bluuebunny/crossref_metadata_2025 huggingface dataset:
Do Hospital Fall Prevention Programs Work? A Systematic Review
Authors: Oliver David , Hopper Adrian , Seed Paul
Published: April 2015

OBJECTIVES: To analyze published hospital fall prevention programs to determine whether there is any effect on fall rates. To review the methodological quality of those programs and the range of interventions used. To provide directions for further research.

DESIGN: Systematic review of published hospital fall prevention programs. Meta‐analysis.

METHODS: Keyword searches of Medline, CINAHL, monographs, and secondary references. All papers were included that described fall rates before and during intervention. Risk ratios and 95% Confidence Intervals (95% CI) were estimated and random effects meta‐analysis employed. Begg's test was applied to detect possible publication bias. Separate meta‐analysis regressions were performed to determine whether individual components of multifaceted interventions were effective.

RESULTS: A total of 21 papers met the criteria (18 from North America), although only 10 contained sufficient data to allow calculation of confidence intervals. A rate ratio of <1 indicates a reduction in the fall rate, resulting from an intervention. Three were randomized controlled trials (pooled rate ratio 1.0 (CI 0.60, 1.68)), seven prospective studies with historical control (0.76 (CI 0.65, 0.88)). Pooled effect rate ratio from these 10 studies was 0.79 (CI 0.69, 0.89). The remaining 11 studies were prospective studies with historical control describing fall rates only. Individual components of interventions showed no significant benefit.

DISCUSSION: The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased by studies that used historical controls not allowing for historical trends in the fall rate before and during the intervention. The randomized controlled trials apparent lack of effect might be due to a change in practice when patients and controls were in the same unit at the same time during a study. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions.
MODELS OF GERIATRICS PRACTICE; The Hospital Elder Life Program: A Model of Care to Prevent Cognitive and Functional Decline in Older Hospitalized Patients
Authors: Reuben David B. , Inouye Sharon K. , Bogardus Sidney T. , Baker Dorothy I. , Leo‐Summers Linda , Cooney Leo M.
Published: April 2015

OBJECTIVES: To describe the Hospital Elder Life Program, a new model of care designed to prevent functional and cognitive decline of older persons during hospitalization.

PROGRAM STRUCTURE AND PROCESS: All patients aged ≥ 70 years on specified units are screened on admission for six risk factors (cognitive impairment, sleep deprivation, immobility, dehydration, vision or hearing impairment). Targeted interventions for these risk factors are implemented by an interdisciplinary team‐including a geriatric nurse specialist, Elder Life Specialists, trained volunteers, and geriatricians—who work closely with primary nurses. Other experts provide consultation at twice‐weekly interdisciplinary rounds.

INTERVENTION: Adherence is carefully tracked. Quality assurance procedures and performance reviews are an integral part of the program.

PROGRAM OUTCOMES: To date, 1507 patients have been enrolled during 1716 hospital admissions. The overall intervention adherence rate was 89% for at least partial adherence with all interventions during 37,131 patient‐days. Our results indicate that only 8% of admissions involved patients who declined by 2 or more points on MMSE and only 14% involved patients who declined by 2 or more points on ADL score. Comparative results for the control group from the clinical trial were 26% and 33%, and from previous studies 14 to 56% and 34 to 50% for cognitive and functional decline, respectively. Effectiveness of the program for delirium prevention and of the program's nonpharmacologic sleep protocol have been demonstrated previously.

CONCLUSIONS: These results suggest that the Hospital Elder Life Program successfully prevents cognitive and functional decline in at‐risk older patients. The program is unique in its hospital‐wide focus; in providing skilled staff and volunteers to implement interventions; and in targeting practical interventions toward evidence‐based risk factors. Future studies are needed to evaluate cost‐effectiveness and long‐term outcomes of the program as well as its effectiveness in non‐hospital settings.
Delivery of Preventive Services to Older Black Patients Using Neighborhood Health Centers
Authors: Wright Paul J. , Fortinsky Richard H. , Covinsky Kenneth E. , Anderson Philip A. , Landefeld C. Seth
Published: April 2015

OBJECTIVES: Older black patients are at risk for underutilization of preventive services. Our objectives were to assess the delivery of five preventive services in Title 330—funded health centers in low income neighborhoods in Cleveland, Ohio, and to determine the association of health system factors and health status with the delivery of these services.

DESIGN: A cross‐sectional study.

SETTING: Four neighborhood health centers in low income neighborhoods of Cleveland, Ohio.

PARTICIPANTS: A total of 683 black men and women, aged 70 and older, who regarded the health center as their primary source of outpatient care.

MEASUREMENTS: Demographic characteristics, independence in basic and instrumental activities of daily living, comorbidity scores, and perceived access were determined by telephone interview. We reviewed charts to determine whether each of five preventive service goals were obtained: influenza vaccination within 1 year; pneumococcal vaccination at any time; mammography within 2 years; Papanicolau screening within 1 year or twice at any time in the past with documentation of normal results; and fecal occult blood testing within 2 years.

RESULTS: The defined goals for influenza vaccination, pneumococcal vaccination, mammography, Papanicolau screening, and fecal occult blood testing were achieved for 59%, 64%, 59%, 51%, and 17% of patients, respectively. Influenza and pneumococcal vaccines were obtained more often in persons with greater comorbidity. Mammography and Papanicolau smear were obtained more often in patients without of ADL or IADL impairments. The four clinical sites varied substantially in the delivery of each preventive service. More frequent office visits were associated with greater delivery of all five preventive services. This relationship persisted in multivariable analyses controlling for health status and clinical site.

CONCLUSIONS: This study shows that Title 330 federally supported neighborhood health center sites providing primary care to older blacks in Cleveland achieved high rates of performance in four of the five recommended preventive services. In addition, preventive services practices were associated with prognostically relevant health status information. The frequency of office visits was related strongly and consistently to the performance of the various preventive services, indicating that more, not fewer, office visits may be necessary to achieve Healthy People 2000 targets. J Am Geriatr Soc 48: 124–130, 2000.
Determinants of Exercise Tolerance After Acute Myocardial Infarction in Older Persons
Authors: Marchionni Niccolò , Fattirolli Francesco , Fumagalli Stefano , Oldridge Neil B. , Del Lungo Francesco , Bonechi Francesco , Russo Laura , Cartei Alessandro , Mottino Giuseppe , Burgisser Costanza , Masotti Giulio
Published: April 2015

OBJECTIVES: Exercise tolerance is reduced with advancing age. Identification of potentially reversible determinants of the age‐related decrement in exercise tolerance, which remain largely unexplored in older subjects and in patients recovering from a recent myocardial infarction (MI), may have useful therapeutic implications. The objective of this study was to identify the independent determinants of exercise tolerance in older patients with a recent MI.

DESIGN, SETTING, AND PARTICIPANTS: Data is from baseline assessment of 265 post‐MI patients (age range 45–85 years) enrolled in the Cardiac Rehabilitation in Advanced Age randomized, controlled trial. Patients with major comorbidities or severe MI complications were excluded from the trial. Exercise tolerance was determined from symptom‐limited exercise testing and expressed as total work capacity (TWC, kg.m) or peak oxygen consumption (V̇o2peak, mL/kg/min). The associations between both TWC and V̇o2peak and baseline demographic, social, clinical, and neuropsychological variables and an index of health‐related quality of life were determined with univariate and multivariate analysis.

RESULTS: With univariate analysis, TWC decreased by 1285 kg.m per decade of increasing age between 45 and 85 years of age. With multivariate analysis, TWC decreased by 922 kg.m per decade. Increasing age (P < .001), female gender (P < .001), a small body surface area (P < .001), a low level of usual physical exercise before MI (P < .002), and the presence of post‐MI depressive symptoms (P < .024) were independently associated with a lower TWC. The same factors, in addition to a small arm muscle area (P < .002), were also independently associated with a lower V̇o2PEAK.

CONCLUSIONS: Age per se accounts for approximately 70% of the age‐related decay in TWC or V̇o2peak. However, the inclusion of modifiable factors such as physical exercise and depression in the prediction model reinforces the importance of a multidimensional approach to the evaluation and treatment of older patients with a recent MI. J Am Geriatr Soc 48: 146–153, 2000.
Modifiable Risk Factors Predict Functional Decline Among Older Women: A Prospectively Validated Clinical Prediction Tool
Authors: MD Catherine A. Sarkisian , Liu Honghu , Gutierrez Peter R. , Seeley Dana G. , Cummings Steven R. , MD Carol M. Mangione
Published: April 2015

OBJECTIVE: To identify modifiable predictors of functional decline among community‐residing older women and to derive and validate a clinical prediction tool for functional decline based only on modifiable predictors.

DESIGN: A prospective cohort study.

SETTING: Four geographic areas of the United States.

PARTICIPANTS: Community‐residing women older than age 65 recruited from population‐based listings between 1986 and 1988 (n = 6632).

MEASUREMENTS: Modifiable predictors were considered to be those that a clinician seeing an older patient for the first time could reasonably expect to change over a 4‐year period: benzodiazepine use, depression, low exercise level, low social functioning, body‐mass index, poor visual acuity, low bone mineral density, slow gait, and weak grip. Known predictors of functional decline unlikely to be amenable to intervention included age, education, medical comorbidity, cognitive function, smoking history, and presence of previous spine fracture. All variables were measured at baseline; only modifiable predictors were candidates for the prediction tool. Functional decline was defined as loss of ability over the 4—year interval to perform one or more of five vigorous or eight basic daily activities.

RESULTS: Slow gait, short‐acting benzodiazepine use, depression, low exercise level, and obesity were significant modifiable predictors of functional decline in both vigorous and basic activities. Weak grip predicted functional decline in vigorous activities, whereas long‐acting benzodiazepine use and poor visual acuity predicted functional decline in basic activities. A prediction rule based on these eight modifiable predictors classified women in the derivation set into three risk groups for decline in vigorous activities (12%, 25%, and 39% risk) and two risk groups for decline in basic activities (2% and 10% risk). In the validation set, the probabilities of functional decline were nearly identical.

CONCLUSIONS: A substantial portion of the variation of functional decline can be attributed to risk factors amenable to intervention over the short term. Using eight modifiable predictors that can be identified in a single office visit, clinicians can identify older women at risk for functional decline. J Am Geriatr Soc 48: 170–178, 2000.
Decision‐Making Capacity to Execute A Health Care Proxy: Development and Testing of Guidelines
Authors: Mezey Mathy , Teresi Jeanne , Ramsey Gloria , Mitty Ethel , Bobrowitz Tracy
Published: April 2015

OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP).

DESIGN: A cross‐sectional study.

SETTING: A 750‐bed not‐for‐profit nursing home located in New York City.

PARTICIPANTS: A random sample of 200 nursing home residents: average age, 87; 99% white; 83% female; average length of stay, 3.05 years; mean Mini‐Mental State Exam (MMSE) score, 15.9.

MEASUREMENTS: Demographic characteristics (Minimum Data Set (MDS)); function and cognitive status (Institutional Comprehensive Assessment and Referral Evaluation (INCARE)); Reisberg Dementia Staging; MMSE; Minimum Data Set‐Cognitive Performance Scale (MDS‐COGS)); an investigator‐developed measure of a nursing home resident's capacity to execute a health care proxy (Health Care Proxy (HCP) Guidelines.)

RESULTS: The internal consistency of the decision‐making scales in the HCP Guidelines, paraphrased recall and recognition, reached acceptable levels, alphas of .85 and .73, respectively. Interrater reliability estimates were .92 and .94, respectively, for the recall and recognition scales; test‐retest reliability estimates were .83 and .90. The discriminant validity of these scales is promising. For example, the MMSE correlation was .51 with the Recall scale and .57 with the Recognition scale. Of residents with severe cognitive impairment (MMSE < 10), 71% completed 50% or more of the scaled items in the HCP guidelines and 95% consistently named a proxy.

CONCLUSIONS: Seventy‐three percent of testable residents, approximately three‐quarters of whom were cognitively impaired, evidenced sufficient capacity to execute an HCP. Of residents with severe cognitive impairment, the HCP guidelines are potentially useful in identifying those with the capacity to execute a HCP. The guidelines are more predictive than the MMSE in identifying residents able to execute a HCP. J Am Geriatr Soc 48: 179–187, 2000.
The Effects of Childhood Residence in Japan and Testing Language on Cognitive Performance in Late Life Among Japanese American Men in Hawaii
Authors: Yano Katsuhiko , Grove John S , Masaki Kamal H , White Lon R , Petrovitch Helen , Chen Randi , Peng Evelyn L , Ross G Webster , Rodriguez Beatrix L , Curb J. David
Published: April 2015

OBJECTIVES: To examine the association of years spent in Japan during childhood with cognitive test performance in late life among Japanese American men, and to assess the influence of the language used for testing on this association.

DESIGN: A cross‐sectional study.

SETTING/PARTICIPANTS: A total of 3734 Japanese American men, aged 71–93 years, who were first‐ or second‐generation migrants and living on Oahu Island, Hawaii.

MEASUREMENTS: The outcome variable was cognitive test performance assessed using the Cognitive Abilities Screening Instrument (CASI), which was developed for cross‐cultural studies of cognitive impairment. The explanatory variable of main interest was the number of years spent in Japan during school‐age childhood years (ages 6–17). The associations of CASI scores with childhood years in Japan was evaluated using a stepwise multiple linear regression model in which a total of 40 potential confounders were included as covariates.

RESULTS: In the total sample, there was an inverse association between CASI scores and middle childhood years in Japan. This association remained significant after controlling for age, education, socioeconomic status, traditional Japanese food consumption, pulmonary function, apolipoprotein E4, proficiency in speaking Japanese, and other possible confounders. When data were analyzed separately for subgroups according to the language preferred at testing (English or Japanese), associations between childhood years in Japan and CASI scores were in opposite directions negative for the group tested in English and positive for the group tested in Japanese. The interaction between the testing language and childhood years in Japan was statistically significant.

CONCLUSIONS: There was an inverse association between years spent in Japan during school‐age years of childhood and cognitive test performance in late life. This association could not be accounted for by age, education, or other confounding factors. However, this finding was not observed in participants who preferred being tested in Japanese. To assess cognitive test performance in older people, it is of prime importance to use the most optimal language for testing, usually the subject's native language. J Am Geriatr Soc 48: 199–204, 2000.
The High Prevalence of Depression and Dementia in Elder Abuse or Neglect
Authors: Dyer Carmel Bitondo , Pavlik Valory N. , Murphy Kathleen Pace , Hyman David J.
Published: April 2015

BACKGROUND: The risk factors for mistreatment of older people include age, race, low income, functional or cognitive impairment, a history of violence, and recent stressful events. There is little information in the literature concerning the clinical profile of mistreated older people.

OBJECTIVES: To describe the characteristics of abused or neglected patients and to compare the prevalence of depression and dementia in neglected patients with that of patients referred for other reasons.

DESIGN: A case control study.

SETTING: Baylor College of Medicine Geriatrics Clinic at the Harris County Hospital District (Houston, Texas).

PATIENTS: Forty‐seven older persons referred for neglect and 97 referred for other reasons.

INTERVENTION: Comprehensive geriatric assessment.

MEASUREMENTS: Standard geriatric assessment tools.

RESULTS: There was a statistically significant higher prevalence of depression (62% vs 12%) and dementia (51% vs 30%) in victims of self‐neglect compared to patients referred for other reasons.

CONCLUSIONS: This is the first primary data study that highlights a high prevalence of depression as well as dementia in mistreated older people. Geriatric clinicians should rule out elder neglect or abuse in their depressed or demented patients. J Am Geriatr Soc 48: 205–208, 2000.
Nutritional Intake Monitoring for Nursing Home Residents: A Comparison of Staff Documentation, Direct Observation, and Photography Methods
Authors: Simmons Sandra F. , Reuben David
Published: April 2015

BACKGROUND: The current approach to assessing nutritional intake requires nursing home (NH) staff to document total percentage of food and fluid consumed at each meal. Because NH staff tend to significantly overestimate total food intake, methods need to be developed to improve the accuracy of food intake measurement.

OBJECTIVE: To compare three methods of assessing the nutritional intake of NH residents.

RESEARCH DESIGN: Validation Study.

SUBJECTS: Fifty‐six NH residents in one facility.

MEASURES: Total percentage of food and fluid intake of each resident for each of nine meals, or all three meals for 3 consecutive days, was assessed by: (1) Nursing home staff chart documentation, (2) Research staff documentation according to direct observations, and (3) Research staff documentation according to photographs of residents' trays before and after each meal.

RESULTS: Research staff documentation of total intake and intake of all individual food and fluid items was similar for the direct observation and photography methods. In comparison with these two methods, NH staff documentation reflected a significant overestimate (22%) of residents' total intake levels. In addition, NH staff failed to identify the more than half (53%) of those residents whose intake levels were equal to or below 75% for most meals.

CONCLUSIONS: The photography method of nutritional assessment yielded the same information as direct observations by research staff, and both of these methods showed the intake levels of NH residents to be significantly lower than the intake levels documented by NH staff. The photography method also has several advantages over a documentation system that relies on an observer to be present to record food and fluid intake levels. J Am Geriatr Soc 48: 209–213, 2000.
Combined Behavioral and Drug Therapy for Urge Incontinence in Older Women
Authors: Burgio Kathryn L. , Locher Julie L. , Goode Patricia S.
Published: April 2015

OBJECTIVE: The purpose of this study was to examine the effects of combining behavioral treatment and drug treatment for urge incontinence in community‐dwelling older women.

DESIGN: Modified crossover design (extension of a randomized clinical trial). Eligible subjects were stratified according to type and severity of incontinence and randomized to behavioral treatment, drug treatment, or a control condition (placebo). Subjects not totally continent or not satisfied after 8 weeks of a single treatment were offered the opportunity to cross over into combined therapy.

SETTING: A university‐based outpatient geriatric medicine clinic.

PARTICIPANTS: Subjects in the clinical trial were 197 ambulatory, nondemented, community‐dwelling women (age 55 years or older) with persistent urge urinary incontinence. Thirty‐five subjects participated in combined treatment.

INTERVENTION: One group of subjects received four sessions (over 8 weeks) of biofeedback‐assisted behavioral training followed by 8 weeks of behavioral training combined with drug therapy (oxybutynin chloride individually titrated from 2.5 mg to 15 mg daily). The second group received drug therapy first, followed by 8 weeks of drug therapy combined with behavioral training.

MEASUREMENTS: Bladder diaries completed by subjects before and after each treatment phase were used to calculate change in the frequency of incontinent episodes.

RESULTS: Eight subjects (12.7%) crossed from behavioral treatment alone to combined behavioral and drug therapy. Additional benefit was seen in improvement from a mean 57.5% reduction of incontinence with single therapy to a mean 88.5% reduction of incontinence with combined therapy (P = .034). Twenty‐seven subjects (41.5%) crossed from drug therapy alone to combined drug and behavioral treatment. They also showed additional improvement, from a mean 72.7% reduction of incontinence with single therapy to a mean 84.3% reduction of incontinence with combined therapy (P = .001).

CONCLUSIONS: This study shows that combining drug and behavioral therapy in a stepped program can produce added benefit for patients with urge incontinence. J Am Geriatr Soc 48: 370–374, 2000.
Binocular Vision in Older People with Adventitious Visual Impairment: Sometimes One Eye Is Better than Two
Authors: Faubert Jocelyn , Overbury Olga
Published: April 2015

PURPOSE: To determine the effect of adventitious visual impairment (low vision) on monocular and binocular spatial contrast sensitivity of older people.

DESIGN: A between‐within repeated measures design.

PARTICIPANTS: Fifty‐nine older adults between the ages of 50 and 96; 49 of the observers had age‐related macular degeneration (AMD).

MEASURES: Visual acuity screening and spatial contrast sensitivity.

RESULTS: In almost half of the population with AMD, the sensitivity to spatial information, as measured by spatial contrast sensitivity, is worse when both eyes are used than when the stimuli are viewed with only one eye. This “binocular inhibition” is not related to the contrast sensitivity of the better eye or to acuities. Furthermore, this inhibition process is reflected primarily in images with medium to low spatial frequency components (medium to large size bars).

CONCLUSIONS: These results have important implications for understanding the functional impact of low vision in older people. They suggest that almost one‐half of older people with AMD view the world best using only one of their eyes, whereas for the other half, there is an advantage to using binocular vision for certain visual tasks. J Am Geriatr Soc 48: 375–380, 2000.
Atrial Fibrillation and Cognitive Disorders in Older People
Authors: Sabatini Tony , Frisoni Giovanni B. , Barbisoni Piera , Bellelli Giuseppe , Rozzini Renzo , Trabucchi Marco
Published: April 2015

OBJECTIVES: To find a correlation between chronic non‐rheumatic atrial fibrillation (CNRAF) and cognitive impairment in a group of older, nondemented patients.

SETTING: Acute Care Unit for the Elderly, Poliambulanza Hospital, Brescia (Italy).

METHODS: Two hundred fifty‐five hospital in‐patients older than 70 years (42 with CNRAF and 213 controls with normal sinus rhythm) were assessed by complete clinical history, physical examination, ECG, serum albumin levels, APACHE II score, mental status (Mini‐Mental State Exam [MMSE] and Geriatric Depression Score [GDS]), functional status (Barthel Index and instrumental activities of daily living [IADL]), number of prescribed drugs, and comorbidity (Charlson Index).

RESULTS: The group of patients with CNRAF had MMSE scores significantly lower than that of the reference group with normal sinus rhythm. Chronic nonrheumatic atrial fibrillation retained an independent relation to cognitive impairment also after adjusting for those variables associated with mental decline in univariate models (GDS, IADL, and APACHE II scores).

CONCLUSIONS: The results of this study support the relationship between nonrheumatic atrial fibrillation and impaired cognitive function. Independent of etiopathogenetic mechanisms (thromboembolic or hemodynamic hypotheses), prevention of cognitive impairment in older persons should take into account the treatment of atrial fibrillation and its consequences. J Am Geriatr Soc 48: 386–390, 2000.
A Cross‐National Survey of Tube‐Feeding Decisions in Cognitively Impaired Older Persons
Authors: Mitchell Susan L. , Berkowitz Randi E. , Lawson Fiona M. E. , Lipsitz Lewis A.
Published: April 2015

OBJECTIVES: Many factors affect the decision to institute long‐term tube‐feeding in older persons. The objectives of this cross‐national survey are to examine the tube‐feeding decision‐making process for cognitively impaired older persons from the perspective of the substitute decision‐makers (SDM) and to contrast this process in US and Canadian healthcare settings.

DESIGN: Survey

SETTING: Chronic care facilities in Ottawa and nursing homes in Boston

PARTICIPANTS: Patients more than age 65 who were tube‐fed for at least 2 months and who were unable to make their own healthcare decisions at the time of tube placement were identified at both sites. The SDMs of 46 patients in Ottawa and 48 patients in Boston were surveyed.

MEASUREMENTS: The survey asked questions relating to the following categories: health status of the patient, advance directives, communication with the healthcare team, perceived goals of tube‐feeding, decision satisfaction, and sociodemographic data.

RESULTS: Tube‐fed patients in Boston were more likely to have a diagnosis of dementia than those in Ottawa (60.4% vs 10.9%, P < .001) and were less likely to have had an acute neurological event (35.4% vs 71.7%, P < .001). There was a greater likelihood in Boston than in Ottawa (68.7% vs 6.5%, P < .001) for tube‐feeding decisions to be made in a nursing home (vs an acute hospital). In the combined cohort, 19.1% of patients had a living will, and only 47.9% of SDMs felt confident that the patients would want to have a feeding tube. The majority of SDMs at both sites felt they understood the benefits (83.0%), but not the risks (48.9%), of tube‐feeding. The most commonly perceived reasons for tube‐feeding were to “prolong life” (84.0%) and to “prevent aspiration” (67.0%). Approximately half of all SDMs felt they had received adequate support from the healthcare team. A minority of SDMs (38.3%) at both sites stated that they would want a feeding tube for themselves, and only 40% of SDMs felt the feeding tube had improved the patients' quality of life.

CONCLUSIONS: A greater proportion of patients have feedings tubes inserted because of a degenerative dementia in Boston compared with an acute neurological event in Ottawa. Despite the difference in diagnostic indication for tube‐feeding, the substitute decision‐making process was seriously limited at both sites by poor implementation of the principle of substituted judgement, a need for broader advance directives, and improved transfer of knowledge between clinicians and decision‐makers. J Am Geriatr Soc 48: 391–397, 2000.
A Drug Use Evaluation of Selected Opioid and Nonopioid Analgesics in the Nursing Facility Setting
Authors: Cramer Gena W. , Galer Bradley S. , Mendelson Marilyn A. , Thompson Gregory D.
Published: April 2015

OBJECTIVES: To determine the medical conditions for which selected analgesics are most frequently prescribed in nursing facilities (NFs), describe the use of pharmacologic and nonpharmacologic pain therapies, and determine the frequency and quality of pain assessment in NF residents.

DESIGN: A multicenter, 3‐month retrospective drug use evaluation conducted by consultant pharmacists.

SETTING: Eighty‐nine NFs having no more than 25% of their patient census representing special populations (e.g., head trauma).

PARTICIPANTS: A total of 2065 adult NF residents who received at least one selected analgesic.

MEASUREMENTS: Primary indication for analgesics, pain type, method of pain assessment, nonpharmacologic therapies for pain, prescribed analgesics and regimens, and comorbid conditions were recorded.

RESULTS: A total of 54.3% of residents had one indication for analgesic therapy, 31.0% had two indications, and 14.7% had three or more indications. Arthritis was the most prevalent indication for analgesics (41.7% of residents), followed by bone fracture (12.4%) and other musculoskeletal conditions (9.7%). More residents (76.8%) were reported to have chronic pain than acute pain (19.9%), and 3.0% had both chronic and acute pain. Pain type was unknown for 0.2% of residents. Observational pain assessments were used more frequently (for 55.9% of residents) than objective methods (16.6%), and pain was not assessed in 40.6% of residents. Most residents (69.4%) received no nonpharmacologic treatment for pain. Of the 2542 opioid and nonsteroidal anti‐inflammatory drug (NSAID) prescriptions, 67.6% were for opioids, 24.8% were for NSAIDs, and 7.6% were for tramadol. Propoxyphene‐containing drugs were the most frequently prescribed opioid group, and propoxyphene with acetaminophen was the most frequently prescribed analgesic (35.6% of all analgesics). Most analgesics (63.2%) were prescribed on an as‐needed (prn) basis.

CONCLUSIONS: The findings show a lack of adequate pain assessments, little use of nonpharmacologic interventions, and inappropriate use of analgesic medication. The small percentage of residents with chronic pain assessed objectively suggests the difficulty of monitoring pain progression in NFs. The prescribing of analgesic for most residents (with propoxyphene used most often, long‐acting opioids used infrequently, and frequent prn use) was inconsistent with recommended pain therapy in older people and attests to the urgent need to educate NF practitioners on the appropriate use of analgesics. J Am Geriatr Soc 48: 398–404, 2000.
Health, Functional, and Psychological Outcomes Among Older Persons with Chronic Dizziness
Authors: Tinetti Mary E. , Williams Christianna S. , Gill Thomas M.
Published: April 2015

OBJECTIVE: The recommended clinical strategy for a health condition should depend both on the known causes of and outcomes associated with the condition. The aim of this study was to determine the range of adverse outcomes associated with chronic dizziness.

DESIGN: Population‐based prospective cohort study

SETTING AND PARTICIPANTS: A probability sample of 1087 persons, age 72 and older, living in the community.

MEASUREMENTS: The following were measured: chronic dizziness, death, hospitalizations, falls, syncope, basic and instrumental activities of daily living, depressive symptoms, self‐rated health, falls self‐efficacy, and social activities.

RESULTS: Of the 1087 participants, 261 (24%) reported chronic dizziness. Over 1 year of follow‐up, chronic dizziness was not associated with mortality, hospitalization for any reason, or change in basic or instrumental activities of daily living, but was associated with risk of falling (unadjusted relative risk [RR] 1.35; 95% confidence interval [CI] 1.06–1.72) and with experiencing syncope (RR 2.31; 95% CI 1.24–4.30). After adjustment for baseline level, chronic dizziness also was associated with worsening of depressive symptoms, self‐rated health, falls efficacy, and social activities. The relationship remained significant, after adjustment for potential confounding factors, for self‐rated health (T‐statistic −2.95, P = .003) and falls efficacy (T‐statistic −2.68; P = .008), and was of marginal significance for depressive symptoms (T‐statistic‐1.73; P = .085).

CONCLUSIONS: These results suggest that the goals of care for older persons with chronic dizziness should be redirected from solely identifying and treating discrete diseases—an often expensive and unrewarding task—toward reducing the symptoms of chronic dizziness and alleviating the resulting physical, psychological, and social disability. J Am Geriatr Soc 48: 417–421, 2000.
Physician Perceptions of HMO Care for Older Persons
Authors: Dixon Melissa K. , Kirschner Pamela B. , Edelberg Helen K. , Ayanian John Z. , Wei Jeanne Y.
Published: April 2015

OBJECTIVE: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients.

DESIGN: A self‐administered one‐page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans.

PARTICIPANTS: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically‐oriented, Medicare HMOs in Massachusetts.

RESULTS: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies.

CONCLUSIONS: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved. J Am Geriatr Soc 48:607–612, 2000.
Epidemiology of Sarcopenia
Authors: III L. Joseph Melton , Khosla Sundeep , Crowson Cynthia S. , O'Connor Michael K. , O'Fallon W. Michael , Riggs B. Lawrence
Published: April 2015

OBJECTIVES: To examine patterns of muscle mass change with aging and to estimate the prevalence of sarcopenia.

DESIGN: Cross‐sectional survey.

SETTING: Population‐based study in Rochester, Minnesota.

PARTICIPANTS: Age‐stratified sample of men and women from the community.

MEASUREMENTS: Muscle mass estimated from total body scans by dual‐energy X‐ray absorptiometry. Sarcopenia was defined as muscle mass more than 2 standard deviations below the sex‐specific young‐normal mean.

RESULTS: Total lean body mass (exclusive of bone) and total skeletal muscle mass both were greater in men than women and declined linearly with age as judged from these cross‐sectional data. Adjustment for height reduced the gender difference. The age‐ and sex‐adjusted prevalence of sarcopenia varied from 6 to 15% among subjects 65 years of age or over, depending on the muscle mass parameter that was evaluated, but prevalence rates were quite sensitive to the normal values used to define cutoff levels. Subjects with sarcopenia appeared to have more physical limitations than the others.

CONCLUSIONS: Late in life, a substantial portion of the population reaches low levels of muscle mass that are associated with increased physical disability. However, additional efforts are needed to validate an operational definition of sarcopenia. J Am Geriatr Soc 48:625–630, 2000.
Silent Ischemia During Voluntary Detraining and Future Cardiac Events in Master Athletes
Authors: Begum Suraiya , Katzel Leslie Ira
Published: April 2015

OBJECTIVES: To determine whether exercise‐induced silent ischemia in older master athletes following a 3‐month period of deconditioning is a predictor of future cardiovascular events.

DESIGN: A longitudinal study of a cohort of master athletes

SETTING: The Geriatric Research Education and Clinical Center (GRECC), Baltimore VA Medical Center, Baltimore, Maryland.

PARTICIPANTS: Ten older (59 ± 8 years, mean ± SD), highly conditioned (maximal aerobic capacity Vo2max 50 ± 5 mL/kg/min), aerobically trained athletes.

INTERVENTION: Five to eight years of longitudinal follow‐up of athletes who had previously participated in a 3‐month‐long detraining intervention.

MEASUREMENTS: At baseline, all 10 athletes had their history taken and underwent physical examinations, metabolic testing, electrocardiogram at rest, exercise treadmill tests, exercise thallium scintigrams, and exercise multigated acquisition scans. After 3 months of deconditioning, they had repeat maximal exercise stress tests. After 5 to 8 years of follow‐up, they were re‐evaluated, including history and physical examination and measurement of their Vo2max.

RESULT: All 10 master athletes had normal studies at baseline. At the end of 3 months of detraining, three of these athletes had exercise‐induced silent ischemia, which disappeared after retraining in two subjects and persisted at a higher heart rate in one subject. Over a 5‐ to 8‐year period of observation, two of these three athletes with silent ischemia experienced major cardiac events (sudden death, cardiac bypass surgery). The other seven athletes did not have any cardiovascular events.

CONCLUSIONS: Exercise‐induced silent ischemia after a short period of detraining in highly trained older athletes may be a predictor of future cardiac events. A study with a larger cohort is warranted. J Am Geriatr Soc 48:647–650, 2000.
Racial Variations in End‐of‐Life Care
Authors: Hopp Faith P. , Duffy Sonia A.
Published: April 2015

OBJECTIVES: To identify differences in advanced care planning and end‐of‐life decision‐making between whites and blacks aged 70 and older.

DESIGN: The Asset and Health Dynamics Among the Oldest Old (AHEAD) study is a nationally representative survey of adults who were aged 70 and older in 1993. Relatives (proxy respondents) for 540 persons who died between the first (1993) and second (1995) waves of the study were surveyed about advanced care planning and end‐of‐life decisions that were made for their family member who died.

SETTING: Respondents were interviewed at home by telephone (n = 444) or in person (n = 95).

PARTICIPANTS: The 540 proxy respondents included 454 whites and 86 blacks.

MEASUREMENTS: Questions were asked about advance care planning and end‐of‐life decisions.

RESULTS: Whites were significantly more likely than blacks to discuss treatment preferences before death (P = .002), to complete a living will (P = .001), and to designate a Durable Power of Attorney for Health Care (DPAHC) (P = .032). The treatment decisions for whites were more likely to involve limiting care in certain situations (P = .007) and withholding treatment before death (P = .034). In contrast, the treatment decisions for blacks were more likely to be based on the desire to provide all care possible in order to prolong life (P = .013). Logistic regression models revealed that race continued to be a significant predictor of advance care planning and treatment decisions even after controlling for sociodemographic factors.

CONCLUSIONS: These findings suggest that there are important differences between blacks and whites regarding advanced care planning and end‐of‐life decision‐making. Health professionals need to understand the diverse array of end‐of‐life preferences among various racial and ethnic groups and to develop greater awareness and sensitivity to these preferences when helping patients with end‐of‐life decision‐making. J Am Geriatr Soc 48:658–663, 2000.
Urinary Incontinence: Does it Increase Risk for Falls and Fractures?
Authors: Brown Jeanette S. , Vittinghoff Eric , Wyman Jean F. , Stone Katie L. , Nevitt Michael C. , Ensrud Kristine E. , Grady Deborah
Published: April 2015

OBJECTIVE: To determine if urge urinary incontinence is associated with risk of falls and non‐spine fractures in older women.

METHODS: Type and frequency of incontinent episodes were assessed by 6049 community‐dwelling women using a self‐completed questionnaire. Postcards were subsequently mailed every 4 months to inquire about falls and fractures. Incident fractures were confirmed by radiographic report. Logistic and proportional hazard models were used to assess the independent association of urge urinary incontinence and risk of falling or fracture.

RESULTS: The mean age of the women was 78.5 (± 4.6) years. During an average follow‐up of 3 years, 55% of women reported falling, and 8.5% reported fractures. One‐quarter of the women (1493) reported weekly or more frequent urge incontinence, 19% (1137) reported weekly or more frequent stress incontinence, and 708 (12%) reported both types of incontinence. In multivariate models, weekly or more frequent urge incontinence was associated independently with risk of falling (odds ratio = 1.26; 95% confidence interval (CI), 1.14‐1.40) and with non‐spine nontraumatic fracture (relative hazard 1.34; 95% CI, 1.06‐1.69; P = .02). Stress incontinence was not associated independently with falls or fracture.

CONCLUSIONS: Weekly or more frequent urge incontinence was associated independently with an increased risk of falls and non‐spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture. J Am Geriatr Soc 48:721–725, 2000.
Outcome and Utilization Differences for Older Persons with Stroke in HMO and Fee‐for‐Service Systems
Authors: Kramer Andrew M. , Kowalsky Jacqueline Cahill , Lin Michael , Grigsby James , Hughes Richard , Steiner John F.
Published: April 2015

OBJECTIVES: To compare treatment and outcomes for older persons with stroke in Medicare health maintenance organizations (HMOs) and fee‐for‐service (FFS) systems.

DESIGN: Inception cohort stratified by payer and followed for 1 year.

SETTING: Six HMOs and five FFS systems with large Medicare populations in the West, Midwest, and Eastern United States.

PARTICIPANTS: A total of 429 randomly selected stroke patients receiving rehabilitation in nursing homes or rehabilitation hospitals (RHs) from June 1993 to June 1995.

MEASUREMENTS: Improvement in activities of daily living (ADLs) during rehabilitation, and ADL recovery, community residence, and utilization until 12 months after stroke. Outcomes were adjusted for premorbid function, marital status, comorbid illness, posthospital function, cognition, psychological problems, and stroke deficits.

RESULTS: At baseline, HMO patients were more likely to be married, and less likely to be blind or have psychiatric diagnoses. HMO patients had shorter hospitalizations (P < .001), were less likely to be admitted to RHs (13% vs 85%, P < .001), and received fewer therapy and physician specialist visits (P < .001) but more home health visits (P < .001). During rehabilitation, FFS patients made greater improvement in ADLs (difference, 0.73 ADLs; 95% CI, .37‐1.09). At 1 year, there was no difference in ADL recovery (difference, −0.24 ADL; 95% CI, −0.64‐0.16), but FFS patients were more likely to reside in the community (adjusted OR, 1.8; 95% CI, 1.1–3.1), and HMO patients were more likely to reside in nursing homes (adjusted OR, 2.4; 95% CI, 1.1–5.5).

CONCLUSION: Study findings suggest that short‐term functional outcomes and eventual community residence rates are poorer for Medicare HMO patients with stroke than for stroke patients receiving FFS care, consistent with the lower intensity of rehabilitation (in nursing homes vs RHs) and less specialty physician care. J Am Geriatr Soc 48:726–734, 2000.
Postmenopausal Hormone Therapy and Cognitive Function in Healthy Older Women
Authors: Grodstein Francine , Chen Jennifer , Pollen Daniel A. , Albert Marilyn S. , Wilson Robert S. , Folstein Marshal F. , Evans Denis A. , Stampfer Meir J.
Published: April 2015

OBJECTIVE: Accumulating biologic evidence suggests that estrogen is related to cognitive function. Several epidemiologic investigations have reported that hormone therapy may reduce the risk of Alzheimer's disease. However, fewer studies have examined the relation of postmenopausal hormone use to general cognitive function in nondemented older women. Thus, we examined the association of hormone therapy to performance on four cognitive tests among healthy participants of the Nurses' Health Study.

DESIGN: Cohort study.

SETTING: The Nurses' Health Study, an ongoing prospective cohort study begun in 1976.

PARTICIPANTS: From the Nurses' Health Study, 2138 women aged 70–78 years.

MEASUREMENTS: From 1995–1999 we administered four cognitive tests (Telephone Interview for Cognitive Status (TICS), immediate and delayed recall of the East Boston Memory Test (EBMT), and verbal fluency) by telephone. Hormone use was ascertained from biennial questionnaires beginning in 1976. Linear and logistic regression models were used to calculate multivariate‐adjusted differences in scores and relative risks of a low score for never users compared to current and past hormone users.

RESULTS: After adjustment for confounders, neither current nor long‐term hormone users demonstrated better performance on an overall measure of cognition (TICS), or on three tests of verbal memory (immediate and delayed recall of the EBMT, immediate recall of the TICS 10‐word list) than never users. On the test of verbal fluency, current hormone users scored significantly better than never users (linear regression estimate of the difference in score = 0.78 points, 95% confidence interval (CI) 0.19‐0.38, P = .01 for any current use; and 0.91 points, 95% CI 0.28‐1.54, P = .005 for ≥5 years current use). Current hormone users also had a 30% decrease (RR = 0.70,95% CI 0.45‐1.09) in their risk of a low score on the test of verbal fluency. These results were similar for women taking estrogen alone and estrogen combined with a progestin.

CONCLUSIONS: Verbal fluency may be enhanced among women taking postmenopausal hormones, however, there is little support for better overall cognitive function in hormone users than nonusers. J Am Geriatr Soc 48:746–752, 2000.