitus (DM), aspirin and/or β‐blockers for those with a history of MI, and warfarin for chronic AF.

DESIGN: A retrospective cohort study.

SETTING: Twenty‐nine hospitals, predominantly tertiary‐care institutions.

PARTICIPANTS: A total of 407 patients randomized to ventricular or dual‐chamber pacing from February 26, 1993, to September 30, 1994, in the Pacemaker Selection in the Elderly (PASE) trial.

MEASUREMENTS: A review of the patient's medical history and a physical exam at study enrollment, three follow‐up timepoints, and a study closeout.

RESULTS: Patients older than 75 years with LVD and/or DM were less likely to be prescribed ACE inhibitors (OR = .56 (0.31‐1.00)); patients older than 75 with a history of MI were less likely to be taking aspirin (OR = .43 (0.19‐.95)), and patients older than 75 with AF were less likely to be prescribed warfarin (OR = .18 (0.05‐.61)). Patients older than 75 years of age with any or all of the conditions studied were less likely to be prescribed indicated medications than those ages 65 to 74 (OR = .35 (0.18‐.70)), after controlling for between‐group differences in comorbidity, gender, and number of noncardiac medications.

CONCLUSION: Older age is a significant independent negative correlate of evidence‐based cardiac medication use in this cohort. Causes for this finding need to be explored. J Am Geriatr Soc 47:145–150, 1999.
An Evaluation of a Family Visit Education Program
Authors: McCallion Philip , Toseland Ronald W. , Freeman Kurt
Published: April 2015

OBJECTIVES: This study was designed to examine the impact of the Family Visit Education Program (FVEP) on family members, nursing staff, and nursing home residents with dementia.

DESIGN: The study employed a 2 × 3 single‐blind, randomized control group design with two study conditions, FVEP or usual care (UC), and three times of measurement, baseline, 3‐months, and 6‐months.

SETTING: The study was conducted in five skilled‐care nursing homes that ranged in size from 120 to 300 beds.

PARTICIPANTS: Sixty‐six residents with dementia and their primary visitor were randomly assigned to FVEP (n = 32) or UC (n = 34).

MEASUREMENTS: Residents were assessed for (1) psychosocial functioning, (2) depression, (3) agitated behavior, and (4) degree of positive social interaction. Nursing staff were assessed for changes in the time and methods used to manage problem behaviors. Visitors were assessed for (1) dementia management skills, (2) extent of perceived caregiving hassles, and (3) visit satisfaction.

RESULTS: FVEP was effective for reducing residents' problem behaviors and for decreasing their symptoms of depression and irritability. It was also effective for improving the way family members and other visitors communicated with residents, but, with the exception of reducing the use of mechanical restraints, it was not effective in changing nurses' management of residents' behavior problems.

CONCLUSIONS: It is possible to educate family members to communicate and interact more effectively with nursing home residents with dementia. This has beneficial effects on residents but not on nursing staff's management of problem behaviors. J Am Geriatr Soc 47:203–214, 1999.
BOOK REVIEWS
Authors: Katz Paul R.
Published: April 2015

Book reviewed in this article:

The Health Care Future: Defining the Argument, Healing the Debate

James J. Pattee and Orlo J. Otteson. Minneapolis: North Ridge Press, 1998, 46 pages, $27.50
Enhanced Cognitive Performance with Estrogen Use in Nondemented Community‐Dwelling Older Women
Authors: Steffens David C. , Norton Maria C. , Plassman Brenda L. , Tschanz Jo Ann T. , Wyse Bonita W. , Welsh‐Bohmer Kathleen A. , Anthony James C. , Breitner John C. S.
Published: April 2015

OBJECTIVE: To examine the association between history of postmenopausal estrogen use and cognitive function in a large sample of nondemented community‐dwelling older women.

SETTING: A community of older residents in Cache County, Utah.

PARTICIPANTS: A total of 2338 nondemented women aged 65 and older.

MEASUREMENTS: All subjects were administered the Modified Mini‐Mental State Examination (3MSE). Self‐reported information on current and past use of estrogen after menopause was also obtained using a structured interview. Estrogen use was drichotomized as: no use, past use, and current use. Apolipoprotein E (APOE) genotype was determined and was dichotomized by the presence of an e4 allele. A series of variance/covariance models was conducted with the 3MSE score as the dependent variable, first considering estrogen use alone, then adding, sequentially as covariates, education, age, health status, APOE genotype, current depression status, and history of head injury.

RESULTS: In the simplest bivariate model, the 3MSE means (and confidence intervals) were 92.1 (91.7–92.4), 93.5 (93.1–93.9), and 94.4 (94.0–94.7) for never‐, past‐, and current users, respectively. In the final model (R2 = 0.28), no use of estrogen replacement therapy (P = .006), lower education (P < .001), poorer perceived health status (P = .035), current depression (P = .014), and presence of at least one APOE e4 allele (P < .001) each independently predicted lower 3MSE score. Both current and past estrogen users had significantly higher 3MSE scores than never‐users (P = .0063 and P = .0096, respectively).

CONCLUSIONS: In this large community study, women who had used estrogen after menopause scored higher on the 3MSE. This finding remained, even after controlling for the effects of age, education, APOE genotype, and other variables that may affect cognition. These data support studies reporting a beneficial role of estrogen on cognition in postmenopausal women, particularly among current estrogen users.
Association Between Bone Mineral Density and Cognitive Decline in Older Women
Authors: Yaffe Kristine , Browner Warren , Cauley Jane , Launer Lenore , Harris Tamara
Published: April 2015

OBJECTIVE: To test the hypothesis that bone mineral density (BMD), a marker of cumulative estrogen exposure, is associated with cognitive function in nondemented older women.

DESIGN: A prospective cohort study.

SETTING: Clinical centers in Baltimore, Maryland, Minneapolis, Minnesota, the Monongahela Valley near Pittsburgh, Pennsylvania, and Portland, Oregon.

PARTICIPANTS: We evaluated 8333 older community‐dwelling women enrolled in the Study of Osteoporotic Fractures who were not taking estrogen replacement.

MEASUREMENTS: Calcaneal and hip BMD were measured at baseline and at follow‐up (4–6 years later);vertebral fractures were ascertained radiologically at year 6. Women were administered a modified Mini‐Mental State Exam, Trails B, and Digit Symbol at baseline and at follow‐up.

RESULTS: Compared with women with higher bone mineral density, women with low baseline BMD had up to 8% worse baseline cognitive scores (P = .001) and up to 6% worse repeat cognitive scores (P = .001), even after multivariate adjustments. For 1 SD decrease in baseline hip BMD or calcaneal BMD, women had a 32% (95% CI, 19–47%) or a 33% (95% CI, 20–48%) greater odds of cognitive deterioration (worst 10th percentile of change). Women with vertebral fractures had lower cognitive test scores and a greater odds of cognitive deterioration than those without fractures (OR = 1.29; 95%CI, 1.03‐1.60).

CONCLUSIONS: Women with osteoporosis, whether measured by baseline BMD, reductions in BMD, or vertebral fractures, have poorer cognitive function and greater risk of cognitive deterioration. Our findings suggest a link between two of the most common conditions affecting older women. Further understanding of this association may be important for new treatment and prevention directions. J Am Geriatr Soc 47:1176‐1182,1999.
Thyroid Function, Morphology and Prevalence of Thyroid Disease in a Population‐Based Study of Danish Centenarians
Authors: Andersen‐Ranberg Karen , Jeune Bernard , Høier‐Madsen Mimi , Hegedüs Laszlo
Published: April 2015

OBJECTIVES: To investigate thyroid function, morphology, and autoimmunity in relation to physical function in an unselected population of centenarians.

DESIGN: A population‐based survey.

SETTING: Denmark.

PARTICIPANTS: All persons living in Denmark who celebrated their 100th anniversary during the period April 1, 1995 to May 31, 1996, a total of 276 persons.

MAIN OUTCOME MEASUREMENTS: Thyroid hormones (TSH, T4, FT4I, T3, FT3I, and T3RU), thyroid autoantibodies (TPOab and Tgab), thyroid volume, activities of daily living according to the Katz Index of ADL.

RESULTS: In all, 207 (75%) of the 276 eligible subjects participated, and 148 agreed to blood tests. Among the participants, 2.9% had previously known hyperthyroidism, and the same proportion had previously known hypothyroid‐ism. The blood tests did not reveal any undiagnosed cases of overt thyroid dysfunction. However 7.2% had a subnormal serum TSH, and 2.9% had an elevated serum TSH; all had normal serum T3 and serum T4 levels. Thyroid autoantibodies were detected in 26 (17.6%) centenarians (11.5% had Tgab and 9.5% had TPOab). Among relatively independent centenarians, low serum T3 was significantly associated with high comorbidity (P = .029), whereas both low serum T3 and thyroid autoantibodies were significantly associated with ADL‐dependency (P < .001 and P = .030, respectively). Ultrasonography (n = 50) revealed a small gland with a median volume of 8.3 mL (range 3.2–27.9) compared with an expected volume of 20 mL (14–26) (P < .001. (There was no significant relationship to body weight. When examined by ultrasound, only 26% had significant morphological alterations.

CONCLUSIONS: Thyroid dysfunction does not seem to be more prevalent among centenarians than among younger old people. Low serum T3 is related to poor physical function and co‐morbidity, whereas thyroid autoimmunity is related only to poor physical functioning. Despite atrophy of the thyroid gland, these findings suggest that thyroid function is well preserved in centenarians. J Am Geriatr Soc 47:1238–1243, 1999.
MediCaring: Development and Test Marketing of a Supportive Care Benefit for Older People
Authors: Lynn Joanne , Dulac Jennie D. , O'Connor Mary Ann S. , Roach Mary Joan , Ross Cathy S. , Wasson John H.
Published: April 2015

OBJECTIVES: To develop an alternative healthcare benefit (called MediCaring) and to assess the preferences of older Medicare beneficiaries concerning this benefit, which emphasizes more home‐based and supportive health care and discourages use of hospitalization and aggressive treatment. To evaluate the beneficiaries' ability to understand and make a choice regarding health insurance benefits; to measure their likelihood to change from traditional Medicare to the new MediCaring benefit; and to determine the short‐term stability of that choice.

DESIGN: Focus groups of persons aged 65+ and family members shaped the potential MediCaring benefit. A panel of 50 national experts critiqued three iterations of the benefit. The final version was test marketed by discussing it with 382 older people (men s 75 years and women a 80 years) in their homes. Telephone surveys a few days later, and again 1 month after the home interview, assessed the potential beneficiaries' understanding and preferences concerning MediCaring and the stability of their responses.

SETTINGS: Focus groups were held in community settings in New Hampshire, Washington, DC, Cleveland, OH, and Columbia, SC. Test marketing occurred in New Hampshire, Cleveland, OH; Columbia, SC, and Los Angeles, CA.

PARTICIPANTS: Focus group participants were persons more than 65 years old (11 focus groups), healthcare providers (9 focus groups), and family decision‐makers (3 focus groups). Participants in the in‐home informing (test marketing group) were persons older than 75 years who were identified through contact with a variety of services.

MEASUREMENTS: Demographics, health characteristics, understanding, and preferences.

RESULTS: Focus group beneficiaries between the ages of 65 and 74 generally wanted access to all possible medical treatment and saw MediCaring as a need of persons older than themselves. Those older than age 80 were mostly in favor of it. Test marketing participants understood the key points of the new benefit: 74% generally liked it, and 34% said they would take it now. Preferences were generally stable at 1 month. In multivariate regression, those preferring MediCaring were wealthier, more often white, more often living in senior housing, and using more homecare services. However, they were not more often in poor health or needing ADL assistance.

CONCLUSIONS: Older persons aged more than 80 years can understand a health benefit choice; most liked the aims of a new supportive care benefit, and 34% would change immediately from Medicare to a supportive care benefit such as MediCaring,. These findings encourage further development of special programs of care, such as MediCaring, that prioritize comfort and support for the old old. J Am Geriatr Soc 47:1058–1064,1999.