bluuebunny/crossref_metadata_2025 huggingface dataset:
Patterns of Use of Common Major Procedures in Medical Care of Older Adults
Authors: Levinsky Norman G. , Ash Arlene S. , Yu Wei , Moskowitz Mark A.
Published: April 2015

OBJECTIVES: We analyzed Medicare data to determine the influence of age, mortality during the study year, and high individual Medicare costs on the frequency of hospitalization for the most common major procedures and for general medical diagnoses.

METHODS: We used 1992 Medicare data to classify the most frequent diagnosis related groups (DRGs), representing one‐half of all admissions, as procedural or general medical. We studied the frequency of hospitalization for the most common procedures (bowel surgery, cardiovascular procedures, hip and femur surgery) and for general medical care in the entire Medicare population, in persons aged 65 to 74, 75 to 84, and 85 or older, in those who died, and in the 5% of persons whose annual Medicare costs were the highest.

RESULTS: In the entire population, common procedures accounted for 21 % of the most frequent DRGs. Among those who died, the procedures were performed in only 8% of admissions. In the 5 % of persons with the highest Medicare costs, 28% of admissions involved procedures. Admissions for cardiovascular procedures and for cancer chemotherapy decreased with age and were infrequent in persons 85 years and older. Hip and femur procedures increased with age and accounted for 70% of the common procedures in persons 85 years and older.

CONCLUSIONS: The most common major procedures account for a minority of hospitalizations of persons more than age 65, of persons 85 and older, of those who died, and of persons with the highest Medicare expenditures. Most hospitalizations are for general medical care. Major procedures appear to be used with restraint in the very old and in persons in their last year of life. J Am Geriatr Soc 47:553–558, 1999.
Medication Management Capacity in Highly Functioning Community‐Living Older Adults: Detection of Early Deficits
Authors: Edelberg Helen K. , Shallenberger Elizabeth , Wei Jeanne Y.
Published: April 2015

OBJECTIVE: The Drug Regimen Unassisted Grading Scale (DRUGS) was developed and employed in testing the hypothesis that the inability to take medication independently may correlate with the presence of cognitive impairment.

DESIGN: Cross‐sectional study.

SETTING: Two continuing care retirement facilities in the Greater Boston area.

PARTICIPANTS: The study population included outpatients ≥ 70 years old.

MEASUREMENTS: We developed a novel performance‐based measure, the DRUGS tool, involving a step‐wise progression of four tasks: (1) identification; (2) access; (3) dosage; and (4) timing.

RESULTS: Fifty‐nine participants aged 84.2 ± 5.1 years (mean ± SD) completed the study. The DRUGS tool score was inversely related to age (r = ‐.41, P = .001). Compared with independent‐living, residence in assisted‐living was associated with lower DRUGS tool scores (82.0% vs 93.8%, P = .009). The DRUGS tool score was associated with self‐reported Medication Management capacity (94.8% able vs 86.2% unable to take medications independently by self‐report, P = .047). Both DRUGS tool score and self‐reported Medication Management capacity were associated with MMSE (P = .0008 and P = .044, respectively). The multivariate model, with DRUGS tool Summary Score as the dependent variable, adjusted for age and sex, included MMSE (P = .023) and self‐reported IADL (P = .038).

CONCLUSION: There is an association between performance on the DRUGS tool and level of cognitive function. The DRUGS tool represents a unique individualized, yet standardized, assessment of the ability to function independently for ambulatory older persons. It may be useful for identifying those highly functioning older persons, at an early phase of cognitive decline, in whom targeted intervention would likely be most effective and efficient. J Am Geriatr Soc 47:592–596, 1999.
Management and Outcome of Acute Myocardial Infarction in Older Patients in the Thrombolytic Era
Authors: Mahon Niall G. , Codd Mary B. , O'Rorke Cliona , Egan Bernadette , McCann Hugh A. , Sugrue Declan D.
Published: April 2015

OBJECTIVE: Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group.

DESIGN: An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI.

SETTING: An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center.

RESULTS: Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short‐ and long‐term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta‐blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care.

CONCLUSION: Patients more than age 75 comprise almost one‐third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.
Prognostic Value of Dipyridamole Thallium Imaging After Acute Myocardial Infarction in Older Patients
Authors: Jain Sudhir , Baird John B. , Fischer Keith C. , Rich Michael W.
Published: April 2015

OBJECTIVE: To assess the utility of intravenous dipyridamole thallium testing for predicting major cardiac events following acute myocardial infarction in older patients.

DESIGN: Prospective cohort study with a median follow‐up of 18 months.

SETTING: A university teaching hospital.

PARTICIPANTS: 73 patients aged 65 years and older with enzymatically confirmed acute myocardial infarction (mean age 75 years, 56% male, 71% white).

MEASUREMENTS: All patients underwent a detailed clinical assessment, an echocardiogram, and an intravenous dipyridamole thallium stress test before hospital discharge. The study endpoint was death or nonfatal reinfarction during the follow‐up period.

RESULTS: Overall, 24 patients (33%) died or developed recurrent myocardial infarction during follow‐up. Among 44 patients with a reversible thallium defect, 19 (43%) reached the study endpoint, compared with only five of 29 patients (17%) without reversible ischemia (P = .04). On multivariate analysis, independent prognostic variables included non‐use of aspirin at hospital discharge (P = .002), decreased left ventricular systolic function (P = .009), non‐use of a beta‐blocker at hospital discharge (P = .013), and reversible ischemia on thallium scintigraphy (P = .025). The relative risks for death or reinfarction associated with non‐use of aspirin, non‐use of a beta‐blocker, left ventricular dysfunction, and reversible ischemia were 2.65, 2.39, 2.01, and 2.51, respectively. Patients with three or four of these risk factors had an 83% probability of death or reinfarction, compared with 41 % in patients with two risk factors and 6% in patients with one or no risk factor (P < .001).

CONCLUSION: Intravenous dipyridamole thallium imaging provides independent prognostic information in older patients with acute myocardial infarction. Moreover, the combination of clinical, echocardiographic, and dipyridamole thallium variables effectively stratifies older postinfarction patients into high‐, intermediate‐, and low‐risk categories for death or recurrent myocardial infarction.
The Driving Habits of Adults Aged 60 Years and Older
Authors: Gallo Joseph J. , Rebok George W. , Lesikar Sandra E.
Published: April 2015

OBJECTIVES: We describe the driving habits of adults aged 60 years and older who were interviewed in the context of a community survey focused on mental disturbances. Our goal was to identify clinical cues that might signal driving difficulty in older adults who might present to the primary care physician for health care.

DESIGN: A population‐based survey.

SETTING: Continuing participants in a follow‐up study of community‐dwelling adults who were living in East Baltimore in 1981.

PARTICIPANTS: Subjects were 1920 continuing participants of the Baltimore sample of the Epidemiologic Catchment Area Program; 589 were aged 60 years and older and provided information on driving habits.

MEASUREMENTS: Respondents were asked about their driving status: had they made adaptations to driving and had they experienced any adverse driving events in the 2 years before the interview. Driving behaviors were assessed in relation to chronic disease, sensory impairment, functional status, and mental status.

RESULTS: Former drivers were more likely to be older, female, and nonwhite. Diabetes, vision impairment, functional impairment, and making an error on the copy design task of the Mini‐Mental State Examination (MMSE) were associated with no longer driving. Women were more likely to report having made adaptations to driving, as were persons with heart disease, arthritis, vision impairment, and those who made an error on the copy design task of the MMSE. Heart disease and hearing impairment were associated with report of an adverse driving event. In multivariate models that included terms for potentially influential characteristics such as age, gender, and miles driven, only the copy design task was associated with driving status, and only heart disease was associated with driving adaptation and adverse driving events.

CONCLUSION: Simple tests that tap visuospatial ability, such as the copy design task of the MMSE, may warrant additional study for use in driving assessment of older adults in primary care. The results underscore the importance of making an inquiry about driving as a separate and independent component of functional assessment.
Survival After Percutaneous Endoscopic Gastrostomy Among Older Residents of Quebec
Authors: Fisman David N. , Levy Adrian R. , Gifford David R. , Tamblyn Robyn
Published: April 2015

CONTEXT: Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population‐based data to guide the use of this intervention in older individuals.

OBJECTIVE: To describe the use of percutaneous endoscopic gastrostomy among older residents of Quebec and to evaluate patient characteristics associated with subsequent survival and hospital discharge.

DESIGN: A population‐based cohort study.

SETTING: Quebec, Canada.

PATIENTS: 175 individuals with a billing claim for percutaneous endoscopic gastrostomy performed in 1993.

MEASUREMENTS: Billing and hospitalization databases were used to collect patient characteristics, medical diagnoses, discharge destinations, and dates of death. The relationships between demographic and diagnostic variables before gastrostomy, and subsequent survival and discharge home, were evaluated using survival analysis.

RESULTS: Median survival after gastrostomy was 210 days. Mortality at 30 days was 18.3%. Decreased survival was associated with a previous diagnosis of malignancy (risk ratio (RR) = 1.71; 95% CI, 1.09–2.68); mortality did not increase with increasing age. Of 163 individuals hospitalized at the time of gastrostomy, 42 (26%) were discharged home. Individuals with a previous diagnosis of stroke (RR = 2.80; 95% CI 1.01–7.77) were more likely to be discharged home than other individuals.

CONCLUSIONS: Survival after percutaneous endoscopic gastrostomy is poor; the requirement for such a procedure appears to be a marker for severe underlying disease. The greater likelihood of return home after gastrostomy among individuals with stroke suggests that the use of this intervention as an adjunct to rehabilitation is appropriate in these individuals.
Secondary Hyperparathyroidism in Patients from Western Australia with Hip Fracture: Relationship to Type of Hip Fracture, Renal Function, and Vitamin D Deficiency
Authors: Bruce David G , St John Andrew , Nicklason Frank , Goldswain Peter R.T.
Published: April 2015

OBJECTIVES: To determine the frequency of vitamin D deficiency and secondary hyperparathyroidism in Australian hip fracture patients living in the community.

PATIENTS: A total of 283 consecutive patients with hip fracture admitted over a 15‐month period to a university teaching hospital in Western Australia. Included were residents of hostels for the elderly, and excluded were nursing home residents and those with malignant fractures.

METHOD: Data collected included biochemistry (25 hy‐droxyvitamin D, parathyroid hormone and creatinine levels), measurements of function and disability (Barthel Index, Frenchay Activity Index), sunshine exposure, and basic demographics.

RESULTS: Vitamin D deficiency occurred in 31.7% and secondary hyperparathyroidism occurred in 17.7% of cases. The major determinants of vitamin D deficiency were outdoor sunshine exposure, ambient daily sunshine, and disability (low Frenchay Activity Index or ADL difficulty). Secondary hyperparathyroidism was related to older age, renal dysfunction, and vitamin D deficiency. Secondary hyperparathyroidism was associated with an excess of trochanteric over subcapital hip fractures.

CONCLUSIONS: Secondary hyperparathyroidism appears to be a heterogeneous condition, caused in approximately equal proportions by vitamin D deficiency and renal dysfunction, that may confer increased cortical bone fragility and trochanteric fractures. Renal dysfunction in old age may be an important additional determinant of senile osteoporosis, which has implications for preventive therapy. Vitamin D deficiency occurs in disabled and, presumably, housebound older people despite near optimal climactic conditions.
A Randomized Trial of a Combined Physical Activity and Environmental Intervention in Nursing Home Residents: Do Sleep and Agitation Improve?
Authors: Alessi Cathy A. , Yoon Eun J. , Schnelle John F. , Al‐Samarrai Nahla R. , Cruise Patrice A.
Published: April 2015

OBJECTIVES: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents.

DESIGN: A randomized trial.

SETTING: One community nursing home in the Los Angeles, California area.

PARTICIPANTS: Twenty‐nine incontinent residents (mean age 88.3 years, 90% female).

INTERVENTION: Subjects were randomized to receive either (1) an intervention combining increased daytime physical activity (14 weeks in duration) plus a nighttime program (5 nights in duration) to decrease noise and sleep‐disruptive nursing care practices (intervention group), or (2) the nighttime program alone (control group). MEASUREMENTS: Daytime physical activity monitors and structured physical function assessments; nighttime wrist activity monitors to estimate nighttime sleep; and timed day time behavioral observations of sleep versus wakefulness, either in or out of bed, and agitation.

RESULTS: Physical function measures did not change significantly (MANOVA for repeated measures, group by time effect). Wrist actigraphy estimation of nighttime percent sleep (time asleep over time monitored in bed at night) increased in intervention subjects from 51.7% at baseline to 62.5% at follow‐up compared with 67.0% at baseline to 66.3% at follow‐up in controls (MANOVA, group by time, F = 4.42, P =. 045, df = 27). At follow‐up, intervention subjects averaged a 32% decrease in the percent of daytime observations in bed compared with baseline, with essentially no change in controls (MANOVA, group by time, F = 5.31, P =. 029, df = 27). Seven of 15 intervention subjects had a decrease in observed agitation at follow‐up, compared with baseline, versus only 1 of 14 controls with a decrease in observed agitation.

CONCLUSIONS: This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents.
Risk Factors for Falls and for Serious Injuries on Falling Among Older Japanese Women In Hawaii
Authors: Davis James W. , Ross Philip D. , Nevitt Michael C. , Wasnich Richard D.
Published: April 2015

OBJECTIVES: To evaluate if similar constellations of factors underlie the risks of falls and injuries on falling for Japanese women as reported for predominately white populations.

DESIGN: A prospective cohort study

SETTING: The island of Oahu

PARTICIPANTS: The older Japanese women who participated in the Hawaii Osteoporosis Study (mean age = 74 ± 5 (SD) years).

MEASUREMENTS: As outcomes: falls and serious injuries on falling. As predictors: anthropometric measurements, measurements of neuromuscular performance, activities of daily living (ADLs), past falls, and other suspected risk factors for falls and serious injuries.

RESULTS: In multivariable models, four subject characteristics were positively associated with having a fall (having a fall in the past year (RR = 2.0 (95% CI, 1.5–2.8)), slow chair stands (RR = 1.4 (95% CI, 1.0–1.9), a short height (RR = 1.5 (95% CI, 1.1–2.1)), difficulties with five or more ADLs (RR = 1.5 (95% CI, 1.1–2.1))). Two subject characteristics were negatively associated with having a fall (ability to perform a full tandem balance with eyes closed (RR =. 7 (95% CI,. 5–1.0)) and having a long functional reach (RR =. 7 (95% CI,. 5–1.0))). The RRs represent as nearly as possible comparisons of the upper (or lower) quartile and the remaining quartiles. In multivariable models, long times for chair stands (odds ratio (OR) = 3.0 (95% CI, 1.5–6.1)) and a low BMI (OR = 3.1 (95% CI, 1.5–6.4)) were positively associated with having a serious injury among women who had a fall. Among the same women, taking part in an activity they did frequently (OR =. 3 (95% CI,. 1−.8)) and slow foot reaction times (OR =. 3 (95% CI,. 1−.8)) were associated negatively with having a serious injury. CONCLUSIONS: The results from this Japanese cohort support the conclusion that women at high risk of falling and serious fall injuries can be identified using a questionnaire and simple, performance‐based tests of neuromuscular function. The risk factors for falling overlapped, but were distinct from, those for suffering a serious injury once a fall had occurred.
The Treatment and Prevention of Coronary Heart Disease in Canada: Do Older Patients Receive Efficacious Therapies?
Authors: McAlister Finlay A. , Taylor Laurel , Teo Koon K. , Tsuyuki Ross T. , Ackman Margaret L. , Yim Rita , Montague Terrence J. ,   The Clinical Quality Improvement Network (CQIN) Investigators
Published: April 2015

OBJECTIVES: To review the evidence for clinical efficacy and cost‐effectiveness of proven medications in the treatment and prevention of myocardial infarction (MI) in older patients; to summarize Canadian data on treatment patterns and clinical outcomes for younger and older patients with coronary heart disease; to explore the reasons for gaps between best care, based on the evidence of efficacy from trials, and usual care, based on the population effectiveness audits; and to explore potential approaches to closing the care gaps.

DESIGN: Review of the recent clinical trial literature on the management of MI, highlighting results in older patients. Review of medication utilization and outcomes data from a series of large, consecutively enrolled patient cohorts with acute MI (N = 7070) in a variety of cardiac care settings (10 centers in five Canadian provinces, including university‐ based teaching hospitals, community hospitals, cardiologist and family physician out‐patient clinics) from 1987 to 1996.

RESULTS: There is no qualitative interaction of cardiac therapies: thrombolytics, beta‐blockers, acetylsalicylic acid (ASA), and statins are efficacious in all clinically relevant patient subgroups, including older people. However, there are consistent gaps between usual care and best care, particularly among older patients (in whom there is also a concomitantly higher mortality risk). Repeated multivariate analyses confirm older age to be an independent contributor to increased risk. Use of efficacious medications is, in contrast, consistently associated with increased survival. Analysis of temporal trends suggests beneficial changes in practice patterns and outcomes are possible to achieve. However, “best care” has not been rapidly or completely achieved. Review of strategies to close these care gaps suggests that audit and feedback, critical pathways, and multifactorial interventions involving patients and other members of the healthcare team as well as physicians may be the most efficacious strategies for change.

CONCLUSIONS: Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population. J Am Geriatr Soc 47: 811–818, 1999.
Prevalence of Combined Fecal and Urinary Incontinence: A Community‐Based Study
Authors: Roberts Rosebud O. , Jacobsen Steven J. , Reilly W. Terence , Pemberton John H. , Lieber Michael M. , Talley Nicholas J.
Published: April 2015

OBJECTIVE: To assess the prevalence of combined fecal and urinary incontinence.

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

SETTING: Olmsted County, Minnesota.

PARTICIPANTS: Men (n = 778) and women (n = 762), aged 50 years or older, selected randomly from the population.

MEASUREMENTS: Participants completed a previously validated self‐administered questionnaire that assessed the occurrence of fecal and urinary incontinence in the previous year.

RESULTS: The age‐adjusted prevalence of incontinence was 11.1% (95% Confidence Interval (CI), 8.8–13.5) in men and 15.2% (95% CI, 12.5–17.9) in women for fecal incontinence; 25.6% (95% CI, 22.5–28.8) in men and 48.4% (95% CI, 44.7–52.2) in women for urinary incontinence; and 5.9% (95% CI, 4.1–7.6) in men and 9.4% (95% CI, 7.1–11.6) in women for combined urinary and fecal incontinence. The prevalence of fecal incontinence increased with age in men but not in women, from 8.4% among men in their fifties to 18.2% among men in their eighties (P for trend =. 001). For women, the prevalence increased from 13.1% among 50‐ year‐old women to 20.7% among women 80 years or older (P for trend =. 5). Among persons with fecal incontinence, the prevalence of concurrent urinary incontinence was 51.1% among men and 59.6% among women (P =. 001 and P =. 003, respectively). Cross‐sectionally, the age‐adjusted, relative odds of fecal incontinence among persons with urinary incontinence was greater in men than in women (Odds Ratio (OR) = 3.0; 95% CI, 1.9–4.8 in men and OR = 1.8; 95% CI, 1.2–2.7 in women, P =. 04).

CONCLUSIONS: These findings suggest that persons with one form of incontinence are likely to have the other form as well. Despite the higher prevalence of urinary and fecal incontinence among women, the association between fecal incontinence and urinary incontinence was stronger among men than women. This finding, and the significant association between fecal incontinence and age observed in men but not in women, suggest that the etiologies may be more closely linked in men than in women.
Gender Differences in the Sequelae of Hospitalization for Acute Myocardial Infarction Among Older Adults
Authors: Wolinsky Fredric D. , Wyrwich Kathleen W. , Gurney James G.
Published: April 2015

OBJECTIVE: To examine the effect of gender differences among older adults hospitalized for an acute myocardial infarction (AMI) on subsequent health outcomes.

DESIGN: Secondary analysis of the Longitudinal Study on Aging. Data from baseline interviews (1984) and three biennial (1986, 1988, and 1990) re‐interviews were linked to Medicare hospitalization and National Death Index records for 1984–1991.

PARTICIPANTS: A total of 6071 community‐dwelling adults aged 70 years or older at baseline.

METHODS: Pooled and stratified multivariable models were used to examine gender differences in the independent effects of being hospitalized for an AMI on all‐ cause mortality, the risk and volume of subsequent hospitalization, and increases in the number of functional limitations. Two comparison groups were used.

RESULTS: Three hundred fifty‐seven AMI cases (6%; 172 women and 185 men) were compared with 3976 hospitalized controls and 1738 nonhospitalized controls. The risk of all‐cause mortality for AMI cases was greater than that for either hospitalized controls or nonhospitalized controls (referent), and this increased risk was significantly (P < .001) stronger for women (adjusted hazards ratio (AHR) = 14.24, 95%CI = 10.99, 18.46) than for men (AHR = 9.91, 95%CI = 7.75, 12.67). Overall, AMI cases were also more likely to be hospitalized subsequently than the hospitalized controls (referent; adjusted odds ratio (AOR) = 1.47, 95%CI = 1.17, 1,85), although in the stratified analysis this association held for men (AOR = 1.73, 95%CI = 1.25, 2.41) but not for women (AOR = 1.25, 95%CI = .90, 1.73). Among those subsequently hospitalized, both women and men AMI cases consumed more hospital resources than the hospitalized controls, and there were gender differences suggesting that the effects on total charges and length of stay were greater for women than for men with AMI. Finally, although the AMI cases had greater adjusted mean increases in the number of instrumental activities of daily living limitations and lower body limitations than the nonhospitalized controls, they were no worse off than the hospitalized controls, and there were no gender differences in those effects.

CONCLUSION: Relative to the appropriate comparison groups, hospitalization for an AMI increases the risk of death and the total costs and lengths of stay of subsequent hospitalizations for women more than for men. Therefore, increased primary prevention, diagnosis, and treatment efforts should be directed toward women. J Am Geriatr Soc 47:151–158, 1999.
Contrasting Results Between Caregiver's Report and Direct Assessment of Activities of Daily Living in Patients Affected by Mild and Very Mild Dementia: The Contribution of the Caregiver's Personal Characteristics
Authors: Zanetti Orazio , Geroldi Cristina , Frisoni Giovanni B. , Bianchetti Angelo , Trabucchi Marco
Published: April 2015

OBJECTIVE: To determine the level of agreement between the primary caregiver's report on patient activities of daily living (ADLs) and ADLs assessed directly in a sample of patients affected by very mild and mild dementia and to assess whether this agreement is influenced by the caregiver's depressive symptoms and burden.

PATIENTS AND METHODS: Data were obtained from the baseline sample of the Mild Dementia Longitudinal Study, consisting of 111 consecutive patients affected by dementia with very mild to mild functional impairment (grades .5 and 1 on the Clinical Dementia Rating Scale). As is usual for patients referred to our Alzheimer's Unit, anamnestic, cognitive, functional and behavioral information are collected from the primary caregiver. Along with sociodemographic characteristics, caregivers' depressive symptoms (Beck Depression Inventory Scale) and burden (Nowak and Guest's Caregiver Burden Inventory Scale) were also evaluated. Patients underwent a performance‐based assessment of the activities of daily living (DAFS) and direct assessment of physical function with the Physical Performance Test (PPT). Caregiver's report and direct observation have been compared for the following ADLs: dressing, toileting, walking, telephone use, shopping, and money use. Discriminant analyses were conducted to examine the degree of agreement between caregiver‐report functional status and performance‐based measures and whether additional agreement is attributable to caregiver's burden and depressive symptoms.

RESULTS: The strength of the association between the caregiver's report and performance‐based measures of ADLs is high for motor performance (walking), moderate to good for dressing, but only moderate for telephone, money use, and shopping. No association was found for toileting. The discrepancies between caregiver report and performance‐based assessment were influenced substantially by the burden caused by demands and restrictions on a caregiver's time.

CONCLUSIONS: With the exception of motor performance (walking), the caregiver's report and the performance‐based assessment of functional status measure different aspects of a patient's functional status. Contrasts between the caregiver's report and observed ADL performance in mildly and very mildly demented patients are influenced by the caregiver's burden. J Am Geriatr Soc 47:196–202, 1999.
Low Serum Calcidiol Concentration in Older Adults with Reduced Muscular Function
Authors: Mowé Morten , Haug Egil , Bøhmer Thomas
Published: April 2015

OBJECTIVE: To examine the association between muscular function and the serum concentrations of 25‐hydroxyvitamin D (calcidiol) and 1,25‐dihydroxyvitamin D (calcitriol).

DESIGN: A randomized population survey. Baseline measurements of serum calcidiol and calcitriol concentrations and assessment of muscular function (hand grip strength, ability to climb stairs, outdoor activity, and fall occurrence).

SETTING: The Medical department, Aker University Hospital, Oslo, and subjects' homes.

PARTICIPANTS: Two hundred forty‐six recently hospitalized older patients and 103 randomly selected older people living at home.

MEASUREMENTS: Serum concentration of calcidiol and calcitriol in relation to muscle function.

MAIN RESULTS: Reduced muscle function was associated with low calcidiol levels. In both the hospital group and the home group, calcidiol concentrations correlated positively to arm muscle strength (r = .22, P < .001, r = .37, P < .001), ability to climb stairs (r = .16, P < .05; r = ‐.42, P = <.001), physical activity (r = ‐.27, P < .001; r = ‐.31, P < .001), and the absence of fall occurrences (r = ‐.27, P < .001; r = ‐.31, P = .004). Calcitriol showed an association with physical activity in the hospital group (r = ‐.19, P < .05), and with fall last month in the home group (r = ‐.22, P < .05).

CONCLUSIONS: Older people with reduced muscle function often had reduced levels of calcidiol serum concentration. Low levels of calcidiol were not associated with signs of general undernutrition, such as low body mass, or with reduced arm‐muscle circumference or triceps skinfold thickness. This finding may suggest a physiological role for calcidiol in muscle function. Reduced muscle strength increased disability in our older subjects, which may be improved by vitamin D supplementation in vitamin D‐deficient subjects. J Am Geriatr Soc 47:220–226, 1999.
A Patient‐Centered Approach to Advance Medical Planning in the Nursing Home
Authors: Gillick Muriel , Berkman Susan , Cullen Lorraine
Published: April 2015

OBJECTIVE: The objective of this study is to determine whether nursing home residents or their surrogates are willing and able to prioritize their goals for care and to demonstrate how these rankings can form the basis of a specific pattern of medical care.

DESIGN: A prospective, descriptive study.

SETTING: A 40‐bed nursing unit for residents with mild to moderate impairments in a 725‐bed teaching nursing home.

RESULTS: Overall, 78% of patients or their families were willing to prioritize their goals, allowing the investigators to infer a pattern of care. The goals were interpreted as implying an intensive pattern in 21%, a comprehensive pattern in 16%, a basic pattern in 18%, palliation in 18%, and comfort only in 6% of residents. Goals chosen by residents who were able to select for themselves translated into more aggressive care than did the goals selected by surrogates.

CONCLUSION: Goal‐centered advance medical planning can be initiated in nursing homes by asking residents or their surrogates to prioritize their goals of care. These prioritizations can form the foundation for specific patterns of care. J Am Geriatr Soc 47:227–230, 1999.
GERIATRICS IN MANAGED CARE: Managed Care for Older People: A Primer for the Geriatrician
Authors: Reed Richard L. , Hepburn Kenneth W.
Published: April 2015

Managed care for older people is growing at a very rapid rate. Many geriatricians and primary care providers are interested in this area but have limited sources of information to guide their decision‐making about whether to participate in these programs. This review provides a basic overview of managed care for older people, including plan types and roles that geriatricians may choose in participating in these programs. Risk and value are central concepts that impact managed care of this population. Several changes in Medicare Managed Care have occurred with the passage by Congress of the Balanced Budget Act of 1997. Geriatricians are strongly encouraged to participate in managed care as it offers the potential for improved models of care delivery for older adults. J Am Geriatr Soc 47:241–249, 1999.
Once‐Weekly Resistance Exercise Improves Muscle Strength and Neuromuscular Performance in Older Adults
Authors: Taaffe Dennis R. , Duret Camille , Wheeler Steve , Marcus Robert
Published: April 2015

OBJECTIVE: To determine the effect of frequency of resistive training on gain in muscle strength and neuromuscular performance in healthy older adults.

DESIGN: A randomized controlled trial with subjects assigned either to high‐intensity resistance training 1 (EXl), 2 (EX2), or 3 (EX3) days per week for 24 weeks or to a control group (CO).

SETTING: An exercise facility at an academic medical center.

SUBJECTS: Forty‐six community‐dwelling healthy men (n = 29) and women (n = 17) aged 65 to 79 years.

INTERVENTION: Progressive resistance training consisting of three sets of eight exercises targeting major muscle groups of the upper and lower body, at 80% of one‐repetition maximum (1‐RM) for eight repetitions, either 1,2, or 3 days per week.

MEASURES: Dynamic muscle strength (1‐RM) using iso‐tonic equipment every 4 weeks, bone mineral density and body composition by dual energy X‐ray absorptiometry (DXA), and neuromuscular performance by timed chair rise and 6‐meter backward tandem walk.

RESULTS: For each of the eight exercises, muscle strength increased in the exercise groups relative to CO (P < .01), with no difference among EXl, EX2 and EX3 groups at any measurement interval. Percent change averaged 3.9 ± 2.4 (CO), 37.0 ± 15.2 (EXl), 41.9 ± 18.2 (EX2), and 39.7 ± 9.8 (EX3). The time to rise successfully from the chair 5 times decreased significantly (P < .01) at 24 weeks, whereas improvement in the 6‐meter backward tandem walk approached significance (P = .10) in the three exercise groups compared with CO. Changes in chair rise ability were correlated to percent changes in quadriceps strength (r = −0.40, P < .01) and lean mass (r = −0.40, P < .01).

CONCLUSIONS: A program of once or twice weekly resistance exercise achieves muscle strength gains similar to 3 days per week training in older adults and is associated with improved neuromuscular performance. Such improvement could potentially reduce the risk of falls and fracture in older adults.
Strength Training Normalizes Resting Blood Pressure in 65‐ to 73‐Year‐Old Men and Women with High Normal Blood Pressure
Authors: Martel G. F. , Hurlbut D. E. , Lott M. E. , Lemmer J. T. , Ivey F. M. , Roth S. M. , Rogers M. A. , Fleg J. L. , Hurley B. F.
Published: April 2015

OBJECTIVE: To determine the effects of heavy resistance strength training (ST) on resting blood pressure (BP) in older men and women.

DESIGN: Prospective intervention study.

SETTING: University of Maryland Exercise Science Laboratory.

PARTICIPANTS: Twenty‐one sedentary, healthy older men (69 ± 1 year, n = 11) and women (68 ± 1 year, n = 10) served as subjects for the study.

INTERVENTION: Six months of progressive whole body ST performed 3 days per week using Keiser K‐300 air‐powered resistance machines.

MEASUREMENTS: One‐repetition maximum (1 RM) strength was measured for seven different exercises before and after the ST program. Resting BP was measured on six separate occasions before and after ST for each subject.

RESULTS: Substantial increases in 1 RM strength were observed for upper body (UB) and lower body (LB) muscle groups for men (UB: 215 vs 265 kg; LB: 694 vs 838 kg; P < .001) and women (UB: 128 vs 154 kg; LB: 441 vs 563 kg; P < .001). The ST program led to reductions in both systolic (131 ± 2 vs 126 ± 2 mm Hg, P < .010) and diastolic (79 ± 2 vs 75 ± 1 mm Hg, P < .010) BP. Systolic BP was reduced significantly in men (134±3vsl27±2 mm Hg, P < .01) but not in women (128 ± 3 vs 125 ± 3mmHg, P < .01), whereas diastolic BP was reduced following training in both men (81 ± 3 vs 77 ± 1, mm Hg, P = .054) and women (78 ± 2 vs 74 ± 2 mm Hg, P = .055).

CONCLUSIONS: Six months of heavy resistance ST may reduce resting BP in older persons. According to the latest guidelines from the Joint National Committee for the Detection, Evaluation, and Treatment of Hypertension, the changes in resting BP noted in the present study represent a shift from the high normal to the normal category.
Using Admission Characteristics to Predict Return to the Community from a Post‐Acute Geriatric Evaluation and Management Unit
Authors: Naughton Bruce J. , Saltzman Susan , Priore Roger , Reedy Karen , Mylotte Joseph M.
Published: April 2015

OBJECTIVE: To compare the Cumulative Illness Rating Scale (CIRS) and the Nursing Severity Index (NSI) as independent predictors of discharge outcome from a post‐acute GEM unit and to define a multivariate model for predicting the same outcome.

DESIGN: Retrospective chart review for the entire sample. The sample was split into two cohorts, a derivation cohort (n = 298) and a validation cohort (n = 154).

SETTING: A 20‐bed, post‐acute GEM unit in a nonproprietary skilled nursing facility.

PARTICIPANTS: All 452 patients admitted to the GEM from the unit's inception in December 1994 until January 1998.

MEASUREMENT: Demographics, CIRS, NSI, functional status, and social support variables were measured using data available on admission to the GEM unit. The discharge outcome was dichotomized as return to the community or not.

RESULTS: A total of 99.7% of the individuals in the derivation cohort were living in the community before the index hospital‐ization; 75.8% of patients in the derivation cohort returned to the community. The NSI, individual “severe” items from the CIRS, age, and social support were in the final logistic regression model fitted to the derivation cohort. A total of 87.7% of the observed discharge outcomes were predicted when the model was applied to the validation cohort and the calculated probability of return to the community.

CONCLUSIONS: Variables for severity of illness, function, social support, and age combined into a logistic regression equation that predicted more than 80% of the dichotomized discharge outcome in the derivation cohort. The proportion of discharge outcomes that were predicted with the validation cohort remained high at 87.7%. The NSI and CIRS were each important to a model that is anticipated to refine the selection of geriatric patients for post‐acute services. J Am Geriatr Soc 47:1100–1104,1999.
Drinking Habits Among Older Persons: Findings from the NHANES I Epidemiologic Follow‐up Study (1982–84)
Authors: Moore Alison A. , Hays Ron D. , Greendale Gail A. , Damesyn Mark , Reuben David B.
Published: April 2015

OBJECTIVES: To describe alcohol use and its sociodemographic correlates among persons aged 65 years and older in a US probability sample.

DESIGN: Cross‐sectional analysis of a national probability sample‐based cohort study.

SETTING: Multiple sites throughout the United States.

PARTICIPANTS: A total of 3448 persons aged 65 and older who participated in the first wave of the NHANES I Epidemiologic Follow‐up Study (1982–84).

MEASUREMENTS: We describe the alcohol use behaviors and demographic characteristics of 3448 persons aged 65 and older. Least squares regression models were used to assess associations between older persons' sociodemographic characteristics and alcohol use.:

RESULTS: Sixty percent of the sample reported having 12 or more drinks of alcohol in at least 1 year of their lives. Seventy‐nine percent of these older drinkers were currently drinking. Twenty‐five percent of all drinkers drank daily (31% men, 19% women). Using gender‐specific definitions (men >2 drinks/day; women >1 drink/day), 16% of men drinking alcohol and 15% of women drinking alcohol were heavy drinkers. Younger age, male gender, and higher income were associated with greater alcohol use.

CONCLUSIONS: Most older persons who ever drank alcohol in their lifetimes were currently drinking. In addition, a substantial number of older persons were drinking currently at levels that may place them at risk of adverse health consequences.
Equilibrium and Limb Coordination in Mild Cognitive Impairment and Mild Alzheimer's Disease
Authors: Franssen Emile H. , Somen Liduïn E.M. , Torossian Carol L. , Reisberg Barry
Published: April 2015

OBJECTIVE: To examine changes in equilibrium and limb coordination in normal aging, mild cognitive impairment, and moderate cognitive impairment associated with early probable Alzheimer's disease (AD), by means of parametric clinical measures.

DESIGN: Case series

SETTING: Out‐patient clinic.

PARTICIPANTS: A consecutive sample of 365 community‐ residing ambulatory volunteers (137 men, 228 women; mean age 70.4 ± 9.4 years; mean educational attainment 14.6 ± 3.1 years), who were followed in an ongoing longitudinal study of aging and AD, comprising cognitively intact individuals, persons with mild cognitive impairment, and patients with mild AD.

MEASUREMENTS: For general magnitude of cognitive function, the Global Deterioration Scale (GDS). For cognition, the Mini‐Mental State Examination (MMSE). Equilibrium was assessed with parametric measurements of single leg stance (SLS) and tandem walking (TW). Limb coordination was assessed with parametric measurements of foot tapping (FT), alternating pronation and supination (PS), and sequential finger to thumb tapping (FTH).

MAIN RESULTS: After adjustment for age, persons with mild cognitive impairment or mild AD had significantly poorer performance on parametric clinical tests of equilibrium and limb coordination compared with cognitively intact individuals (P <. 05).

CONCLUSIONS: Changes in equilibrium and limb coordination are clinically demonstrable in persons with mild cognitive impairment and mild AD using simple parametric tests. Such tests could potentially identify individuals with increased risk of falling. Early diagnosis and treatment of conditions that can jeopardize equilibrium and limb coordination, as well as balance and coordination training, might help cognitively impaired older people to maintain optimal function and may decrease the risk of falls and injuries.
Alzheimer's Disease Symptom Severity in Blacks and Whites
Authors: Shadlen Marie‐Florence , Larson Eric B. , Gibbons Laura , McCormick Wayne C. , Teri Linda
Published: April 2015

OBJECTIVE: In order to determine whether there are racial differences in Alzheimer's Disease (AD) symptom severity and vascular comorbidities, we compared African‐American (black) and Caucasian (white) patients with AD from similar socioeconomic backgrounds at the time the disease was first recognized.

DESIGN: Cross‐sectional observational study from a population‐based dementia registry.

PARTICIPANTS: Patients were enrolled from an HMO base population of 23,000 persons more than age 60 in Seattle, Washington. This study examines 453 subjects with probable AD (38 blacks (mean age 76.5, SD 6.4), and 415 whites (mean age 79.7, SD 6.7)).

MEASUREMENTS: Measured were patient demographics, age at onset of AD, AD symptom duration, Mini‐Mental State Exam (MMSE) score, Blessed Dementia Rating Scale, presence of psychiatric symptoms, and vascular comorbidities.

RESULTS: Blacks had significantly lower mean cognitive scores (MMSE = 17.2, SD 5.6) compared with whites (MMSE = 20.2, SD 5.2, unpaired t test P <. 01). The significant racial difference in MMSE scores persisted after controlling for education, duration of AD symptoms, age, and ADL impairment. Blacks and whites did not differ significantly regarding gender distribution, education level, income, or percent with early age of onset of AD. No statistically significant race‐related differences were found in impairments in activities of daily living or symptoms of paranoia, hallucinations, or agitation. Blacks had significantly higher rates of hypertension (56%) compared with whites (34%) (Fisher's exact test, P =. 013), but the rates of stroke and ischemic heart disease were similar.

CONCLUSIONS: Despite uniform detection methods and controlling for reported duration of dementia symptoms, measured cognitive impairment is significantly more severe when AD is recognized in blacks compared with whites. The significantly higher prevalence of hypertension among black AD cases was not associated with excess cerebrovascular disease comorbidity. This study highlights a need for normative measurements of cognitive function in minority AD groups in order to distinguish differential cognitive symptom severity from possible measurement bias.
Estimating the True Extent of Cognitive Decline in the Old Old
Authors: Brayne Carol , Spiegelhalter David J. , Dufouil Carole , Chi Lin‐Yang , Dening Tom R. , Paykel Eugene S. , O'Connor Daniel W. , Ahmed Anne , McGee Magnus A. , Huppert Felicia A.
Published: April 2015

OBJECTIVE: To measure cognitive change using a brief measure over a period of 9 years and to adjust for attrition in the sample.

DESIGN: The Cambridge City over 75 Cohort (CC75C), a complete sample of the 75 years and older age group from five group general practices in the city of Cambridge with a systematic one‐third of a further practice, all followed on four occasions.

SETTING: Cambridge city, UK, the respondents' place of residence.

PARTICIPANTS: A total of 2106 subjects were included at study entry.

MEASUREMENTS: A brief interview, administered by a trained interviewer, containing a short cognitive scale and the Mini‐Mental State Examination (MMSE) at baseline, 2.4 years, 6 years, and 9 years.

RESULTS: Decline in MMSE scores occurred across the population and was greater in the oldest age groups. Attrition at later stages of the follow‐up was associated with greater decline at earlier stages. Adjusting the results for loss to the sample leads to considerably higher estimates of decline, with the older age groups declining faster from lower levels.

CONCLUSIONS: To date, cognitive decline in the very old has been considerably underestimated by longitudinal studies. If studies of population samples are to reflect the health and social needs of this frail group accurately, adjustments for the effect of attrition must be included before true decline can be estimated. J Am Geriatr Soc 47:1283–1288, 1999.