bluuebunny/crossref_metadata_2025 huggingface dataset:
Research on the Cognitively Impaired: Lessons and Warnings from the Emergency Research Debate
Authors: Karlawish Jason H. T. , Sachs Greg A.
Published: April 2015

OBJECTIVES: To demonstrate that the recent events in emergency research have broad implications for the conduct of human subjects research with the cognitively impaired. This essay illustrates the similarities between the two kinds of research and suggests how understanding these similarities might help to resolve issues in human subjects research on the cognitively impaired.

METHODS: A review of pertinent journal articles, books, regulations, and court cases.

RESULTS: The emergency research controversy resulted in large part because of conflicting interpretations of arguably inadequate research regulations. The proposed Food and Drug Administration (FDA) regulations include advance informed consent, a broad role for family in approving a subject's participation, replacement of a threshold of permissible risk, called minimal risk, with a more sensible balancing of risks and benefits, and a role for the community in research approval. The current state of research on the cognitively impaired suggests that many of the same problems exist now that existed in emergency research before the FDA issued its proposed regulations. The ongoing case of T.D. et al. vs N.Y. State Office of Mental Health suggests that unless steps are taken similar to those taken in emergency research, much of clinical research on the cognitively impaired could cease.

CONCLUSION: Representatives of the government, medicine, and the public must recognize the unresolved issues and inadequate regulations relating to research on the cognitively impaired. The proposed FDA regulations for emergency research may provide guidance for a settlement of these issues.
Physician Attitudes Concerning Warfarin for Stroke Prevention in Atrial Fibrillation: Results of a Survey of Long‐Term Care Practitioners
Authors: Monette Johanne , Gurwitz Jerry H. , Rochon Paula A. , Avorn Jerry
Published: April 2015

BACKGROUND: The prevalence of atrial fibrillation (AF) increases dramatically with advancing patient age, and, as a result, this condition is common in persons residing in the long‐term care setting.

OBJECTIVES: To assess the knowledge and attitudes of physicians regarding the use of warfarin for stroke prevention in patients with atrial fibrillation in long‐term care facilities.

METHODS: We surveyed physicians actively providing primary care to older patients in 30 long‐term care facilities located in New England, Quebec, and Ontario. Physicians were requested to complete a structured questionnaire about use of warfarin therapy for stroke prevention in patients with AF residing in long‐term care facilities. The questionnaire included two clinical scenarios designed to provide substantial contrasts in patient characteristics including underlying comorbidity, functional status, bleeding risk, and stroke risk.

RESULTS: A total of 269 physicians were asked to participate in the survey, and 182 (67.7%) completed the questionnaire between February 1, 1995, and July 31, 1995. Only 47% of respondents indicated that the benefits of warfarin therapy “greatly outweigh the risks” in this setting; the remainder of physicians indicated that benefits only “slightly outweigh the risks” (34%) or that risks “outweigh benefits” (19%). The most frequently cited contraindications to warfarin use were: excessive risk of falls (71%), history of gastrointestinal bleeding (71%), history of other non‐central nervous system bleeding (36%), and history of cerebrovascular hemorrhage (25%). Among the 164 physicians who reported using the international normalized ratio to monitor warfarin therapy, 27% indicated a target range with a lower limit less than 2, 71% indicated a target range between 2 and 3, and 2% indicated an upper limit greater than 3. Among respondents who answered questions about the two clinical scenarios, estimates of the risk of a stroke without warfarin therapy and the risk of an intracranial hemorrhage with therapy varied widely.

CONCLUSIONS: Our findings suggest that many uncertainties surround the decision to prescribe warfarin to patients with AF in the long‐term care setting, as well as questions about the appropriate intensity of this treatment when it is prescribed. Concerns about the risks of bleeding appear to prevail over stroke prevention when physicians make such prescribing decisions.
Psychotic Symptoms and Physically Aggressive Behavior in Alzheimer's Disease
Authors: Gilley David W. , Wilson Robert S. , Beckett Laurel A. , Evans Denis A.
Published: April 2015

OBJECTIVE: To examine the relationship between psychotic symptoms and subsequent physically aggressive behavior in outpatients with Alzheimer's disease.

DESIGN: This observational study used a time series design to measure the presence and frequency of physically aggressive behavior over a 52‐week period. Multiple regression models were used to evaluate delusions and hallucinations, assessed at baseline, as predictors of physical aggression, controlling for demographic and clinical variables. SETTING AND PARTICIPANTS: Of 315 consecutive eligible outpatients from the Rush Alzheimer's Disease Center, referred for evaluation for dementia, 270 (86%) participated in the study. All participants met NINCDS/ADRDA criteria for probable Alzheimer's disease; Mini‐Mental State Examination scores ranged from 0 to 27, with a mean of 14.9 (SD = 5.6).

MEASUREMENTS: Psychotic symptoms, previous episodes of physical aggression, and demographic variables were measured at baseline through a structured interview with an informant living in the same household. Physically aggressive behavior was measured sequentially at 1‐week intervals over a period of 52 consecutive weeks and also through structured informant interviews.

RESULTS: A total of 75 persons had one or more episodes of physical aggression during the 52 weeks of observation. The presence of delusions significantly predicted the presence and frequency of physical aggression. Of participants with high rates of physical aggression (>1 episode/month), 80% had delusions. This effect was robust, even after controlling for the effects of other clinical variables. By contrast, hallucinations did not reliably predict episodes of physical aggression.

CONCLUSIONS: These data suggest that delusions, but not hallucinations, predict physically aggressive behavior in persons with Alzheimer's disease. In light of the persecutory nature of most delusional ideation in Alzheimer's disease, delusions may be associated with distortions in the perception of threat in common social situations.
Use of the Diagnosis “Failure to Thrive” in Older Veterans
Authors: Hildebrand Jeanne K. , Joos Sandra K. , Lee Melinda A.
Published: April 2015

OBJECTIVES: To describe how physicians apply the term “failure to thrive” (FTT) to older patients. Specifically, to describe the clinical presentation, underlying etiologies, diagnostic and therapeutic interventions, and discharge outcomes of veterans having the discharge diagnosis of FTT.

DESIGN: Retrospective chart review.

SETTING: The Department of Veterans Affairs Medical Center (VAMC), Portland, Oregon, a 400‐bed referral and teaching hospital.

PARTICIPANTS: All veterans 65 years of age and older admitted to the Portland VAMC from October 1, 1990, through September 30, 1993, whose coded discharge diagnoses included FTT (n = 132).

MEASUREMENTS: Medical records were reviewed by a trained abstractor to obtain key data about clinical presentation, etiologies, interventions, and discharge outcomes.

RESULTS: Subjects were predominantly male (98%), with a mean age of 76 years ± 9 years. Weight loss was a key feature: 67% of subjects had evidence of weight loss by study criteria. Anemia was present in 55%, low cholesterol in 50%, and low albumin in 44%. Lymphopenia was common, present in 66% of subjects. Most patients were admitted from home (83%); only 7% came from nursing homes. On admission, the majority (82%) were dependent in at least One ADL, and 36% were cognitively impaired. Cancer was the most common underlying diagnosis (30%), followed by infection (18%), dehydration (13%), and depression (12%). Only 46% of subjects were discharged home, while 34% went to nursing homes. Fourteen percent of subjects died during the hospitalization, an additional 11% died within 30 days after discharge, and 32% died within 1 year after discharge. The subgroup of subjects with cancer and/or infection had increased mortality rates at 30 days and 1 year after hospitalization.

CONCLUSION: We conclude that FTT may constitute a discrete syndrome with diagnostic, therapeutic and prognostic implications in older people, but in the absence of consensus about diagnostic criteria, there is a large degree of subjective variation in how physicians apply the term. J Am Geriatr Soc 45:1113–1117, 1997.
CONGESTIVE HEART FAILURE IN OLDER PATIENTS: The Clinical Diagnosis of Heart Failure in Older Patients*
Authors: Tresch Donald D.
Published: April 2015

OBJECTIVE: To review the differences in presentation and clinical manifestation of heart failure in older and younger patients and to determine if these differences influence the ability to diagnose the disorder clinically. Based on this information, an approach to diagnosing heart failure in older patients is provided.

DATA SOURCE: Scientific reports regarding heart failure in both the general population and the geriatric population were identified from repeated searches of MEDLINE data base and citations from appropriate articles.

DATA EXTRACTION AND SYNTHESIS: Relevant data were obtained from articles, with special importance placed on studies designed to examine older patients exclusively or as a subgroup in a larger study. Review of data pertaining to clinical characteristics and presentation of heart failure was performed, with emphasis on comparing the characteristics between age groups. Specific cardiac diseases that cause ventricular impairment in older patients were assessed, and the importance of systolic versus diastolic dysfunction in this age group was analyzed.

CONCLUSION: Clinical diagnosis of heart failure in older patients may be difficult because of the absence of typical symptoms and physical findings. When present, the symptoms and signs may be mistakenly diagnosed as caused by concomitant disorders or aging changes. In other older patients, the symptoms and signs will be obscured by the presence of aging changes or the presence of other diseases. As a result of these difficulties, the initial diagnosis of heart failure in older patients is made later in the course of the cardiac disease process; older patients will be more unstable, and secondary preventive therapies may be of less benefit than in younger patients with the disorder. Though clinically difficult, the differentiation between systolic and diastolic ventricular dysfunction is mandatory in all older patients with heart failure. J Am Geriatr Soc 45:1128–1133,1997.
Predictors of Mortality in Patients with Bacteremia: The Importance of Functional Status
Authors: Deulofeu Francesc , Cervelló Betlem , Capell Santiago , Martí Carmina , Mercadé Vicenç
Published: April 2015

OBJECTIVE: To evaluate the influence of functional status on the outcome in older patients with bacteremia.

DESIGN: Prospective study of all episodes of bacteremia that occurred in adults during a 27‐month period (January 1991 to March 1993).

SETTING: A 280‐bed community hospital.

PARTICIPANTS: During the study period, bacteremia was diagnosed in 242 consecutive patients (incidence of 11.2 bacteremic episodes per 1000 hospital admissions). One hundred twenty‐seven of these patients were 65 years of age or older, and 115 were less than age 65.

MEASUREMENTS: On identification of a positive blood culture, data on demographics, clinical findings, and a series of factors frequently cited as predisposing to infection were collected. The patient's functional status was assessed using the Barthel index (a score of <60 identifies moderately and highly dependent patients).

RESULTS: The overall mortality rate was 14.9% (36 of 242). In the univariate analysis, mortality was associated significantly with age greater than 65 years, nosocomial infection, absence of fever, shock, leukocytosis or leukopenia, inappropriate therapy, more than one underlying disease, immunocompromised state, and limited functional status. Multiple logistic regression analysis revealed that shock (OR = 27.6, 95% CI 5.7–133), a Barthel score less than 60 (OR = 11.7, 95% CI 3.2–43), nosocomial infection (OR = 6.7, 95% CI 1.8–25.5), absence of fever (OR = 5.2, 95% CI 1.05–26), and immunocompromised state (OR = 15.6, 95% CI 2.4–101.5) were significantly associated with death attributable to bacteremia.

CONCLUSION: The main prognostic factors in a patient with bacteremia were the presence of shock, impaired functional status, immunodeficiency state, acquisition of infection in the hospital, and absence of fever on admission. Age alone did not influence outcome.
Decreasing Hospitalization Rates for Older Home Care Patients with Symptoms of Depression
Authors: Flaherty Joseph H. , McBride Mary , Marzouk Shaden , Miller Douglas K. , Chien Norman , Hanchett Marilyn , Leander Sheila , Kaiser Fran E. , Morley John E.
Published: April 2015

OBJECTIVE: To target medically ill older home care patients with symptoms of depression in order to reduce their rate of hospitalization.

DESIGN: A case‐control study.

SETTING: A private, nonprofit home care organization, the Visiting Nurse Association of St. Louis.

PARTICIPANTS: Home care patients 65 years of age and older with symptoms of depression who were participants of a Total Quality Management (TQM) intervention (n = 81) were compared with an historical control of home care patients 65 years of age and older with symptoms of depression (n = 69).

INTERVENTION: Utilization of TQM principles to develop a plan including: (a) an educational seminar on depression for home care staff involved in the project; (b) letters to physicians introducing the TQM project; (c) use of the Geriatric Depression Scale (GDS) for screening; (d) recommendation to the primary physician of a home social service (SS) consultation for patients with a GDS of 10 to 14; (e) recommendation to the primary physician of three interventions for patients with a GDS ≥ 15: home SS consultation + mental health (MH), or gerontological nurse (GN) consultation + antidepressant medication (a pharmacotherapeutic algorithm sent by facsimile to the primary physician upon request).

OUTCOME MEASURES: Hospitalization rates of the control group compared with the TQM intervention group, the degree to which part (e) of the plan was implemented, and the effect this had on hospitalization rates.

RESULTS: The TQM intervention patients had a higher mean age than the historical control patients but were not different in percent female, percent white race, percent with a caregiver in the home, functional status, and in 15 of 16 diagnostic categories. Overall, the TQM intervention group had a hospitalization rate of 23.5% (19/81) compared with a rate of 40.6% (28/69) for the historical control group (P = .024). For part (e) of the plan (56/81 patients had a GDS ≥ 15), 29/56 (52%) received the recommended SS consultation, 50/56 (89%) received the recommended MH or GN consultation, and 32/56 (57%) received antidepressant medication. One type of intervention did not seem to lower hospitalization rates more than another although having received the MH or GN visits approached significance (12/50, 24%; P = .052) when compared with the control group.

CONCLUSION: Utilization of TQM principles and the development of an intervention such as the one described here can decrease hospitalization rates for medically ill older home care patients with symptoms of depression.
Benzodiazepine Exposure and Functional Status in Older People
Authors: Ried L. Douglas , Johnson Richard E. , Gettman David A.
Published: April 2015

OBJECTIVE: To determine the association between benzodiazepine exposure and functional status in older patients.

DESIGN: A nonexperimental, observational study design.

SETTING: Kaiser Permanente, Northwest Division, a health maintenance organization (HMO) providing prepaid, comprehensive inpatient and outpatient care for more than 410,000 persons.

PATIENTS: Patients were the 4192 Social HMO Project members 65 years of age and older, enrolled for 1 full year, who returned their annual health status survey during 1990.

MEASUREMENTS: Functional status was measured using self‐reported activities of daily living and instrumental activities of daily living. Predictor variables were self‐reported medical conditions and benzodiazepine exposure during the previous 12 months.

RESULTS: Age, gender, and living status were associated with functional status. Severe memory loss, stroke, Parkinson's disease, circulation problems, lung problems, hip fracture, urinary problems, arthritis, heart trouble, diabetes, stomach/bowel problems, and cancer were associated independently with functional status. Persons exposed to a benzodiazepine scored lower on the functional status measure. Benzodiazepine exposure added significantly to the prediction of functional status after controlling for patients' sociodemographic characteristics and medical conditions.

CONCLUSIONS: Age and medical conditions were the most significant predictors of functional status. Benzodiazepine exposure was associated with functional status to the same extent as several chronic medical conditions. When prescribing benzodiazepines for older people, caution should be taken to minimize the possibility of iatrogenic‐functional limitations.
Dementias That Present With and Without Posterior Cortical Features: An Important Clinical Distinction
Authors: Royall Donald R. , Polk Marsha
Published: April 2015

There are distinct qualitative differences between the dementias that present with and without posterior cortical features. These can be utilized in dementia assessment. This paper reviews the validity and potential utility of a dichotomy based on generalized cortical (Type 1) versus isolated frontal system pathology (Type 2). These syndromes are associated with distinct differentials and problem behaviors. They may also result in different caregiving burdens or treatment responses. Alzheimer's disease (AD) is by far the most common cause of the Type 1 syndrome. Type 2 presentations select for potentially reversible non‐AD conditions. Common cognitive screening instruments are insensitive to Type 2 cases. However, the Type 1/Type 2 distinction can be made reliably using qualitative clinical rating scales. We will review these instruments and discuss their application in clinical settings.
Managed Care and the Goals of Medicine
Authors: Callahan Daniel
Published: April 2015

The goals of medicine encompass the relief of pain and suffering, the promotion of health and the prevention of disease, the forestalling of death and the promoting of a peaceful death, and the cure of disease when possible and the care of those who can not be cured. Managed care, as a system of integrated healthcare delivery designed to control costs, is not, in principle, incompatible with the goals of medicine, but in practice it may well be, depending on whether profit is sought, whether the integrity of physicians' medical judgment is protected, and whether government regulations control managed care practices to prevent abuse and to enhance the quality of care.
Identifying Nursing Home Residents at Risk for Falling
Authors: Kiely Dan K. , Kiel Douglas P. , Burrows Adam B. , Lipsitz Lewis A.
Published: April 2015

OBJECTIVES: To develop a fall risk model that can be used to identify prospectively nursing home residents at risk for falling. The secondary objective was to determine whether the nursing home environment independently influenced the development of falls.

DESIGN: A prospective study involving 1 year of follow‐up.

SETTING: Two hundred seventy‐two nursing homes in the state of Washington.

PARTICIPANTS: A total of 18,855 residents who had a baseline assessment in 1991 and a follow‐up assessment within the subsequent year.

MEASUREMENTS: Baseline Minimum Data Set items that could be potential risk factors for falling were considered as independent variables. The dependent variable was whether the resident fell as reported at the follow‐up assessment. We estimated the extrinsic risk attributable to particular nursing home environments by calculating the annual fall rate in each nursing home and grouping them into tertiles of fall risk according to these rates.

RESULTS: Factors associated independently with falling were fall history, wandering behavior, use of a cane or walker, deterioration of activities of daily living performance, age greater than 87 years, unsteady gait, transfer independence, wheelchair independence, and male gender. Nursing home residents with a fall history were more than three times as likely to fall during the follow‐up period than residents without a fall history. Residents in homes with the highest tertile of fall rates were more than twice as likely to fall compared with residents of homes in the lowest tertile, independent of resident‐specific risk factors.

CONCLUSIONS: Fall history was identified as the strongest risk factor associated with subsequent falls and accounted for the vast majority of the predictive strength of the model. We recommend that fall history be used as an initial screener for determining eligibility for fall intervention efforts. Studies are needed to determine the facility characteristics that contribute to fall risk, independent of resident‐specific risk factors. J Am Geriatr Soc 46:551–555, 1998.
The Sequelae of Hospitalization for Ischemic Stroke Among Older Adults
Authors: Wolinsky Fredric D. , Gurney James G. , Wan George J. , Bentley David W.
Published: April 2015

OBJECTIVES: To estimate the independent effect of hospitalization for ischemic stroke on change in functional status, subsequent hospitalization, and mortality.

DESIGN: Secondary analysis of the nationally representative Longitudinal Study on Aging. Baseline (1984) interview data were linked to Medicare hospitalization and death records for 1984–1991 and to functional status reports at three biennial follow‐ups.

SETTING: In‐person and telephone interviews were conducted.

PARTICIPANTS: A total of 6071 noninstitutionalized respondents 70 years old or older at baseline.

MEASUREMENTS: Hospitalization for ischemic stroke was defined as having one or more episodes with primary discharge ICD9‐CM codes of 433.0–434.9, 436, and 437.0–437.1. Two reference groups were used: those who were hospitalized for something other than stroke, and those who were not hospitalized at all. The statistical methods employed were multivariable proportional hazards, logistic, and linear regression.

RESULTS: The adjusted hazards ratio for having a primary hospital discharge diagnosis of ischemic stroke on mortality was 7.57 (CI95% = 6.47 to 8.85) versus 3.67 (CI95% = 3.28 to 4.10) for having been hospitalized for something other than stroke (both compared with the reference category of those not hospitalized at all). The adjusted odds ratio for having any subsequent hospitalization associated with having a primary hospital discharge diagnosis of ischemic stroke (compared with having been hospitalized for something other than stroke) was not significantly elevated (AOR = 1.16; CI95% = .94 to 1.42). However, the percent increases in the subsequent number of hospital episodes, total charges, and total length of stay for those who were hospitalized for ischemic stroke relative to those hospitalized for something other than stroke were significant (P < .001), and ranged from 16.3 to 39.0%. Hospitalization for ischemic stroke was also related significantly to greater increases in the regression‐adjusted mean number of instrumental activities of daily living and lower body function limitations at follow‐up.

CONCLUSION: Hospitalization for ischemic stroke among older adults substantially increases the risk of subsequent mortality, the volume of hospital resource consumption, and greater functional decline, even when compared with hospitalization for something other than stroke. Therefore, greater attention to the prevention and management of ischemic stroke is needed. J Am Geriatr Soc 46:577–582, 1998.
Alprazolam as an Alternative to Low‐Dose Haloperidol in Older, Cognitively Impaired Nursing Facility Patients
Authors: Christensen Dale B. , Benfield William R.
Published: April 2015

OBJECTIVES: To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes).

SETTING: Twenty‐five community nursing homes in western Washington.

PARTICIPANTS: Older nursing home residents (N = 48) receiving a low‐dose neuroleptic for the treatment of agitation and behavioral disturbances.

INTERVENTION: Randomized, double‐blind, crossover trial of alprazolam and low dose haloperidol. Data were gathered at baseline and at the end of 6 and 12 weeks from direct observation and from clinical forms completed routinely by trained nurses.

MEASUREMENTS: Number of behavioral episodes, activities of daily living as measured by the Blessed Dementia Scale, extrapyramidal symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS), and psychopathology as measured by the Clinical Global Impressions (CGI) and the Sandoz Clinical Assessment ‐ Geriatric (SCAG) scales

RESULTS AND CONCLUSIONS: No significant differences were observed between patients using haloperidol or alprazolam in terms of behavioral episodes per week. Further, with few exceptions, no significant differences were found in other outcome scales. Essentially the same findings were found when analyses were repeated for subgroups of patients with high levels of cognitive impairment and for patients with low and high levels of recorded problematic behavioral episodes. Alprazolam was as effective as low dose haloperidol in this population. J Am Geriatr Soc 46:620–625, 1998.
Executive Dyscontrol: An Important Factor Affecting the Level of Care Received by Older Retirees
Authors: Royall Donald R. , Cabello Maria , Polk Marsha J.
Published: April 2015

OBJECTIVES: To examine the relative contributions of Executive Control Function (ECF), general cognition, mood, problem behavior, physical disability, demographic variables, and the number of prescribed medications to the level of care received by older retirees.

DESIGN: Multivariate regression and discriminant modeling.

SETTING: A single Continuing Care Retirement Community (CCRC) in San Antonio, Texas.

PARTICIPANTS: A total of 107 older retirees (mean age = 83.7 ± 7.2 years), including 17 community‐dwelling, well, older controls and 90 CCRC residents. CCRC subjects represented a convenience sample of consecutive referrals for geropsychiatric assessment. Sixty‐one subjects resided at a noninstitutionalized level of care, and 46 were institutionalized.

MEASUREMENTS: Tests of ECF (the Executive Interview (EXIT25)), general cognition (the Mini‐Mental State Examination (MMSE)), mood (the Geriatric Depression Scale short‐form (sGDS)), problem behavior (the Nursing Home Behavior Problem Scale (NHBPS)), physical disability (the Cumulative Illness Rating Scale (CIRS)), age, gender, years of education, and the number of prescribed medications were studied.

RESULTS: All variables except gender and education varied significantly across level of care. Four variables made significant independent contributions; EXIT25 score (r2 = .48, P < .001), medication usage (partial r2 = .11, P < .001), sGDS score (partial r2 = .06, P = .001), and problem behavior (partial NHBPS r2 = .04, P < .04). These variables accounted for 69% of the total variance in level of care (R2 = .69; F (df 7,99) = 32.1, P < .001). A discriminant model based on the number of prescribed medications, EXIT25, sGDS, and NHBPS scores classified 83.2% of cases correctly (Wilke's lambda = .50, F (5, 101) = 20.1; P < .001). The MMSE enters but fails to contribute significantly, independent of the other variables. Age and CIRS scores fail to enter.

CONCLUSIONS: Cognitive (particularly ECF) impairment contributes most to the observed variance in level of care received by older retirees in this CCRC. In contrast, markers of general cognition, depression, and physical illness contributed relatively little additional variance. ECF is not detected well by traditional cognitive measures and must be sought by specific tests. Further study is needed to replicate these findings in other populations.
Prevalence and Outcome of Methicillin‐Resistant Staphylococcus Aureus Colonization in Two Nursing Centers in Georgia
Authors: MD Ali R. Rahimi
Published: April 2015

OBJECTIVES: To evaluate the cost‐effectiveness and validity of aggressive diagnosing and eradication of methicillin‐resistant Staphylococcus aureus (MRSA) colonization.

DESIGN: An observational study of MRSA colonization.

SETTING: Two skilled nursing facilities in Georgia.

PARTICIPANTS: Eighty‐seven residents of the abovementioned skilled nursing facilities

INTERVENTION: No changes were made in either nursing facility practices or patient treatments.

MEASUREMENTS: The presence or absence of MRSA colonization was determined at the beginning of the study, after hospitalizations or absences from the facility, and 12 months after initial testing.

RESULTS: Eighty‐seven participants began the study, and 56 completed it. At the beginning of the study, 17.9% of the 56 who later completed the study were positive for MRSA. By the end of the study, colonization had decreased to 14.3%. The difference in the number of positive cultures for residents returning from the hospital compared with those returning from non‐hospital settings was not statistically significant (P = .546). No deaths or hospitalizations were attributable to MRSA infection.

CONCLUSION: Because no significant correlation was found between MRSA colonization and active MRSA‐related infections, patients colonized by MRSA should not be barred from admission to nursing homes.
A Prospective Study of Posturography in Normal Older People
Authors: Baloh Robert W. , Corona Sonia , Jacobson Kathleen M. , Enrietto Jane A. , Bell Theodore
Published: April 2015

OBJECTIVE: To follow posturographic measurements over time in a group of normal older subjects to see if sway increases with aging and if sway is greater in those with deteriorating balance and falls.

SUBJECTS: Seventy‐two community‐dwelling older people (age range 79–91 years), who initially had normal neurological evaluations, were followed with three yearly follow‐up examinations.

MEASUREMENTS: Amplitude and velocity of sway on static and dynamic posturography, Tinetti gait and balance score, reports of falls.

RESULTS: Velocity of sway on dynamic tests increased significantly during the 3 years of follow‐up. The percentage increase in sway was about the same in the anterior‐posterior and medial‐lateral directions and with eyes open and eyes closed. Subjects with low Tinetti scores had higher sway amplitude and velocity, particularly on dynamic tests, but no measure of sway was significantly different in those who reported falls compared with those who did not report falls.

CONCLUSIONS: Sway increases in normal subjects over time, and sway is greater in older subjects with deteriorating balance compared with those with normal balance. Sway was not greater in those who fell compared with those who did not fall, probably because falls are highly dependent on individual behavior.
Relationships Between Sleep and Body Temperature in Middle‐Aged and Older Subjects
Authors: Campbell Scott S. , Murphy Patricia J.
Published: April 2015

OBJECTIVES: Although changes in the circadian timing system are thought to be a major factor in the decline of sleep quality that often accompanies aging, few reports have actually examined this relationship in detail. Because some treatments for age‐related insomnia are based on putative circadian changes, it is important to expand the limited database that specifically addresses this issue. This study examined age‐related changes in sleep, and relationships between those sleep changes and alterations in the circadian timing system, in a group of middle‐aged and older subjects.

DESIGN: Sixty healthy men and women between the ages of 40 and 84 were studied. A subset of older subjects (< 65 years) had reported sleep disturbance for at least 1 year before participation. Polysomnography was obtained, and body core temperature was recorded continuously for 24 hours. All recordings took place in the Laboratory of Human Chronobiology, Department of Psychiatry, Cornell University Medical College.

RESULTS: There were no differences in sleep quality between middle‐aged and non‐sleep‐disturbed older subjects. However, timing of the minimum body temperature was earlier in the older non‐sleep‐disturbed subjects than in the middle‐aged group. In contrast, sleep‐disturbed older people had shorter total sleep times, reduced sleep efficiency, more waking time after sleep onset, and a reduced proportion of REM sleep compared with non‐sleep‐disturbed older subjects. Yet, there were no differences between the two older groups in the rhythm of body temperature. For the entire group, age was correlated negatively with total sleep time, sleep efficiency, percentage of stage 2 sleep, and the timing of the temperature minimum.

CONCLUSION: The results support the widely held notion that sleep and circadian rhythm changes occur with aging. However, the hypothesis that age‐related changes in sleep may be associated with aging of the circadian system was supported only to a limited degree, suggesting that age‐related sleep disturbance is likely to have multiple causes. Thus, treatment strategies that incorporate a combination of interventions may be the most effective.
Age Dependence of Choroidal Blood Flow
Authors: Dallinger Susanne , Findl Oliver , Strenn Karin , Eichler Hans‐Georg , Wolzt Michael , Schmetterer Leopold
Published: April 2015

OBJECTIVE: To investigate the age dependence of choroidal blood flow.

DESIGN: A cross‐sectional study.

SETTING: Department of Clinical Pharmacology, Vienna University.

PARTICIPANTS: A total of 130 healthy volunteers between the ages of 19 and 83 years.

MEASUREMENTS: Fundus pulsation amplitude (FPA) with a recently developed laser interferometric method, mean arterial pressure (MAP) with an automated oscillometric device, intraocular pressure (IOP) with an applanation tonometer, and ocular perfusion pressure (OPP) as calculated from MAP and IOP.

RESULTS: There was a significant correlation of FPA with age r = −0.242 (P = .005). MAP, IOP, and OPP showed a significant positive correlation with age. Multiple regression analysis showed that FPA is associated with age but not with MAP, IOP, or OPP.

CONCLUSION: Choroidal blood flow is reduced in older subjects, which argues in favor of an increase in ocular vascular resistance with age. This may be a risk factor in the development of common ocular diseases such as age‐related macular degeneration or glaucoma
A Census‐Based Comparison of Centenarians in New Zealand with Those in the United States
Authors: Wilkinson Tim J. , Sainsbury Richard
Published: April 2015

OBJECTIVE:To describe the characteristics of New Zealand's centenarians, as given in the 1991 census, and to compare these characteristics with those of centenarians from the United States.

DESIGN:A census‐based descriptive study.

SETTING:The complete national population as defined by the 1991 New Zealand census.

RESULTS:In 1991, there were 246 female and 51 male centenarians in New Zealand. Fifty‐one percent of the men and 29% of the women lived at home; 16% lived at home with someone else (55% with children). People who were widowed were more likely to be living in a residential institution (69%) than people who were married (40%). Forty‐three percent of men and 39% of women earned less than NZ$10,000 per year. Most had no formal educational qualification. Fourteen percent of men and 35% of women living at home did housework in the previous week. Compared with the United States, there are fewer New Zealand centenarians per number of population. People of European race were overrepresented in the New Zealand centenarian population, whereas African Americans were overrepresented in the United States centenarian population.

CONCLUSIONS:Our data have shown the heterogeneity associated with extreme ageing and can be used as a basis for comparison with other countries.
Cross‐Cultural Adaptation of the Hearing Handicap Inventory for the Elderly‐Screening Version (HHIE‐S) for Use with Spanish‐Speaking Mexican Americans
Authors: Lichtenstein Michael J. , Hazuda Helen P.
Published: April 2015

OBJECTIVE: To cross‐culturally adapt the Hearing Handicap Inventory for the Elderly‐Screening Version (HHIE‐S) for use with older Spanish‐speaking Mexican Americans.

SUBJECTS AND SETTING: Two different samples were used. First, a convenience sample of 100 older community‐dwelling Mexican American men and women in San Antonio, Texas, was used to test technical equivalence of the Spanish and English language versions of the HHIE‐S. Second, a neighborhood‐based sample of older Mexican Americans was used to establish conceptual (n = 433) and criterion equivalence (n = 381) of the two HHIE‐S language versions.

METHODS: Independent forward and back translations were done to create a Spanish language version of the HHIE‐S. In the convenience sample, subjects were administered the English and Spanish HHIE‐S in random order on separate days. In the neighborhood sample, the HHIE‐S was given on one occasion in the language of the subject's preference. Depressive symptoms were assessed using the Geriatric Depression scale to see if the two language versions of the HHIE‐S were similarly associated with depression (conceptual equivalence). Hearing impairment was assessed using the Welch‐Allyn AudioscopeTM to see if the two language versions were similarly associated with an audiometric measure for hearing loss (criterion equivalence).

RESULTS: In the convenience sample, the overall mean (SD) Spanish and English HHIE‐S scores were 6.2 (8.7) and 6.2 (9.3), respectively (P = 1.00). Total scores of the English and Spanish versions were highly correlated (r = .89), and regression analysis indicated that the two language versions gave nearly identical results.

In the neighborhood‐based sample, men had higher HHIE‐S scores than women (OR 2.0, 95% CI = 1.3–3.5). Having depressive symptoms (OR 3.2, 95% CI = 1.9–5.5) or hearing impairment (OR 6.1, 95% CI = 3.5–10.5) was associated with higher HHIE‐S scores. After adjustment for gender, depressive symptoms, and/or hearing impairment, the language of interview was not associated with HHIE‐S score.

CONCLUSION: We have developed and tested a Spanish translation of the HHIE‐S that yields equivalent results to those obtained with the English version in bilingual Mexican Americans. The Spanish HHIE‐S presented here is suitable for clinical use and research studies involving older Mexican Americans.
Getting Meaningful Informed Consent from Older Adults: A Structured Literature Review of Empirical Research
Authors: Sugarman Jeremy , McCrory Douglas C. , Hubal Robert C.
Published: April 2015

OBJECTIVES: To perform a structured literature review of the published empirical research on informed consent with older adults in order to make recommendations to improve the informed consent process and to highlight areas needing further examination.

DESIGN: Relevant literature was identified by searching electronic databases (AGELINE, BIOETHICSLINE, Cancer‐Lit, Ethics Index, Health, LegalTrac, MEDLINE, PAIS International, PsycInfo, and Sociofile). Studies were included if they were reports of primary research data about informed consent and, if patients or other subjects were used, older subjects were included in the sample. Data related to the aspect of informed consent under study (recruitment, decision‐making capacity, voluntariness, disclosure of information, understanding of information, consent forms, authorization, and policies and procedures) were abstracted and entered into a specially designed database.

MEASUREMENTS: Characterization of the population, age of subjects, setting, whether informed consent was being studied in the context of research or treatment, study design, the nature of outcome or dependent variables, independent variables (e.g., experimental conditions in a randomized controlled trial or patient/subject characteristics in a nonrandomized comparison), and results according to the aspect of informed consent under study.

RESULTS: A total of 99 articles met all the inclusion criteria and posed 289 unique research questions covering a wide range of aspects of informed consent: recruitment (60); decision making capacity (21); voluntariness (6); disclosure (30); understanding (139); consent forms (7); authorization (11); policies (13); and other (2). In the secondary analyses of numerous studies, diminished understanding of informed consent information was associated with older age and fewer years of education. Older age was also sometimes associated with decreased participation in research. Studies of disclosure of informed consent information suggest strategies to improve understanding and include a variety of novel formats (e.g., simplified, storybook, video) and procedures (e.g., use of health educators, quizzing subjects, multiple disclosure sessions).

CONCLUSIONS: A systematic review of the published literature on informed consent reveals evidence for impaired understanding of informed consent information in older subjects and those with less formal education. Effective strategies to improve the understanding of informed consent information should be considered when designing materials, forms, policies, and procedures for obtaining informed consent. Other than empirical research that has investigated disclosure and understanding of informed consent information, little systematic research has examined other aspects of the informed consent process. This deficit should be rectified to ensure that the rights and interests of patients and of human subjects who participate in research are adequately protected.
Aerobic Exercise and Lumbar Spine Bone Mineral Density in Postmenopausal Women: A Meta‐Analysis
Authors: Kelley George
Published: April 2015

PURPOSE: To use the meta‐analytic approach to examine the effects of aerobic exercise on lumbar spine bone mineral density in postmenopausal women.

DATA SOURCES: Studies were retrieved from computer searches (MEDLINE, Current Contents) as well as cross‐referencing from the bibliographies of retrieved studies and review articles.

STUDY SELECTION: A total of 17 effect sizes consisting of 330 subjects (192 exercise, 138 nonexercise) were included from the 10 studies that met the criteria for inclusion: (1) aerobic activity as the only exercise intervention, (2) postmenopausal women as subjects, (3) comparative nonexercise group included, (4) changes in lumbar spine bone mineral density reported, (5) studies published in English‐language journals between January 1975 and December 1994.

DATA EXTRACTION: The primary outcome measure of interest was the treatment effect Δ3, defined as the percent change in lumbar spine bone mineral density, calculated by subtracting the percent change in the exercise group from the percent change in the nonexercise group.

RESULTS: Using a fixed effects model, bootstrap analysis (10,000 replications) showed that significant changes in lumbar spine bone mineral density occurred (X̄ ± SD = 2.83 ± 0.77%, 95% confidence interval (CI) = 1.33 to 4.35%). This overall average increase was caused primarily by the loss of lumbar spine bone mineral density in the nonexercise group relative to the exercise group (X̄ ± SD, exercise = .32 ± 2.46%, 95% CI = −0.94 to 1.58; nonexercise = −2.51 ± 2.69%, 95% CI = −4.60 to −0.96).

CONCLUSION: The results of this meta‐analysis suggest that aerobic exercise helps to maintain lumbar spine bone mineral density in postmenopausal women.
Effects of Home‐Based Intervention on Unplanned Readmissions and Out‐of‐Hospital Deaths
Authors: Stewart Simon , Pearson Sue , Luke Colin G. , Horowitz John D.
Published: April 2015

OBJECTIVE: To determine the effect of a home‐based intervention (HBI) on the frequency of unplanned readmission and out‐of‐hospital death among patients discharged home from acute hospital care.

DESIGN: A randomized controlled trial comparing HBI with usual care (UC).

SETTING: A tertiary referral hospital servicing the northwestern region of Adelaide, South Australia.

PARTICIPANTS: Medical and surgical patients (n = 762) discharged home after hospitalization.

INTERVENTION: Home‐based intervention (n = 381) consisted of counseling of all patients before discharge followed by a single home visit (by a nurse and pharmacist) to those patients considered to be at high risk of readmission (n = 314) in order to optimize compliance with and knowledge of the treatment regimen, identify early clinical deterioration, and intensify follow‐up of such patients where appropriate.

MEASUREMENTS: The primary endpoint was the number of unplanned readmissions plus out‐of‐hospital deaths over a 6‐month follow‐up period.

RESULTS: During the study follow‐up, the major endpoint occurred most commonly in the UC group (217 vs 155 episodes: P < .001). Overall, the HBI group demonstrated fewer unplanned readmissions (154 vs 197: P = .022), out‐of‐hospital deaths (1 vs. 20: P < .001), total deaths (12 vs. 29: P = .006), emergency department attendances (236 vs 314: P < .001), and total days of hospitalization (1452 vs 1766: P < .001). There was a disproportionate reduction in multiple events among HBI patients (P = .035). Hospital‐based costs of health care during study follow‐up tended to be lower in the HBI group ($A2190 vs $A2680 per patient: P = .102). Mean cost of HBI was $A190 per patient visited, whereas other community‐based health care costs were similar for both groups.

CONCLUSIONS: Among high‐risk patients discharged from acute hospital care, HBI is beneficial in limiting unplanned readmissions and reducing risk of out‐of‐hospital death. It may be particularly cost‐effective if applied selectively to patients with a history of frequent unplanned hospital admission.
Use of Antipsychotic Drugs in Nursing Homes: Current Compliance with OBRA Regulations
Authors: Llorente Maria D. , Olsen Edwin J. , Leyva Oscar , Silverman Michael A. , Lewis John E. , Rivero Jesus
Published: April 2015

OBJECTIVE: To examine the degree and patterns of compliance with the Omnibus Budget Reconciliation Act (OBRA) regulations regarding the use of antipsychotic drugs in nursing homes.

DESIGN: Retrospective chart review of all resident records.

PARTICIPANTS: Eight nursing homes: five community, two county‐owned, and one university‐affiliated Veterans Administration facility.

MEASUREMENTS: A structured assessment instrument to track compliance with each aspect of the OBRA regulations regarding antipsychotic drug use.

RESULTS: A total of 1573 nursing home residents' pharmacy records were reviewed between August 1994 and March 1996. Two hundred seventy‐nine residents were actively taking antipsychotic medications (prevalence = 17.7%). Mean compliance greater than 70% was found for (1) appropriate diagnostic indication (X̄ = 70.9%), (2) dosage within recommended limits (X̄ = 90.1%), and 3) documented appropriate target symptoms (X̄ = 90.4%). Dosages were more likely to exceed limits in those patients with histories of major mental illness, particularly schizophrenia.

CONCLUSIONS: Nursing homes were better able to comply with those guidelines that are most specific. Educational interventions now need to focus on behavioral interventions, monitoring of adverse effects, and efficacy. These data are useful in establishing threshold levels of performance and can be used by nursing homes for continuous quality improvement. OBRA continues to impact neuroleptic drug prescribing practices in nursing homes significantly.