bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of Falls in an Inner‐City Elderly African‐American Population
Authors: MD Jeane Ann Grisso , Schwarz Donald F. , Wolfson Virginia , Polansky Marcia , LaPann Karin
Published: April 2015

Objective

To describe the impact of falls in an elderly African‐American urban community and to identify predictors of poor recovery from falls.

Design

Prospective cohort study.

Setting

Emergency departments of 11 hospitals in western Philadelphia.

Subjects

Interviews were conducted with 197 African‐American persons 65 years and older residing in West Philadelphia who were treated at an emergency department because of a fall. Second interviews were conducted a median of 7 months after the fall with a sample of 70 patients who had not recovered at the time of the first interview.

Main Outcome Measures

Information abstracted from emergency department medical records and information on recovery obtained from two subsequent interviews.

Results

A median of 8 weeks after the fall occurred, 43% of persons reported continued pain or restriction in their usual activities as a result of the fall. Predictors of poor recovery included the presence of grandchildren in the household, hearing impairment, severity of the injury, and injury to the lower extremities. Having someone present at the time of the fall was associated with a lower risk of poor recovery. Forty‐one percent of the 70 persons interviewed a second time reported continued pain or restriction in usual activities a median of 7 months after the fall occurred. However, only 7% and 39% had received the services of a home health aide or physical therapist, respectively, and only 14% reported that a physician or other health professional had been particularly helpful since the fall had occurred.

Conclusions

A large proportion of elderly African‐American persons treated at emergency departments for falls experience continued pain and restriction of activities after the fall. Many individuals have not recovered 7 months or longer after the fall and few persons report that a physician or other health professional has been particularly helpful since the fall occurred. We suggest that follow‐up programs be developed for elderly persons in minority communities who come to emergency departments after a fall.
Quantitative Assessment of Bed Rise Difficulty in Young and Elderly Women
Authors: Alexander Neil B. , Fry‐Welch Donna K. , Ward Michael E. , Folkmier Linda C.
Published: April 2015

Objective

To describe the motions which occur during rising from bed, specifically the motions that appeared to characterize difficulty in rising from a bed in older adults.

Design

Development of a Mobility assessment tool.

Setting

Retirement center and two university laboratories.

Participants

Three groups of female volunteers: young controls (n = 17, mean age 24), community‐dwelling older adults (n = 12, mean age 71), and retirement center‐dwelling older adults who admitted to difficulty in rising from a bed (n = 15, mean age 86).

Intervention

Videotaping of motions occurring during controlled rises from a supine to sitting position.

Main Outcome Measures

These motions were rated on the specially developed Bed Rise Difficulty (BRD) scale, a scale designed to measure movements that characterize difficulty in rising from a bed in older adults. Subject groups were compared in total BRD score, individual BRD item score, and total time to rise. Item relationships and scale reliability were also assessed.

Results

Older adults with no apparent difficulty in rising based on total time to rise or on the BRD score nevertheless showed differences in upper extremity use when compared to young controls. Older adult subjects with difficulty in rising from a bed, when compared to other older adults with no apparent difficulty, differed more often in their upper extremity and leg use to facilitate the rise. Five BRD scale items, including use of extremity pushes, discontinuity of trunk and leg motion, multiple shoulder/pelvic adjustments, multiple leg adjustments, and poor vertical heel clearance may have best indicated true bed rise difficulty.

Conclusions

These data provide a reliable and valid method to characterize difficulty in rising from a bed and provide the basis for biomechanical analyses of the strength and joint ranges of motion required to rise from a bed.
Surgical Results and Complications in Elderly Patients with Benign Lesions of the Spinal Canal
Authors: Smith Edward B. , Hanigan William C.
Published: April 2015

Objective

To describe the long‐term outcome and complications of spinal surgery in a population of elderly patients.

Design

Retrospective chart review and clinical follow‐up.

Setting

A 700‐bed tertiary care midwestern hospital.

Patients

Patients 70 years of age or older who underwent elective surgical procedures for the treatment of benign lesions of the spinal canal.

Main Outcome Measures

Data obtained from chart review included age, sex, nature and duration of neurological symptoms, activities of daily living (ADL), associated illnesses, length of hospitalization, type of surgery, and complications attributable to surgery. Outcome measurements included changes in neurological symptoms and ADL and a standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses.

Results

Seventy‐eight patients with lumbar canal stenosis or soft disc herniations underwent laminectomies, foraminotomies or discectomies. Eleven patients underwent cervical laminectomies for multilevel spondylitic myelopathy. Limb and spine pain were the most common neurological symptoms in patients with lumbar lesions; diminished ADLs were present in eight patients with cervical myelopathies. Six patients died of unrelated causes, and 78 were followed for an average of 27.1 months. Twenty‐three (85.2%) of 27 patients with lumbar disc herniations reported improvements or resolution of limb pain while 35 (81.4%) of 43 patients with lumbar canal stenosis reported fair or good results. Five of eight patients with multilevel cervical spondylosis reported improvements of myelopathic symptoms. Twenty‐six (28.6%) complications were attributable to 91 surgical procedures including five severe complications and one fatality. Patients with three or more associated illnesses demonstrated a significantly higher incidence of postoperative complications.

Conclusions

Elderly patients with benign lesions of the spinal canal may achieve significant reduction in limb pain and increases in ADL following appropriate surgery, with a tolerable rate of severe complications. The preoperative physical condition of the elderly patient served as an indicator for operative morbidity.
Joint Impairment and Hand Function in the Elderly
Authors: Hughes Susan L. , Gibbs James , Edelman Perry , Singer Ruth , Chang Rowland W.
Published: April 2015

Objective

To test the contribution of joint impairment to observed hand function (grip strength and Williams Test) in the elderly, using a multivariate model.

Design

Cross‐sectional observational data (baseline data from an ongoing longitudinal study).

Subjects

Five hundred forty‐one persons over age 60, including continuing care retirement community (n = 222), homebound (n = 72), and ambulatory (n = 247) respondents. Mean age at assessment 76.7, (SD = 9.0).

Measurement

Independent variables included sociodemographics, physician measures of upper joint impairment, an index of comorbidities derived from physical examination or chart abstract, self‐assessed arthritis pain, depression, and anxiety. The dependent variables included grip strength and a modified Williams Test [Williams Test (M)].

Main Results

The multiple regression explained 59% (Adjusted R2 = .59) of the variance in grip strength, with joint impairment accounting for a change in R2 of .07. Upper joint impairment and grip strength accounted for 3% and 5%, respectively, of the variance in the Williams Test (M) (total amount of explained variance = 45%).

Conclusions

Demographics explain most of the variance in grip strength and performance on the Williams Test (M). Controlling for demographics, musculoskeletal disease represented by joint impairment is associated with diminished grip strength. Reduced grip strength is associated with poorer performance on the Williams Test (M).
Comorbid Mental and Substance Disorders among Older Psychiatric Patients
Authors: Speer David C. , Bates Kathie
Published: April 2015

Objective

To investigate the rate and configurations of current comorbid mental and substance disorders among older psychiatric patients.

Design

A descriptive, retrospective study.

Setting

A non‐acute, public residential psychiatric treatment facility for adults 55 years of age and older (mean length of stay: 3 months).

Patients

128 patients discharged during a 2‐year period.

Measures

DSM‐III‐R diagnoses, demographic and history data.

Results

The overall prevalence rate of concurrent mental and substance disorders during the present treatment episode was 21%. This is comparable to the 6‐month rate of 19.8% found in the Epidemiological Catchment Area Study among adults in treatment (all ages). Nearly 50% of the dually diagnosed subsample received more than two diagnoses, with 60% of the subsample receiving a personality disorder diagnosis. Concurrent affective, alcohol, and personality disorder diagnoses were common.

Conclusion

Older patients with comorbid substance‐use and mental disorders may differ substantively from comorbid younger patients. Among older patients in an intermediate‐term psychiatric facility, the triple occurrence of alcoholism personality disorder and depression was common.
Modeling Recovery from Stumbles: Preliminary Data on Variable Selection and Classification Efficacy
Authors: Grabiner M. D. , Jahnigen D. W.
Published: April 2015

Objective

The primary purpose of this preliminary investigation was to determine the functional relationship between selected information processing time and response execution variables and measures of postural stability in elderly women. A secondary purpose was to explore the efficacy of a neuromotor model using selected variables to retrospectively identify subjects with a self‐reported history of falling.

Design

Descriptive, retrospective, cohort.

Setting

General community.

Subjects

Convenience sample of 17 community‐dwelling females with a mean age of 72.2 years.

Main Outcome Measures

Postural stability variables included the amplitude and frequency of postural sway during static vision‐aided and no‐vision conditions. Information processing and response execution variables were collected using a simple‐choice reaction time paradigm for an isometric knee extension task.

Results

Postural stability and information processing variables were functionally independent. Based upon significant intergroup differences, simple and choice pre‐motor reaction time and non‐vision aided anterior posterior sway amplitude were selected for inclusion in a discriminant analysis. The resulting discriminant function was significant (P = 0.01), correctly categorizing all of the subjects with a self‐reported history of falling and identifying six out of seven of the non‐fallers.

Conclusions

These preliminary results suggest that it is feasible to identify a predisposition to falling by detecting an inability to respond successfully to a postural disturbance.
The Relationship of Patient's Age to the Perceptions of the Rehabilitation Environment
Authors: Strasser Dale C. , Falconer Judith F. , Martino‐Saltzman David
Published: April 2015

Objective

To compare the perceptions of the rehabilitation environment among staff, younger (<65), and older patients (>65).

Design

The Ward Atmosphere Scale (WAS) was administered to 55 patients and 108 staff members in a rehabilitation hospital.

Setting

A large university‐associated free‐standing rehabilitation hospital.

Subjects

Patients and staff primarily associated with one of three treatment teams, each on a separate floor. The teams were selected to reflect a diversity of treatment styles and patients' diagnoses.

Main Outcome Measure

The WAS is a 100 true/false questionnaire with 10 subscales which combine to form three dimensions: relationship, program orientation, and system maintenance. These dimensions represent the principal constructs of the instrument.

Main Results

Multivariate analysis of variance was performed on three groups completing the WAS—staff, patients less than 65 years old, and patients 65 years and older. This analysis revealed significant differences among the three groups on the Relationship (F = 14.3; P <0.01) and Program Dimensions (F = 36.5; P < 0.01), and between staff and patients on the System Maintenance Dimension (F = 11.4; P < 0.01). Compared to younger patients and staff, older patients had lower perceptions in the combined areas of involvement, support, spontaneity, autonomy, practical orientation, personal problem orientation, and anger and aggression. Likewise, older patients perceived more staff control than staff and younger patients. Younger patients scored between older patients and staff.

Conclusions

This study suggests that there may be a mismatch between current rehabilitation environments and the needs of elderly individuals.
The Cost of Institutional Care in Alzheimer's Disease: Nursing Home and Hospital Use in a Prospective Cohort
Authors: Welch H. Gilbert , Walsh John S. , Larson Eric B.
Published: April 2015

Objective

To assess the nursing home and hospital use of patients with Alzheimer's Type Dementia.

Design

A prospective cohort study of 126 patients entered into an Alzheimer's disease registry after diagnosis at a university hospital clinic between 1980 and 1982. Only four patients were in nursing homes at enrollment.

Measurements and Main Results

Data regarding nursing home use came from the registry and the individual nursing homes themselves. Hospital‐use data were obtained using Medicare claims files. Follow‐up was obtained on 123 patients (98%). Eighty‐five (69%) had died by July 1, 1989. Three‐quarters of the cohort (92) eventually resided in nursing homes. The median nursing home length of stay was 2.75 years (mean 2.95, 95% CI = 2.5, 3.4), over 10 times the national median length of stay for all diagnoses. Based on prevailing rates in the region, nursing home charges for the cohort were estimated to be between $4.3 and $6.4 million ($35,000–$52,000 per patient). During the 5‐year period 1983–1988, 69 patients filed Part A (hospital) claims to Medicare for 76 admissions and 616 inpatient days. Part A Medicare reimbursement for the cohort totaled $460,000 over 5 years ($3,700 per patient), an expenditure comparable to what a random Medicare cohort might incur.

Conclusions

The combination of a high rate of nursing home entry and lengthy stays makes long‐term care the largest determinant of the cost of care in Alzheimer's disease. While Alzheimer's Type Dementia undoubtedly has profound indirect costs, this study demonstrates that the direct institutional costs alone are considerable.
Progressive Impairment of Left Ventricular Diastolic Filling with Advancing Age: A Doppler Echocardiography Study
Authors: Cacciapuoti Federico , D'Avino Maria , Lama Diana , Bianchi Ugo , Perrone Nicolò , Varricchio Michele
Published: April 2015

Objective

To identify the sequence and significance of left ventricular filling abnormalities associated with progressive aging in humans.

Design

Cross‐sectional study comparing three age groups. Setting: Department of Geriatrics at University of Naples.

Participants

Seventy‐five healthy subjects in three age groups: 25 subjects from 25 to 45 years (Group I), 25 subjects from 46 to 65 years (Group II), and 25 subjects from 66 to 85 years (Group III).

Intervention

None.

Main Outcome Measures

All underwent pulsed‐doppler echocardiography under color guide to measure the following parameters: peak velocity flow for early (E wave) and late (A wave) mitral flow; A/E wave ratio; deceleration time of mitral flow (MDt); isovolumic relaxation time (IRT); ratio of velocity time integrals of the A wave to the velocity time integrals of the entire mitral spectrum (VTIA/VTIM).

Results

Peak velocity of the E wave was slightly lower in Group II and III compared to Group I; in contrast, peak velocity of the A wave was greater (P < 0.005) in aged individuals. Also A/E wave ratio, MDt, and IRT were significantly greater with advancing age (P < 0.01; P < 0.05 and P < 0.001, respectively). Finally, VTIA/VTIM tended to be greater in the oldest group, but not significantly so.

Conclusions

Left ventricular relaxation is progressively impaired in late middle age and old age, presumably an early marker of cardiac aging. Increased left atrial pressure is compromised only in the oldest group, presumably representing a compensation for impaired left ventricular relaxation.
Assessment of Cognitive, Psychiatric, and Behavioral Disturbances in Patients with Dementia: The Neurobehavioral Rating Scale
Authors: Sultzer David L. , Levin Harvey S. , Mahler Michael E. , High Walter M. , Cummings Jeffrey L.
Published: April 2015

Objective

To assess the validity of the Neurobehavioral Rating Scale (NRS) in patients with Alzheimer's disease (AD) or multi‐infarct dementia (MID) and to characterize the cognitive, psychiatric, and behavioral disturbances that occur in these patients.

Design

Cross‐sectional evaluation.

Setting

West Los Angeles VAMC Geropsychiatry Inpatient Unit, Neurobehavior Inpatient Unit, and Dementia Clinic; UCLA Alzheimer's Disease Clinic.

Patients

Convenience sample of 61 patients with AD and 22 patients with MID.

Main Outcome Measure

The NRS, a 27‐item observer‐rated instrument that measures cognitive, psychiatric, and behavioral disturbances.

Results

The NRS demonstrated content and convergent validity in this patient group. Principal components analysis of the NRS ratings identified a six‐factor solution, and each factor contained clinically related symptoms. The factors were Cognition/Insight, Agitation/Disinhibition, Behavioral Retardation, Anxiety/Depression, Verbal Output Disturbance, and Psychosis. Among the patients with AD, agitation, disinhibition, hostility, poor insight, poor motivation, suspiciousness, and delusions were more severe in patients with more advanced dementia. Depressive symptoms occurred with equal severity in patients with mild and advanced dementia, but depressed mood was more severe in patients with earlier age of onset of AD.

Conclusion

The NRS is a useful instrument for structured assessment of a broad range of cognitive, psychiatric, and behavioral disturbances in patients with dementia.
Psychiatric Status among the Homebound Elderly: An Epidemiologic Perspective
Authors: Bruce Martha Livingston , McNamara Robert
Published: April 2015

Objective

To compare the prevalence of specific psychiatric disorders in the homebound elderly to other elders, controlling for demographic, physical health, and socio‐economic factors.

Design

Survey.

Setting

Epidemiologic Catchment Area (ECA) project in New Haven, CT.

Participants

2,553 non‐institutionalized elders representing the total elderly population of the greater New Haven area.

Intervention

None

Main Measures

Homebound status determined by self‐report; psychiatric status according to DSM III by the Diagnostic Interview Schedule (DIS); cognitive status by Mini‐Mental Status Examination.

Results

Cognitive impairment (21.8% vs 11.0%, P < 0.001), depression (2.3% vs 0.7%, P < 0.01), dysthymia (3.9% vs 1.7%, P < 0.01), and anxiety disorders (2.2% vs 0.4%, P < 0.001) were each at least twice as prevalent among elders confined to a bed or chair as among non‐homebound elders. Most of this increase was consistent with the poorer physical health status of the homebound; after controlling for health status, only dysthymia (Odds ratio = 2.1, P < 0.01) was significantly more prevalent among elders confined to a bed or chair.

Conclusions

The higher prevalence of disorders among the homebound support recommendations that psychiatric assessments become routine in primary care examinations of homebound elders and that the availability of preventive and therapeutic psychiatric services to the homebound increase.
Asymptomatic Bacteriuria, Urinary Antibody, and Survival in the Institutionalized Elderly
Authors: Nicolle L. E. , Brunka J. , McIntyre M. , Murray D. , Harding G. K. M.
Published: April 2015

Objective

To compare clinical status of elderly institutionalized subjects with asymptomatic bacteriuria and normal urinary antibody to those with elevated urinary antibody to the major outer membrane of Escherichia coli.

Design

Retrospective review.

Setting

Long term facility for the elderly.

Participants

Convenience sample of 63 elderly subjects, 26% of those resident in the institution, aged 78.8 ± 8.4 years with urine specimens collected and stored in 1987.

Main Outcome Measures

Differences in clinical or functional status, demographic features, and outcome during 3‐years follow‐up between bacteriuric subjects with normal and elevated urine antibody.

Results

Thirteen subjects had no bacteriuria, and 12 had infrequent, intermittent bacteriuria; 38 (60%) had persistent bacteriuria, including four with frequent, intermittent infections. In the persistently bacteriuric group, 18 (47%) had persistently elevated urine antibody. There was no significant differences between bacteriuric residents with normal vs elevated urine antibody in clinical or functional status, age, duration of residence, or infecting organisms. However, 11 of 20 in the cohort with normal urine antibody were alive at 3 years compared to 3 of 18 with elevated urine antibody (P = 0.014).

Conclusions

Elderly institutionalized subjects with persistent bacteriuria and elevated urine antibody have decreased survival compared to those with normal urine antibody. No differences in underlying illness or clinical course to explain this survival difference were identified.
An Overview of Allocation and Rationing: Implications for Geriatrics
Authors: Pawlson L. Gregory , Glover Jacqueline J. , Murphy Donald J.
Published: April 2015

Geriatricians are faced with increasing pressure from insurers and the public to control costs. At the same time, sub‐specialist colleagues, patients, and the courts often demand ever more costly high‐technology interventions. This conflict will only intensify given the sustained increase in the percentage of GNP spent on medical care. A number of prominent biomedical ethicists and others have explored rationing of medical care services as one response to these concerns.

This is the second§ in a series of articles in the Journal in response to the Oregon Health Decisions Initiative and is designed to provide (1) a brief ethical perspective on rationing and allocation; (2) an analysis of our present, largely implicit, approach to rationing and allocation; and (3) some suggestions that might move the United States closer to a more coherent and reasonable means of allocating and rationing health care.
BOOK REVIEWS
Authors: Katz Paul R. , Hastings Margaret M.
Published: April 2015

Improving the Health of Older People: A World View By Kane RL, Evans JG and MacFadyen, D (eds.). Oxford University Press (on behalf of the World Health Organization) 1990. 709 pages. $705.00.
BOOK REVIEWS
Authors: Heinemann Gloria D.
Published: April 2015

Mirrored Lives: Aging Children and Elderly Parents. By Koch, Tom. New York, Praeger Publishers, 1990. 217 pages. $19.95.
Mild Vitamin D Deficiency and Secondary Hyperparathyroidism in Nursing Home Patients Receiving Adequate Dietary Vitamin D
Authors: McMurtry Cynthia T. , Young Shari E. , Downs Robert W. , Adler Robert A.
Published: April 2015

Objective

To compare the vitamin D metabolite and nutritional status of institutionalized elderly males with a non‐institutionalized control group.

Design

Case‐control study.

Setting

Veterans Administration Medical Center Nursing Home (NH) in Richmond, Virginia.

Patients

Fifty‐seven consecutive nursing home subjects were screened. After excluding blacks, those receiving anticonvulsants, glucocorticoids, or vitamin supplements, and those with liver or renal failure (creatinine > 1.5 mg/dL), 35 subjects were enrolled, and 22 completed the study. The noninstitutionalized control group (n = 18) consisted of consecutive volunteers, meeting the above criteria, from either a senior citizen group or a geriatric clinic.

Measurements and Main Results

The serum 25‐hydroxyvitamin D level in the NH residents was significantly lower than in community dwellers (17.4 ± 5.2 ng/mL vs 31.2 pg/mL ± 8.0 ng/mL, P < 0.0001). No significant difference was demonstrated in 1,25‐dihydroxyvitamin D levels (36.5 pg/mL ± 10.5 in NH residents vs 42.0 pg/mL ± 11.1 in controls). In the NH group PTH levels were inversely correlated with 25 OHD levels (P < 0.008) and positively correlated with length of stay in the NH (P < 0.016). There was no significant seasonal variation in vitamin D metabolite levels in the NH group. In the NH patients, the mean dietary intake of vitamin D was 232 ± 378 mg/day and of calories was 1811 ± 447 kcal/day.

Conclusion

Despite apparently adequate calories, calcium, and vitamin D intake, hypovitaminosis D with compensatory PTH elevations occurs, regardless of season, in the nursing home population.
Safety And Efficacy of Metoprolol in the Treatment of Hypertension in the Elderly
Authors: LaPalio Lawrence , Schork Anthony , Glasser Stephen , Tifft Charles
Published: April 2015

Objective

To assess the short‐term efficacy and safety of metoprolol in the treatment of hypertension in a large population of older patients.

Design

Prospective, open‐label surveillance study.

Setting

Multicenter outpatient offices.

Participants

21,692 patients with mild‐to‐moderate hypertension between the ages of 50 to 75 years. Patients were excluded if they had a contraindication to beta‐blocker therapy.

Intervention

Patients were treated with 100 mg of metoprolol once daily for 4 weeks. If the blood pressure was controlled, therapy was continued for an additional 4 weeks. If adequate blood pressure was not achieved after 4 weeks, 25 mg of hydrochlorothiazide was added. At the end of 8 weeks, final therapy decisions were recorded. If the blood pressure was controlled, therapy was continued for an additional 4 weeks.

Main Outcome Measures

Blood pressure, heart rate and side‐effects.

Results

After 4 weeks of therapy, mean systolic and diastolic blood pressures decreased significantly from 162/95 to 148/87 mm Hg (P < 0.001). Fifty‐eight percent of the patients had satisfactory blood pressure control. At the end of 8 weeks, mean systolic and diastolic blood pressure decreased to 143/84 mm Hg. Blood pressure response was similar in all age groups. At the termination of the study, 50% of the patients were continued on monotherapy, and 27% were continued on combined therapy. Overall, there was less than a 5% incidence of medical problems, and excellent or good tolerability was noted for 94% of the patients.

Conclusions

Metoprolol administered as monotherapy or in combination with hydrochlorothiazide was effective in normalizing blood pressure in a majority of elderly hypertensive patients. Both drug regimens were well tolerated.
Reducing the Use of H2‐Receptor Antagonists in the Long‐Term‐Care Setting
Authors: Gurwitz Jerry H. , Noonan James P. , Soumerai Stephen B.
Published: April 2015

Objectives

To examine the patterns of H2 blocker use in the long‐term‐care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns.

Design

Time‐series quasi‐experimental study and retrospective chart review.

Setting

A large academically‐oriented long‐term‐care facility.

Patients

Institutionalized elderly patients with a mean age of 88 years receiving H2 blocker therapy.

Interventions

Two interventions involving group discussions with the medical staff, supporting educational materials, and physician‐specific listings of patients receiving H2 blockers were employed sequentially over a 32‐month period.

Results

Each intervention resulted in substantial reductions in medication use (59.6% and 32.1%, respectively). Indications for H2 blocker use were determined retrospectively for patients identified as receiving therapy prior to the interventions (n = 110). Forty‐one percent were found to be receiving therapy for reasons unsubstantiated by the medical literature. These patients were more likely to be discontinued from therapy than those receiving therapy for substantiated indications (P < 0.01), consistent with the primary focus of the educational interventions.

Conclusions

These results suggest that the excessive use of H2 blocker therapy in the long‐term care setting responds to educational interventions with therapeutically appropriate reductions in utilization. Repeated interventions are necessary to maintain such reductions over time although there may be some reduction in the effectiveness of the intervention with repetition.
Reducing and Managing Restraints in Long‐Term‐Care Facilities
Authors: Schnelle John F. , Newman Daniel R. , White Marilyn , Volner Timothy R. , Burnett Juanita , Cronqvist Agnita , Ory Marcia
Published: April 2015

Objective

To evaluate a management system designed to improve staff adherence to a federal regulation that stated restrained residents should be released, exercised, and repositioned every 2 hours.

Design

A delayed intervention, controlled, cross‐over design with three phases. During phase one, baseline, the length of intervals that residents remained in restraints was monitored. The intervention was implemented at site A in Phase two while site B remained in baseline. During Phase three, the intervention was replicated at site B.

Setting

Two long‐term care proprietary nursing facilities.

Patients

Sixty‐three physically restrained residents in the two facilities.

Intervention

The intervention was a system of restraint release using colored pads corresponding to specific hours. The management rule was that the resident should be on a different colored pad every 2 hours. Staff had to lift residents to place the pad, and the colors made the system easy for supervisors to check.

Main Outcome Measures

Checks by research personnel by black light and invisible ink, to detect movement of the knot tying the restraints.

Results

During the baseline phase, the majority of residents at both sites were inappropriately restrained longer than 2 hours (site A: 54.1%; site B: 60.1%). The percentage of residents restrained over 2 hours was significantly reduced during the intervention phase to 13.9% (site A) and 19.4% (site B). Three weeks after the end of the intervention, inappropriate use of restraints remained low, 14.2%, but rose to 47.7% after another 3 weeks.

Conclusion

The management system is an effective way to increase the consistency with which nursing‐home staff release and reposition restrained residents.
BOOK REVIEWS
Authors: Katz Paul R. , Ackerman Kathleen
Published: April 2015

Quality Assurance for Long‐Term‐Care Providers. By Ammentorp W, Gossett KD, and Euchner Poe N. California, Sage Publications, Inc, 1991. 163 pages. $14.00 (soft cover).
Prevalence and Characteristics of Symptomatic Gastroesophageal Reflux Disease in the Elderly
Authors: Räihä I.J. , Impivaara O. , Seppälä M. , Sourander L. B.
Published: April 2015

Objective: To study prevalence and characteristics of symptomatic gastroesophageal reflux disease in the elderly.

Objective: Survey by questionnaire of stratified random sample.

Setting: City of Turku, Finland.

Subjects: Population‐based random sample consisting of non‐institutionalized subjects aged 65 years or over. A questionnaire was sent to 559 subjects. The response rate was 92%. Twenty‐nine incompletely filled forms were rejected. Thus, the questionnaires from 487 subjects, representing 87% of the original number, constitute the basis for the study.

Measurements: The questionnaire inquired about the following symptoms: heartburn, regurgitation, chest pain, dysphagia, dyspepsia, respiratory symptoms, vomiting, and belching.

Results: The age‐adjusted prevalence of daily symptoms suggestive of gastroesophageal reflux disease was 8% in men and 15% in women (P < 0.05). Fifty‐four percent of men and 66% of women reported that they had symptoms at least once a month (P < 0.05). The prevalence of symptoms was roughly the same across age groups. The occurrence of chest pain, dyspepsia, vomiting, belching, dysphagia, chronic cough, hoarseness, and wheezing were associated with symptoms suggestive of gastroesophageal reflux disease.

Conclusions: Symptoms suggestive of gastroesophageal reflux disease are common in elderly subjects. Women suffer from these symptoms more frequently than men. Typical reflux symptoms are often associated with atypical complaints, such as abdominal symptoms, chest pain, or respiratory symptoms. J Am Geriatr Soc 40:1209–1211
An Audit of Cardiac Pacing in the Elderly: Effect of Myocardial Infarction on Outcome
Authors: Rashid A. , Shah I. U. , Haboubi N. Y. , Hudson P. R.
Published: April 2015

Objective

To audit the outcome of temporary endocardial pacing in an elderly population.

Design

Retrospective case‐series analysis.

Setting

The Department of Medicine for the Elderly at the Wrexham Maelor Hospital, a District General Hospital with 612 beds serving a catchment population of 220,000.

Subjects

A sample of 50 consecutive elderly patients, with an age range of 65 to 99 years, undergoing transvenous cardiac pacing.

Main Outcome Measures

Length of stay in hospital, complications of the pacing procedure, whether a permanent pacemaker was installed, and whether the patient died within 1 month of admission.

Results

There was no difference in length of stay between those with a myocardial infarction and those without. Minor complications occurred in three patients (one local infection and two “failures to pace”). Major complications occurred in two patients (septicemia and pneumonia). More patients without a myocardial infarction (86.9%) went on to implantation of a permanent pacemaker than those with an infarction (11.1%, P = 0.001), and fewer of them died (8.7% compared with 48.1%, P = 0.0025). In those patients with a myocardial infarction who died, there was no difference between the proportions who had inferior (7/18) and anterior (5/9) infarctions.

Conclusion

Cardiac pacing seems to be a safe and reliable procedure in the elderly, although long term morbidity and mortality may be dependent on the presence or absence of myocardial ischaemic disease. Myocardial infarction in the elderly is an event of major significance, carrying with it a high mortality rate, particularly if accompanied by cardiogenic shock and the need for cardiac pacing.
Correlates of Cognitive Function Scores in Elderly Outpatients
Authors: Mangione Carol M. , Seddon Johanna M. , Cook E. Francis , Krug Joseph H. , Sahagian Christine R. , Campion Edward W. , Glynn Robert J.
Published: April 2015

Objective

To determine medical, ophthalmologic, and demographic predictors of cognitive function scores as measured by the Telephone Interview for Cognitive Status (TICS), an adaptation of the Folstein Mini‐Mental Status Exam. A secondary objective was to perform an item‐by‐item analysis of the TICS scores to determine which items correlated most highly with the overall scores.

Design

Cross‐sectional cohort study.

Setting

The Glaucoma Consultation Service of the Massachusetts Eye and Ear Infirmary.

Subjects

472 of 565 consecutive patients age 65 and older who were seen at the Glaucoma Consultation Service between November 1, 1987 and October 31, 1988.

Measurements

Each subject had a standard visual examination and review of medical history at entry, followed by a telephone interview that collected information on demographic characteristics, cognitive status, health status, accidents, falls, symptoms of depression, and alcohol intake.

Results

A multivariate linear regression model of correlates of TICS score found the strongest correlates to be education, age, occupation, and the presence of depressive symptoms. The only significant ocular condition that correlated with lower TICS score was the presence of surgical aphakia (model R2 = .46). Forty‐six percent (216/472) of patients fell below the established definition of normal on the mental status scale. In a logistic regression analysis, the strongest correlates of an abnormal cognitive function score were age, diabetes, educational status, and occupational status. An item analysis using step‐wise linear regression showed that 85 percent of the variance in the TICS score was explained by the ability to perform serial sevens and to repeat 10 items immediately after hearing them. Educational status correlated most highly with both of these items (Kendall Tau R = .43 and Kendall Tau R = .30, respectively).

Conclusion

Education, occupation, depression, and age were the strongest correlates of the score on this new screening test for assessing cognitive status. These factors were stronger correlates of the TICS score than chronic medical conditions, visual loss, or medications. The Telephone Interview for Cognitive Status is a useful instrument, but it may overestimate the prevalence of dementia in studies with a high prevalence of persons with less than a high school education.
The Problems of Pain and Its Detection among Geriatric Nursing Home Residents
Authors: Sengstaken Elizabeth A. , King Steven A.
Published: April 2015

Objective

To assess physicians' detection of pain among geriatric nursing home residents and to determine if there are factors that may interfere with their ability to do this.

Design

Chart review and patient interview.

Setting

Geriatric nursing home.

Participants

One hundred nursing home residents age 65 or older. Seventy‐six were communicative.

Measurements

Demographic information, diagnoses, and medication use were compared for several groups of residents to determine their effects on the detection of pain.

Results

Sixty‐six percent of the communicative residents were identified as having chronic pain. Treating physicians did not detect this problem in 34% of these residents. Those whose pain was not so identified were more likely to have a neurologic disorder other than dementia. When non‐communicative residents were compared with those who were communicative, the physicians were found to have identified pain less frequently in the former cohort.

Conclusions

Chronic pain is a common problem among geriatric nursing home residents and is frequently undetected. Identification of this problem among communicative residents may be markedly improved by direct questioning about this problem at frequent intervals. New methods of assessing pain need to be created to assist in its detection among the non‐communicative population.
Dopamine B Hydroxylase Deficiency Responsible for Severe Dysautonomic Orthostatic Hypotension in an Elderly Patient
Authors: Gentric A. , Fouilhoux A. , Caroff M. , Mottier D. , Jouquan J.
Published: April 2015

We report the case of an elderly woman with severe dysautonomic orthostatic hypotension in whom a deficit in dopamine B hydroxylase has been established. In the literature, such a deficit has been described in six young adults with long standing symptoms of postural hypotension. This enzyme catalyses the conversion of dopamine to noradrenaline. In our elderly patient, noradrenaline and adrenaline were undetectable in the plasma, but plasma dopamine was detectable. Treatment with the synthetic amino acid, DL‐threodihydroxyphenylserine, which is converted to noradrenaline by dopa‐decarboxylase, resulted in a significant increase in blood pressure. The mechanism of this acquired deficit is not elucidated.
BOOK REVIEWS
Authors: Gaylord Susan Ann
Published: April 2015

Handbook of the Biology of Aging, Third Edition. Edited by Edward L. Schneider and John W. Rowe. New York, Academic Press, 1990. 489 pages. $99 (hardback); $39.95 (paperback).
Public Opinion Regarding Consent to Treatment
Authors: Singer Peter A. , Choudhry Sujit , Armstrong Jane
Published: April 2015

Objective

To examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.

Design

Cross‐sectional random‐digit‐dialing telephonic survey.

Setting

General public.

Participants

One thousand randomly‐selected adults living in Ontario.

Interventions

None.

Main Outcome Measures

Self‐reported attitudes and behaviors.

Results

Of 5,708 telephone numbers drawn, 641 were non‐valid or non‐residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would want their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life‐saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling.

Conclusions

These data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent‐related issues including disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.
Observations on the Prevalence of Protein‐Calorie Undernutrition in VA Nursing Homes
Authors: Abbasi Adil A. , Rudman Daniel
Published: April 2015

Objective

To determine the prevalence of underweight and hypoalbuminemia in Veterans Affairs nursing home residents and the frequency with which physicians, nurses, and dieticians documented their awareness of the presence of underweight and hypoalbuminemia.

Design

Retrospective survey of medical records.

Setting

Twenty‐six Department of Veterans Affairs nursing homes located in the Department's Central Region.

Patients

2811 residents.

Main Outcome Measures

(1) Prevalence of underweight (defined as body weight less than 80% of standard) and hypoalbuminemia (defined as serum albumin less than 3.5 g/dl); (2) frequency with which physicians, nurses, and dieticians documented the prevalence of underweight and hypoalbuminemia in the records.

Results

Three hundred thirty‐two (11.8%) of the patients were underweight and 772 (27.5%) were hypoalbuminemic. The prevalence of the two conditions varied widely across nursing homes. The prevalence of low serum albumin ranged from 5% to 58% in the 26 institutions, and the prevalence of body weight less than 80% of standard ranged from 2% to 20%. In the Region as a whole, the dietician's notes in the medical charts mentioned underweight in an average of 95% of affected cases but mentioned the suboptimal albumin level in only 82% of the hypoalbuminemic individuals. In the nurses's notes, these figures were only 80% and 45%, respectively, and in the physician's notes, only 62% and 46%, respectively. The frequency of documented awareness of underweight and hypoalbuminemia by nurses and physicians varied tremendously across the 26 facilities (as few as 7% of the undernourished cases in one nursing home, 100% of the affected individuals in another).

Conclusions

This study showed a high prevalence of calorie and protein undernutrition in the nursing home residents of VA nursing homes, wide variation in the prevalence across nursing homes, and frequent lack of documentation of these nutritional deficiencies by physicians and nurses.
The Nursing Home Medical Director Role in Transition
Authors: Elon Rebecca
Published: April 2015

Objective

To compare the self‐reported role of nursing home medical directors in 1989 (prior to the implementation of the nursing home reform amendments of OBRA 87 in 1990) with the role outlined in the Joint Commission on Accreditation of Healthcare Organizations Long Term Care Standards Manual.

Design

Survey.

Measurements

Using a telephone interview survey, physicians were questioned about their role as nursing home medical director. Responses were compared with the definition of the medical director's role in the Long Term Care Standards Manual. Information about time spent per month and reimbursement received for medical direction was also obtained.

Participants

Physicians serving as nursing home medical directors in 1989 in Houston/Harris County, Texas.

Results

Of 50 nursing home medical director positions in Houston/Harris County in 1989, interviews were completed for 36 (72%). The majority of the medical directors met the criteria for having a signed agreement with the facility, assuring continuous medical coverage, developing emergency procedures, and participating in quality assurance activities. Twenty‐eight percent of the medical directors received no monetary compensation for their work. Of those who were paid, the mean monthly earnings for nursing home medical direction were $345.

Conclusion

Although all nursing facilities are now required by regulation to have medical directors, a wide variation in medical directors' level of involvement and commitment was documented.
Social Service Interventions for Caregivers of Patients with Dementia: Impact on Health Care Utilization and Expenditures
Authors: Weinberger Morris , Gold Deborah T. , Divine George W. , Cowper Patricia A. , Hodgson Lynne G. , Schreiner Pamela J. , George Linda K.
Published: April 2015

Objectives

An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short‐term (ie, 6‐month) health services utilization and expenditures.

Design

Randomized controlled trial.

Setting

University‐based memory disorders clinic.

Participants

Caregivers of patients with progressive memory disorders.

Main Outcome Measures

Service utilization and expenditures.

Results

The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline.

Conclusions

Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.
BOOK REVIEWS
Authors: Lavizzo‐Mourey Risa
Published: April 2015

Clinics in Geriatric Medicine: Health Promotion and Disease Prevention. Edited by Gilbert S. Omenn, Eric Larson, Edward Wagner, Itamar Abrass. Philadelphia, W.B. Saunders, 1990. 223 pages. $18.00.
BOOK REVIEWS
Authors: McCann Robert
Published: April 2015

The Living‐At‐Home Program By Morton D. Bogdonoff, Susan L. Hughes, William G. Weissert and Emily Paulsen. New York, Springer Publishing Co., 1991. 318 pages. $44.95.