bluuebunny/crossref_metadata_2025 huggingface dataset:
Completeness of Admission of Residents Assessments in Teaching Nursing Homes
Authors: Lavizzo‐Mourey Risa , Mezey Mathy , Taylor Lynne
Published: April 2015

In order to assess one aspect of the quality of care within teaching nursing homes, we examined how well these homes conform to geriatric experts' expectations for the admission assessment of elderly nursing home residents. Four hundred‐sixty records representing new admissions to five teaching nursing homes over a 1‐year period were assessed for completion of items considered important parts of the admission assessment by geriatric experts. Univariate and multivariate analyses both suggest the following four findings. First, the admission assessments performed at teaching nursing homes reflect geriatric experts' priority areas with two exceptions: (1) the assessment of affective disorders and (2) the identification of advance directives. Second, physician‐nurse practitioner teams perform the high priority parts of the admission assessment to a degree similar to that of physicians alone. Third, resident's age and expected length of stay partially determine the extent of the admission assessment, as patients with shorter lengths of stay generally received a more complete assessment. Fourth, even among teaching nursing homes, there are significant differences between nursing homes in the performance of comprehensive admission assessment by nursing home clinicians.
The Management of Geriatric Hypertension in Health Maintenance Organizations
Authors: Preston Jeanette A. , Retchin Sheldon M.
Published: April 2015

Objective: To evaluate the quality of medical care received by Medicare enrollees with hypertension in health maintenance organizations (HMOs) compared to that received by a similar group of elderly hypertensives in a fee‐for‐service (FFS) setting.

Design: A quasi‐experimental design was used to study an historical cohort of newly evaluated hypertensive patients over a 2‐year period.

Setting: Medicare HMO and FFS practice settings.

Participants: Eight Medicare HMOs and 87 FFS primary care physicians in the same communities were selected. A sample of 685 elderly hypertensive patients was studied, 336 in FFS settings and 349 in HMOs.

Measurements and Main Results: An expert panel of physicians selected standards of care for the management of geriatric hypertension, and medical records were reviewed. The results showed significant differences (P < 0.01) in recording medications (94.5% HMO versus 88% FFS) and smoking histories (75.8% HMO versus 64.7% FFS), checking orthostatic blood pressures (9.5% HMO versus 3.3% FFS), performing funduscopy (44.4% HMO versus 27% FFS), completing cardiac examinations (90.8% HMO versus 79.8% FFS), and obtaining chest x‐rays (72.8% HMO versus 64.3% FFS, P < 0.05). Treatment and follow‐up were similar between the two groups, except that FFS hypertensives were more likely to have medications adjusted and electrolytes ordered.

Conclusions: The results suggest that elderly hypertensives in HMOs receive equal or better quality of care for most criteria compared to elderly hypertensives in FFS settings.
An Evaluation of a Brief Health Status Measure in Elderly Veterans
Authors: Weinberger Morris , Samsa Gregory P. , Hanlon Joseph T. , Schmader Kenneth , Doyle Marti E. , Cowper Patricia A. , Uttech Kay M. , Cohen Harvey J. , Feussner John R.
Published: April 2015

Objective: To examine the feasibility of a brief 36–item health status measure in elderly male veterans, by comparing it with the 136–item Sickness Impact Profile.

Design: Cross‐sectional study in which all subjects completed both measures in a random order.

Setting: Durham VAMC General Medicine and Geriatrics Clinics.

Patients: Convenience sample of 25 male veterans aged 65 and older (mean age = 73.5 years; 68% white; 68% currently married; mean annual income = $7,000).

Main Outcome Measures: Two well‐validated health status measures, the Sickness Impact Profile and the SF‐36.

Results: The SF‐36 took less time to administer than the Sickness Impact Profile in both the Geriatrics Clinic (mean: 15 vs 33 minutes) and General Medicine Clinic (mean: 14 vs 21 minutes). Although SIP scores consistently displayed a more optimistic picture of respondents' health compared with the SF‐36, the two instruments were highly correlated: overall functioning (r = 0.73), physical functioning (r = 0.78), and social functioning (r = 0.67).

Conclusions: These two measures provide a similar ranking of elderly male veterans' health status. The significantly shorter administration time of the SF‐36 is an attractive feature for both researchers and clinicians interested in assessing health status.
Incidence and Characteristics of Antibiotic Use in Aged Nursing Home Patients
Authors: Warren John W. , Palumbo Francis B. , Fitterman Leslye , Speedie Stuart M.
Published: April 2015

Objective. To measure the prevalence, incidence, types, and certain characteristics of antibiotics prescribed in nursing homes.

Design and Setting. Periodic survey over 1 year of patient charts in 53 stratified, randomly selected nursing homes in the state of Maryland.

Patients. All patients 65 years of age or more residing in these nursing homes on the first day of study.

Results. Of 4,165 patients in 53 nursing homes, records over the year were satisfactory in 3,899 patients in 52 nursing homes. The prevalence of antibiotic use on the first day of the study was 8%. Over the next 12 months, observations of more than one million patient‐days revealed an incidence of 0.46 antibiotic courses/100 patient‐days; 54% of the 3,899 patients received at least one antibiotic course.

For presumed active infections, beta lactam antibiotics were the most commonly used, 54% of antibiotic orders. For all antibiotics, urinary tract infection was the most common indication, eliciting 36% of orders including 9% for asymptomatic bacteriuria. Skin, lower respiratory, and upper respiratory infections comprised 14%–17% each. Physicians prescribed 94% of courses but documented examinations of only 44% of patients at the outset of these courses. Consensus criteria for minimal diagnostic evaluation of four selected infections were met in only 11% of episodes of infection. Although the most serious infections tended to be better evaluated than others, 31% of the former were not noted to have been examined by a physician. Three percent of orders were for prophylaxis and two‐thirds of these antibiotics were administered for more than 2 days.

Conclusions. Antibiotics are frequently prescribed for aged nursing home patients, often in the absence of a physician's examination and other features commonly performed in evaluation of specific infectious diseases. More than one‐fifth of antibiotics prescribed by presumed active infections were for two infections usually thought not to require antibiotic therapy, “viral” upper respiratory infection (13%) and asymptomatic bacteriuria (9%). To optimize antibiotic use in nursing homes, greater attention should be directed to appropriate durations of prophylaxis for urologic, dental, and minor surgical procedures; to standards for diagnostic evaluations of common infections; and to the roles of antibiotics in upper respiratory infections and in asymptomatic bacteriuria.
Two‐Year Trends in Physical Performance following Supervised Exercise among Community‐Dwelling Older Veterans
Authors: Morey Miriam C. , Cowper Patricia A. , Feussner John R. , DiPasquale Robert C. , Crowley Gail M. , Samsa Gregory P. , Sullivan Robert J.
Published: April 2015

The extent to which exercise can delay the normal decline in physical performance associated with aging is unknown. We examined the impact of 2 years of supervised exercise on cardiovascular fitness, flexibility, and strength in a group of elderly (age 65–74) veterans. Seventy‐five patients exercised 3 days/week for 90‐minute sessions emphasizing aerobic, flexibility, and strength development. Thirty‐six (47%) completed 2 years of a voluntary supervised exercise program (n = 16–25 with complete data). Over a 2‐year follow‐up period, cardiovascular outcome variables improved significantly: metabolic equivalents increased 20% (7.4 ± 2.2 to 9.0 ± 2.4, P < 0.001) and submaximal heart rate decreased 7% (131.4 ± 14.8 to 121.0 ± 18.5 beats/minute, P = 0.06). Resting heart rate decreased 8% (68.5 ± 8.0 to 63.6 ± 8.4 beats/minute, P = 0.02) but this difference did not reach statistical significance. Flexibility, measured by hamstring length, improved 11% (57.5 ± 15.1 to 64.0 ± 11.1 degrees, P = 0.02). Strength variables did not improve. The study indicates that improvements in cardiovascular function and flexibility achieved by the elderly in the early stages of an exercise program can be maintained for at least 2 years.
Fever Response in Elderly Nursing Home Residents: Are the Older Truly Colder?
Authors: Castle Steven C. , Norman Dean C. , Yeh Michael , Miller Denver , Yoshikawa Thomas T.
Published: April 2015

Objective To test the hypothesis that many nursing home residents with an apparently blunted fever response (maximum temperature <101°F) may actually have a significant change in temperature (ΔT ≥ 2.4°F) which is not recognized because of a low baseline temperature.

Design: Retrospective chart review for cases of infection that met specific criteria and for chart‐recorded baseline and infection temperatures. Chart‐recorded baseline temperatures were prospectively compared with re‐measurement of morning temperatures.

Setting: Nursing Home Care Unit of the VAMC West Los Angeles.

Patients: Random review of 40 residents' charts resulted in the detection of 69 infections among 26 residents over a 20‐month period. Fifty randomly selected residents prospectively underwent comparison of chart‐determined and actual re‐measurement of baseline temperatures.

Results: In 50 randomly selected residents, the mean oral baseline temperature of 97.4 ± 0.2 (°F ± SEM) closely approximated the mean nurse‐recorded measures in the charts (97.6 ± 0.1). Chart review detected 69 infections among 26 residents, with 53 episodes having a temperature recorded during the infection. The mean maximum temperature (Tmax) during an infection was 101.3 ± 0.3 (°F ± SEM) but 47% (25/53) of the episodes had a “blunted” fever response (Tmax < 101°F). Of the 25 “blunted” fevers (Tmax < 101°F), about one‐fourth demonstrated an adequate change in temperature from baseline (ΔT ≥ 2.4°F) but failed to reach 101°F because of a low baseline. Most infections (89%) had a Tmax > 99°F.

Conclusion: Establishing a nursing home patient's basal temperature and monitoring for changes in temperature (AT > 2.4°F) and/or lowering the threshold for recognition of fevers (to 99° or 100°F) in nursing home residents with a change in function should assist in early recognition of infections.
Detectable Serum Levels of Tumor Necrosis Factor Alpha May Predict Early Mortality in Elderly Institutionalized Patients
Authors: Mooradian Arshag D. , Reed Richard L. , Osterweil Dan , Scuderi Philip
Published: April 2015

Objective: To determine if detectable serum tumor necrosis factor alpha (TNF) levels are associated with higher mortality in nursing home residents.

Subjects and methods: The basal serum concentrations of TNF and interleukin‐1 alpha (IL‐1) were measured in 129 elderly nursing home patients (mean age of 89 years), and survival in the cohort was monitored over a 13‐month period.

Results: At 4 months follow‐up, seven out of 33 patients with detectable serum TNF levels had died (21.2%), and only three out of 96 patients with undetectable serum TNF levels had died (3.1%) (P<0.001). The difference in mortality remained significant up to 13 months of follow‐up (P<0.05). Those with detectable serum TNF levels and those with undetectable levels were comparable in age, body mass index, hematocrit, lymphocyte counts, and serum level of albumin, prealbumin, and retinol‐binding protein. When patients with detectable serum IL‐1 levels were compared to those with undetectable levels, there were no significant differences in mortality over a 13‐month period.

Conclusion: Detectable serum TNF levels in elderly nursing home patients may be a predictor of early mortality.
Medicare Reimbursement for Geriatric Assessment: Report of the American Geriatrics Society Ad Hoc Committee on Geriatrics Assessment
Authors: Rubenstein Laurence Z. , Applegate William B. , Burton John R. , Hyer Kathryn , Pawlson L. Gregory , Winograd Carol H.
Published: April 2015

This ad hoc committee report from the American Geriatrics Society proposes the prompt initiation of Medicare reimbursement for geriatric assessment (GA) services (also termed comprehensive geriatric assessment or geriatric evaluation and management services). Despite an extensive body of literature documenting the effectiveness of GA for improving health care outcomes in many settings for identifiable groups of frail elderly patients, no explicit Medicare reimbursement mechanisms currently exist to cover GA services provided by either hospital or physician. We believe that new physician reimbursement codes specific for geriatric assessment should be established in the Current Procedural Technology (CPT‐4) manual and that reimbursement for GA should be specifically provided under Part B of Medicare. Further, we believe that hospital reimbursement within the Medicare prospective payment system should be modified to encourage GA during inpatient stays for appropriate patients.

This paper summarizes the background for these recommendations. It defines the major content of GA at three levels of intensity—screening, intermediate, and comprehensive. It describes the major sites for conducting GA—hospital, office, home, nursing home. Finally, it proposes criteria for targeting patients most likely to benefit from GA.
Subcutaneous Fluid Administration in Elderly Subjects: Validation of an Under‐Used Technique
Authors: Lipschitz S. , Campbell A. J. , Roberts M. S. , Wanwimolruk S. , McQueen E. G. , McQueen M. , Firth L. A.
Published: April 2015

In a crossover study in six volunteers over the age of 65, absorption of 500 mL of normal saline given subcutaneously was compared with that given intravenously. Tritiated water and technetium pertechnetate were used as water tracers. Tritium radioisotope levels in the blood increased in a smooth curve during subcutaneous infusion, reaching equilibrium levels within 60 minutes. The area under the curve after subcutaneous infusion was almost identical to that after intravenous infusion in all subjects. Radioactivity could not be demonstrated at the subcutaneous site 1 hour after completion of the infusion. Subcutaneous infusion is an effective method of giving fluid to elderly people and deserves more widespread use.
International Comparison of Long‐Term Care: the Need for Resident‐Level Classification
Authors: Fries Brant E. , Ljunggren Gunnar , Winblad Bengt
Published: April 2015

Differences between long‐term care facilities in Stockholm (1134 residents) and New York (95,000 residents statewide) were examined. The comparison employed a resident classification system, Resource Utilization Groups (RUG‐II), which links individuals' characteristics to resource use. Distributions of Activity of Daily Living functionality and RUG‐II categories demonstrated significant differences between these two populations, with the Stockholm facilities more akin to the heavier care skilled nursing facilities in New York. These differences may indicate different uses of long‐term care beds in the United States and Sweden and demonstrate the need for resident‐level classification systems in cross‐national studies.
Progression of Cognitive Impairment in Alzheimer's Disease
Authors: Burns Alistair , Jacoby Robin , Levy Raymond
Published: April 2015

Change in cognitive function was assessed over 12 months in 110 patients over the age of 65 satisfying National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) criteria for “probable” Alzheimer's Disease. A highly significant deterioration in cognitive function was observed. Decline in cognitive scores was relatively normally distributed. Patients who died during the follow‐up had more apraxia at entry to the study than survivors. A greater rate of decline was seen in patients whose parents suffered from dementia (but not in those where a sibling or other relative was affected), in subjects who had moderate dementia, and those who had been ill for less than 24 months. Age, age of onset, and the presence or absence of aphasia or apraxia had no influence on rate of progression. A cluster analysis revealed three patterns of decline.
Forearm Blood Flow Response to Posture Change in the Very Old: Non‐Invasive Measurement by Venous Occlusion Plethysmography
Authors: Lipsitz Lewis A. , Bui Matthew , Stiebeling Maureen , McArdle Colin
Published: April 2015

Little is known about the peripheral vascular response to posture change in very elderly people who are vulnerable to the development of orthostatic hypotension. This is due, in part, to the risks of currently utilized invasive vascular monitoring techniques in the elderly population. We studied the forearm vascular response to active standing in 18 healthy young, 10 healthy old, and 19 impaired elderly subjects, using the non‐invasive technique of venous occlusion plethysmography. In six subjects this technique was compared to duplex doppler ultrasonography for the measurement of postural changes in forearm blood flow. Forearm blood flow changes determined by venous occlusion plethysmography were 11% larger than doppler measurements, but the two methods strongly correlated (r = 0.90, P < .001). Mean forearm vascular resistance increased to a significantly greater extent at 1 minute of standing in young subjects than in both groups of old, although the response was quite variable in all groups. Two healthy elderly (20%) and eight impaired elderly (40%) subjects had unexpected forearm vasodilatation at 1 minute of standing. By 3 minutes, forearm vascular resistance had increased by similar amounts in all three groups of subjects. Five impaired elderly and no healthy young or healthy old subjects had orthostatic hypotension, defined as ≥10 mm Hg decline in mean arterial blood pressure at 1 or 3 minutes of standing. Forearm vascular resistance changes did not correlate with blood pressure response to standing. Thus, forearm vascular response to 1 minute of active standing is attenuated in many elderly subjects. This abnormality may impair adaptation to orthostatic stress in advanced age
BOOK REVIEWS
Authors: Katz Paul R. , Richardson James P.
Published: April 2015

Handbook of Prescribing Medications for Geriatric Patients By Judith C. Ahronheim, MD. Boston, MA, Little, Brown and Company, 1992. 463 pages. $26.50.
Low to Moderate Intensity Endurance Training in Healthy Older Adults: Physiological Responses after Four Months
Authors: Posner Joel D. , Gorman Kevin M. , Windsor‐Landsberg Lisa , Larsen James , Bleiman Michael , Shaw Carl , Rosenberg Beth , Knebl Janice
Published: April 2015

Objective

To determine the physiological adaptations in previously sedentary healthy older men and women (mean age = 68) to a 16‐week low‐to‐moderate‐intensity exercise program.

Design

Randomized, controlled trial.

Setting

An exercise facility and testing laboratory in a gerontological research institute.

Participants

Two‐hundred forty‐seven community‐dwelling older persons free of significant cardiovascular, pulmonary, or uncontrolled metabolic disease, anemia, electrolyte abnormality, resting BP of 165/90 or greater, or chronic disease affecting the ability to exercise on a bicycle.

Intervention

Subjects were randomly assigned to either an exercise (n = 166) or attention control group (n = 81). Exercisers trained thrice weekly for 40 minutes on a cycle ergometer (5‐minute warm up, 30 minutes at training heart rate (THR), 5‐minute cool down). THR was set at 70% of peak heart rate attained on a maximal exercise test (mean = 115 ± 15). Control subjects attended weekly group talks. Testing took place before and after the program.

Results

Peak attained oxygen uptake (VO2max) increased 8.5% in exercisers and decreased slightly in controls (p < .001) and oxygen uptake at ventilatory threshold (VeT VO2) increased by 3.5% in exercisers and decreased by 3% in controls (p < .001). This pattern of a greater increase in VO2max than VeT VO2 is different from that seen in young and middle‐aged subjects.

Conclusion

This study demonstrated that a large scale training program is feasible for healthy older people, that physiologic improvements can be measured after 16 weeks of low‐to‐moderate‐intensity training, and that mechanisms of adaptation to exercise may be different in elderly subjects from those in younger ones.
Use of a Vacuum Tumescence Device in the Management of Impotence in Men with a History of Penile Implant or Severe Pelvic Disease
Authors: Korenman Stanley G. , Viosca Sharon P.
Published: April 2015

Purpose

To evaluate the use of a vacuum tumescence device in the treatment of impotence in couples wishing to restore coital function, whose male partners had unsatisfactory results from penile implants or in whom the man was impotent following treatment for prostate or colon carcinoma.

Subjects

Convenience sample of seventeen couples seeking treatment of male factor sexual dysfunction.

Methods

After completion of a comprehensive diagnostic evaluation of the male partner, couples who expressed a wish to restore coital function were instructed in the use of the vacuum tumescence device. Partners each filled out and initialled a daily diary of sexual activity and returned to clinic for followup at 3 and 6 months.

Results

Sixteen patients were able to obtain firm to hard erections lasting an average of 14.9 minutes and had satisfactory coitus with vaginal ejaculation an average of 3.9 times per month. There were no significant complications.

Conclusion

The vacuum tumescence device can be effective in the treatment of impotence after penile prosthesis explantation, in enhancement of inadequate erections with a prosthesis in place, and after surgical or radiation therapy for prostate or colon carcinoma.
Ethics Rounds at the Nursing Home: An Alternative to an Ethics Committee
Authors: Libow Leslie S. , Olson Ellen , Neufeld Richard R. , Martico‐Greenfield Theresa , Meyers Helene , Gordon Natalie , Barnett Peggy
Published: April 2015

The increased attention in US medicine to medical ethics reflects in large part the “new” demography of a growing elderly population and the conflict of whether decisions regarding medical care should be based on cost‐effectiveness or “human‐effectiveness.” Currently, about 40 percent of the nation's elderly end up in nursing homes where they confront ethical and legal dilemmas that would not arise in their own homes. In the nursing home, difficult medical‐ethical decisions generally rely on two approaches: the often used but frequently invalid concept of informed consent and little used ethics committees.

At The Jewish Home and Hospital for Aged in New York City we have developed a program of “ethics rounds” as an alternative to ethics committees. We conduct the rounds in the open style of a forum or clinical conference rather than with the aura of a decision‐making group. We encourage the participation of patients and family and seek to educate the staff, any one of whom may choose to attend. The rounds consist of a multidisciplinary case presentation, an interview of patient and/or family, a discussion by the staff, and an overview by an ethicist.

Staff response to the educational and interdisciplinary aspects of the rounds has been remarkably positive.
The Risk Factors of Age and Family History and Their Relationship to Screening Mammography Utilization
Authors: Costanza Mary E. , Stoddard Anne , Victoria P. , Zapka Jane G.
Published: April 2015

Objective

To study the association of two well known risk factors for breast cancer and the association of knowledge of those risk factors with mammography utilization.

Design

Cross sectional: two independent random telephone surveys.

Setting

Two Northeastern metropolitan communities surveyed in 1987 and in 1989.

Participants

Women without breast cancer who spoke English and who were between 45 and 75 years of age.

Main Outcome Measures

The two risk factors measured were a family history of breast cancer and being 65 or older. Participants were surveyed about their knowledge of risk factors, presence of risk factors, selected beliefs, attitudes, reinforcing factors and mammography use. Results were analyzed for women 50–75.

Results

There was a substantial increase in mammography use over the 2‐year period. Having a positive family history or being older is not associated with increased mammography utilization. Knowledge that family history and/or age are risks is associated with increased utilization. However, knowledge of risk factors is not associated with having those risks. Older women have lower utilization than younger women regardless of their knowledge of age as a risk. Increased physician recommendation is associated with increased utilization.

Conclusion

Since knowing that a factor is a risk and having a physician recommend mammography are each associated with increased use, we conclude that the primary care physicians' role in increasing mammography utilization is critical.
Hypnotics, Sleep, and Mortality in Elderly People
Authors: Morgan Kevin
Published: April 2015

Objective

To re‐assess relationships between mortality, hypnotic use, subjective insomnia, and sleep duration.

Design

A prospective study examining 5‐year mortality among hypnotic drug users and respondents with subjective insomnia identified in a longitudinal study of health, activity, and lifestyle (Nottingham Longitudinal Study of Activity and Ageing).

Setting

General community.

Participants

1042 survey respondents, aged over 65 years, randomly selected from the community and stratified at age 75 years.

Main Outcome Measure

Recorded mortality.

Results

During the 5‐year period, 352 respondents died. The mortality rate was significantly greater among those taking some form of medication for sleep (n = 208) than for those not taking sleep medication (n = 812; chi‐square = 4.91, df = 1, P = 0.027). When sleep medication users were categorized as either “hypnotic users” (ie, users of medication with recognized hypnotic or sedative actions) or “other users” (including analgesics and other over‐the‐counter medicines), only “other users” showed significant excess mortality (chi‐square = 7.27, df = 1, P = 0.007). Logistic regression showed that “other users” were 2.5 times more likely to die than “non‐users” even when gender, health risk, and usual sleep duration were controlled. There were no significant relationships between mortality and subjective insomnia or reported duration of sleep.

Conclusions

Earlier reported relationships between excess mortality and use of medication for sleep are replicated in this study. Among elderly people, however, this relationship does not derive from the pharmacological characteristics of prescription hypnotics. Rather, it appears that reported self‐medication to promote sleep, using a variety of non‐sedative products, provides an epidemiological “marker” for a group within which levels of morbidity and mortality are particularly high. Excess mortality associated with very short or long sleep duration was not replicated in this study. Overall, these findings provide little epidemiological support for a widespread interaction between benzodiazepine hypnotic use and sleep disordered breathing in old age.
Risk Factors for Early Hospital Readmission in a Select Population of Geriatric Rehabilitation Patients: The Significance of Nutritional Status
Authors: Sullivan Dennis H.
Published: April 2015

Objective

To test the strength of the evidence in favor of the hypothesis that protein‐energy undernutrition is an independent risk factor for non‐elective hospital readmission within 3 months of discharge in a population of elderly hospitalized patients.

Design

Retrospective analysis of data from prospective observational study.

Methods

All 110 elderly patients admitted to a geriatric recuperative care and rehabilitation unit during a 6‐month period completed a comprehensive in‐patient evaluation. Ninety‐eight of these patients were subsequently discharged alive and followed prospectively for 3 months. All hospital readmissions during the observation period were identified by patient interview and, within the VA hospital system, computer tracking of admissions. Based on the discharge assessment, the strongest predictors of non‐elective readmission were identified using univariate and multivariate statistical procedures.

Results

Twenty‐eight of the 98 patients discharged alive and completing the 3‐month follow‐up (29%) had at least one non‐elective readmission. The patients discharged home were non‐electively readmitted more frequently than were the patients discharged to a nursing home (32% vs 11%, P = 0.05). Of the 109 discharge assessment variables analyzed, the best predictor of which patients would have at least one non‐elective hospital readmission was the discharge serum albumin, followed by a diagnosis of dementia, discharge gamma globulin, the subscapular skinfold thickness, home ownership, and the discharge Katz Index of ADL score. Discharge serum albumin concentration, subscapular skinfold thickness, and discharge serum gamma globulin concentration were all negatively correlated with risk of non‐elective readmission. The presence of functional debilitation or dementia was associated with a lower likelihood of non‐elective readmission compared with the absence of these conditions.

Conclusions

Protein‐energy undernutrition appears to be a strong independent risk factor for non‐elective hospital readmission especially among the highest risk patients, those who are functionally independent and cognitively intact.
Urinary Tract Infections and Estrogen Use in Older Women
Authors: Orlander Jay D. , Jick Susan S. , Dean Alan D. , Jick Hershel
Published: April 2015

Objective

To examine the relationship between exogenous estrogen use and risk of clinically diagnosed urinary tract infection (UTI) in older women.

Design

A case‐control study.

Setting

Two hundred seventy‐six general practices.

Patients

Cases (n = 3,616) were women, age 50–69 years, with a first recorded UTI in the calendar years 1989 or 1990. Controls (n = 19,162) were matched for age and practice.

Main Outcome Measure

Clinical diagnosis of UTI.

Results

Women using estrogens for ≥1 year had an increased risk of being diagnosed with a UTI compared to non‐users, crude odds ratio (OR) 1.9 (95% CI 1.5–2.2). All of this excess risk was observed in women with intact uteri, OR 2.1 (CI 1.7–2.7). Hysterectomized women had no increased risk, OR 1.1 (CI 0.8–1.5). Controlling for diabetes, neurologic deficit, atrophic vaginitis, incontinence, and age did not affect the observed associations.

Conclusion

Estrogen use is associated with an increased risk of UTI in older women with intact uteri but not in hysterectomized women. This observed differential effect on women with or without uteri may be explained by prescribing biases between these two groups of women, but we lack any evidence to support this conclusion over several alternative possibilities.
Book Reviews
Authors: Katz Paul R. , Ferrell Bruce A.
Published: April 2015

Geriatric Medicine, 2nd Ed. Edited by Cassel CK, Riesenberg DE, Sorenson LB, Walsh JR. New York, Springer‐Verlag, 1990. 697 pages, 150 figures (28 in full color). $99.95.
Book Reviews
Authors: Tangalos Eric G.
Published: April 2015

Principles and Practice of Nursing Home Care. Edited by Paul R. Katz, MD and Evan Calkins, MD. New York, Springer Publishing Company, Inc., 1989. 443 pages. $43.95.1
Diabetes Support Groups Improve Health Care of Older Diabetic Patients
Authors: Gilden Janice L. , Hendryx Michael S. , Clar Steven , Casia Carla , Singh Sant P.
Published: April 2015

Objective

To assess whether knowledge or psychosocial and glycemic benefits of a diabetes education program are enhanced by a support group for older patients.

Design

A partially randomized controlled trial involving two groups of patients: Group A, subjects who received an education program followed by 18 months of support group sessions; Group B, only the diabetes education program. A third convenience sample, Group C, received neither intervention. Groups A and B were assessed before and immediately after the education program, and all groups were assessed 2 years after the education program.

Setting

Diabetes clinic at a Veterans Affairs Medical Center. Patients: All subjects were male (mean age = 68 ± 1.3 years, range = 57–82 years; duration of diabetes = 10 ± 2 years, range 3–16). Sample sizes were 11 in Group A, 13 in Group B, and 8 in Group C.

Intervention

The education program consisted of six weekly sessions covering aspects of diabetes self‐care. The support group consisted of 18 monthly sessions for continuing education, discussion, and structured social activities.

Outcome Measures

Diabetes knowledge, psychosocial factors (self‐care‐related quality of life, stress, family involvement in care, and social involvement), depression, and glycemic control.

Results

Group A scored better (at least P < 0.05) on knowledge, quality of life, and depression than the other groups. Groups A and B showed less stress, greater family involvement, better glycemic control, but less involvement in social activities than Group C.

Conclusion

Diabetes education programs can have long term benefits on knowledge, psychosocial functioning, and glycemic control for older diabetic patients. The addition of support groups enhances diabetes knowledge and psychosocial functioning.
BOOK REVIEWS
Authors: Dean Elizabeth
Published: April 2015

Health Promotion and Exercise for Older Adults: An Instructor's Guide. By Lewis CB and Campanelli LC. Rockville, Maryland, Aspen Publishers, Inc., 1990. 188 pages. Softcover, $39.00.
BOOK REVIEWS
Authors: Jahnigen Dennis W.
Published: April 2015

Handbook of Geriatric Assessment. By Gallo JJ, Reichel W, Andersen L. Gaithersburg, Maryland, Aspen Publishers, Inc., 1988. 231 pages. $32.00.
Alcohol as a Risk Factor for Fall Injury Events among Elderly Persons Living in the Community
Authors: Nelson David E. , Sattin Richard W. , Langlois Jean A. , DeVito Carolee A. , Stevens Judy A.
Published: April 2015

Objective

To determine if alcohol use is a risk factor for fall injury events among community‐dwelling older persons.

Design

Case‐control study.

Setting

South Miami Beach, Florida.

Participants

320 persons 65 or older who sought treatment at six area hospitals for injuries resulting from falls; 609 controls, matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files.

Main Independent Variables

Self‐reported current alcohol use.

Results

No association was found between fall injury events and average weekly alcohol use.

Conclusions

Further efforts at reducing injuries to older persons from falls should concentrate on other modifiable risk factors, including adequate treatment of underlying medical conditions, reducing inappropriate psychotropic medication use, and installing safety devices in the home.
Effects of Advancing Age on the Efficacy and Side Effects of Antiarrhythmic Drugs in Post‐Myocardial Infarction Patients with Ventricular Arrhythmias
Authors: Akiyama Toshio , Pawitan Yudi , Campbell W. Barton , Papa Louis , Barker Allan H. , Rubbert Pat , Friedman Lawrence , Keller Marcia , Josephson Richard A. ,   the CAST Investigators
Published: April 2015

Objective

To determine the effect of age on the response to anti‐arrhythmic drugs.

Design

Randomized controlled trial comparing particular drugs.

Setting

Multi‐institutional (The Cardiac Arrhythmia Suppression Trial, CAST).

Participants

2,371 patients, age <80, with ventricular arrhythmias after a recent myocardial infarction. Subjects classified by age as ≤55, 56–65, and 66–79 years.

Intervention

Upwardly titrated doses of encainide, flecainide or moricizine. After identification of a tolerated and effective dose of one of the drugs, participants were randomized to that drug and dose versus its placebo for up to 10 months.

Main Outcome Measures

Efficacy of drug (suppression of ventricular premature depolarizations and/or non‐sustained ventricular tachycardia), side effects and mortality.

Results

Older patients had more previous MIs, congestive heart failure (CHF), hypertension, NSVT, repolarization abnormalities, digitalis use, and diuretic use. They had less pathologic Q‐waves or electrocardiographic injury pattern, and their left ventricular ejection fraction (LVEF) was lower. First dose VPD suppression with the first drug averaged 53% and is not associated with age (P = 0.29). Adverse events including death are more frequent in older patients taking study drugs (P < 0.001). This trend is consistent in all three study drugs and at varying LVEFs. History of prior MI, low LVEF, VPD (in log scale), and digitalis therapy also correlates with adverse events (all P < 0.05). Following adjustment for these factors, older age is an independent predictor of adverse events (relative risk 1.30 per decade of age, P < 0.001).

Conclusions

Older age increases the susceptibility to adverse cardiac events from a class of relatively toxic antiarrhythmic agents.
Predictors of Advance Directive Restrictiveness and Compliance with Institutional Policy in a Long‐Term‐Care Facility
Authors: Batchelor Allison J. , Winsemius David , O'Connor Patrick J. , Wetle Terrie
Published: April 2015

Objective

To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility‐wide policy.

Design

Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement.

Setting

A 315‐bed multilevel nursing home.

Participants

Four hundred twenty‐four nursing home residents (mean age 85, 74.9% female, 96.1% white).

Outcome Measures

Level of advance directive status chosen—full code, do not resuscitate (DNR) or palliative care only—and date documented in the medical record.

Results

Factors predictive of restricted advance directives (DNR or palliative care) included age >85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P < 0.001), low cognitive function (P < 0.001), and having a nursing home‐employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy.

Conclusion

In logistic models, nursing home‐employed physicians were more likely to write restricted advance directive orders than community‐based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.
Validation of a Telephone Version of the Mini‐Mental State Examination
Authors: Roccaforte William H. , Burke William J. , Bayer Barbara L. , Wengel Steven P.
Published: April 2015

Objective

To assess the construct validity of a telephone‐administered version of the Mini‐Mental State Examination (MMSE).

Design

Validity testing by comparing a telephone version of the MMSE administered first to a face‐to‐face evaluation done several days later.

Setting

Outpatient geriatric assessment center.

Subjects

100 of 175 consecutive referrals.

Main Outcome Measures

MMSE and a brief neuropsychological screening test (BNPS) face‐to‐face and a telephone version of the MMSE as part of the Adult Lifestyles and Function Interview (ALFI‐MMSE).

Results

Test scores of the two MMSE versions correlated strongly for all subjects (Pearson's r = 0.85, P = 0.001) and remained significant for the cognitively intact (P = 0.02) and questionably (P = 0.002), mildly (P = 0.0001), and moderately (P = 0.003) demented. Comparison of the two versions' equivalent 22 items revealed no significant difference for scores of all subjects (P = 0.07) but with a trend toward higher scores in the original version. Diminished hearing, reported either by the subject (P = 0.003) or by the collateral source (P = 0.02) was associated with lower scores on the telephone version. Five individual test items were biased by the route of test administration. Sensitivity and specificity relative to the BNPS were 67% and 100% for the ALFI‐MMSE and 68% and 100% for the MMSE, respectively.

Conclusion

The scores on the ALFI‐MMSE correlated strongly with the scores of the original version given face‐to‐face in subjects undergoing geriatric assessment. The results indicate that the ALFI‐MMSE could be a useful and economical tool to screen for cognitive impairment.
BOOK REVIEWS
Authors: Edwards John A.
Published: April 2015

Dementia Care: Patient, Family and Community. Edited by Mace NL. Baltimore, Johns Hopkins University Press, 1990. 400 pages. $34.50.
BOOK REVIEWS
Authors: Miller Ronald L.
Published: April 2015

Medical Direction in the Nursing Home: Principles and Concepts for Physician Administrators By Pattee JJ and Otteson OJ. Minneapolis, MN, North Ridge Press, 1991. 450 pages. $49.50.
Decline in Physical Function following Hip Fracture
Authors: Marottoli Richard A. , Berkman Lisa F. , Cooney Leo M.
Published: April 2015

Objective

The main objective of the study was to determine the change in physical function following hip fractures in a community‐living elderly population. A secondary objective was the determination of baseline factors predictive of altered function following hip fracture.

Design

Prospective, cohort study.

Setting

Urban, community‐living elders.

Participants

120 members of a cohort of 2806 individuals age 65 and older in New Haven, CT who sustained a hip fracture from 1982 to 1988 and were treated in the two New Haven hospitals.

Outcome Measure

Self‐reported performance of dressing, transferring, walking across a room, climbing stairs, and walking one‐half mile before the fracture occurred and 6 weeks and 6 months post‐fracture. Baseline factors were assessed before the hip fracture occurred.

Results

Of the 120 cohort members who sustained a hip fracture in the 6‐year study period, 22 died within 6 months of the fracture. Among survivors there was a sustained decline in function at 6 weeks after the fracture with little improvement by 6 months. At baseline, 86% could dress independently versus 49% at 6 months; 90% could transfer independently versus 32% at 6 months; 75% could walk across a room independently versus 15% at 6 months; 63% could climb a flight of stairs versus 8% at 6 months; and 41% could walk one‐half mile versus 6% at 6 months. Physical function and mental status were the only baseline factors significantly associated with physical function at 6 months after the fracture in bivariate analysis, while physical function and depression were associated in multivariate analysis.

Conclusion

We found a substantial decline in physical function following hip fracture in a prospectively followed community‐living elderly population. Only pre‐morbid physical and mental function predicted this decline.
Geriatric Education Part II: The Effect of a Well Elderly Program on Medical Student Attitudes toward Geriatric Patients
Authors: Adelman Ronald D. , Fields Suzanne D. , Jutagir Rajendra
Published: April 2015

Objective

To assess impact of exposure to healthy elderly on medical students' attitudes toward the elderly.

Design

Prospective, randomized, controlled intervention trial.

Setting

Community‐based Well Elderly Program.

Participants

Ninety‐three fourth year medical students on a required Geriatric Medicine clerkship who were assigned to either a tertiary care university medical center or a teaching nursing home.

Intervention

Thirty‐five students were randomly assigned to participate in a Well Elderly Program and were compared to a control group of 58 students at equivalent sites who did not participate.

Measurements

Pre‐ and post‐rotation, students were given the Aging Semantic Differential (ASD), a validated geriatric attitudinal scale.

Main Results

By repeated measures analysis of variance, the difference between pre‐ and post‐rotation ASD scores were most significant for students who participated in the Well Elderly Program; site did not exert a significant interaction effect.

Conclusion

These results underscore the importance of exposure to healthy older people on effecting positive attitude changes among medical students on geriatrics rotations.
BOOK REVIEWS
Authors: Katz Paul R. , Schulz Richard
Published: April 2015

Handbook of the Psychology of Aging, Third Ed. By Birren JE and Schaie KW, eds. and Gatz M Salthouse TA and Schooler C, associate eds. New York, Academic Press, 1990. 452 Pages.
BOOK REVIEWS
Authors: Overeynder Jenny C.
Published: April 2015

Activities with Developmentally Disabled Elderly and Older Adults Edited by Keller MJ. Binghamton, NY, Haworth Press, Inc, 1991. 156 pages. $22.95
BOOK REVIEWS
Authors: Pawlson L. Gregory
Published: April 2015

Quality and Cost Containment in Care of the Elderly: Health Services Research Perspectives by Romeis C and Coe M. New York, Springer Publishing Co., 1991. 235 pages. $42.95
Sensitivity and Specificity of Death Certificate Diagnoses for Dementing Illnesses, 1988–1990
Authors: Macera Caroline A. , Sun Richard K. P. , Yeager Kimberly K. , Brandes Debra A.
Published: April 2015

Objective

To evaluate the extent to which mortality data, which is often used to track secular trends for specific diseases, underestimates the prevalence of dementia.

Design

Retrospective analysis of existing data.

Setting

Department of Mental Health inpatient facilities in South Carolina.

Subjects

Inpatients at Department of Mental Health facilities who were listed in the South Carolina Statewide Alzheimer's Disease and Related Disorders Registry and who died between 1988 and 1990 (n = 450).

Main Outcome Measures

Sensitivity and specificity of dementia diagnoses on death certificates compared to medical record diagnoses for inpatients with a pre‐mortem dementia diagnosis.

Results

Twenty‐three percent of death certificates contained any dementia diagnosis (104/450). The sensitivity of death certificates varied by type of dementia (28 percent for Alzheimer's disease; 8 percent for multi‐infarct dementia) as well as by race, sex, and age.

Conclusions

Mortality statistics substantially underestimate the prevalence of dementing illnesses and do not fully represent the public health burden of dementia.