bluuebunny/crossref_metadata_2025 huggingface dataset:
Comprehensive Geriatric Assessment in a Day Hospital
Authors: Siu Albert L. , Morishita Lynne , Blaustein Jenna
Published: April 2015

OBJECTIVE: To assess the effectiveness of comprehensive geriatric assessment conducted in day hospitals.

DESIGN: Retrospective cohort comparison study with restricted inclusionary criteria and adjustment for baseline characteristics.

SETTING: A hospital‐based geriatric day hospital and geriatric clinic sites (both in the university and in the community).

PATIENTS: Four hundred sixty‐eight patients referred for comprehensive geriatric assessment during a 12‐month period.

INTERVENTION: Comprehensive geriatric assessment in a geriatric day hospital compared with assessment received in clinic sites without a day hospital.

MAIN OUTCOME MEASURES: Services received in the first 2 weeks; hospitalization, emergency room visits, placement, death, and change in selected health status measures. Follow‐up data was obtained from medical records, a telephone survey, and death certificates.

RESULTS: Except in the case of rehabilitative services, day hospital patients were more likely to receive interdisciplinary services. The population seen in the day hospital was more functionally impaired and had significantly more dementia and depression. After adjusting for subjects' baseline characteristics and limiting the analyses to subjects meeting specific inclusionary criteria, the day hospital had no significant effect on mortality, use of emergency or hospital services, placement, or change on selected measures of health status. For example, compared with the clinic patients, receiving care in the day hospital was associated with an adjusted odds ratio of 1.01 (95% confidence interval: 0.53, 1.91) of being at a higher level of care at 6 months. The results were not sensitive to the choice of inclusionary criteria.

CONCLUSION: Given their cost and uncertain effectiveness, day hospitals need additional evaluation before their further diffusion occurs.
The Use of Dietary Restrictions in Malnourished Nursing Home Patients
Authors: Buckler Debra A. , Kelber Sheryl T. , Goodwin James S.
Published: April 2015

OBJECTIVE: To evaluate the dietary prescriptions of nursing home patients who show evidence of malnutrition.

DESIGN: A descriptive chart review.

SETTING: Four chronic care facilities in Milwaukee, Wisconsin.

PATIENTS: A total of 336 charts were randomly selected from the four facilities. Analysis was done on the 217 charts that included a recorded serum albumin.

MAIN OUTCOME MEASURES: Serum albumin, height, most recent weight, weight recorded 6 months previously, major diagnoses, and current diets were recorded. Average weight change per month and body mass index were calculated.

RESULTS: In 109 of the 217 patients, the serum albumin was less than 3.5 g/dL. 75.2 percent of the hypoalbuminic patients were on some sort of dietary restriction, including caloric restriction in 18% and sodium restriction in 35%. Sixty‐six of the 217 patients had an average weight loss of greater than 1 pound per month, and 59% of this group were on dietary restrictions, with 21% on sodium restriction and 20% on limited calories.

CONCLUSIONS: Malnutrition is a common problem in the nursing home population. A restricted diet is one possible factor that might contribute to this. While this study does not prove a causal relationship between a restricted diet and malnutrition, it would seem inappropriate that most patients with evidence of malnutrition are on diets that might discourage nutrient intake.
Geriatric Home Assessment After Hospital Discharge
Authors: Kravitz Richard L. , Reuben David B. , Davis James W. , Mitchell Anne , Hemmerling Karen , Kington Raynard S. , Siu Albert L.
Published: April 2015

OBJECTIVES: To evaluate the feasibility of an intervention involving post‐discharge geriatric home assessment and follow‐up and to describe the spectrum of significant clinical problems identified during the home assessment.

DESIGN: Prospective observational study nested within a randomized controlled trial.

SETTING: Inpatient service of a large academic medical center in Southern California.

PATIENTS: There were 152 adults aged 65 or greater who had one or more specific risk factors for functional decline or increased mortality, who were awaiting discharge from the hospital, and who were assigned to the intervention arm of a randomized controlled trial of post‐discharge comprehensive geriatric home assessment.

MAIN RESULTS: During the home assessment, the gerontologic nurse practitioner (GNP) identified new or worsening problems in 150 patients (99%); 61 problems (eg, serum sodium 125 mg/dL; severe orthostatic hypotension) were considered by a reviewing physician to require urgent medical attention. Older age, non‐white race, and new incontinence were associated independently with a greater number of findings (P < 0.05). Based on the findings, an interdisciplinary team made an average of 3.4 recommendations per patient; only two of 111 requests for written approval of recommendations were rejected.

CONCLUSIONS: Post‐discharge visitation by a GNP to patients at high risk is capable of detecting a high yield of important and potentially reversible clinical problems. This multidisciplinary approach is acceptable to physicians. Research is needed to identify additional links between short hospital stays, impairment or instability at discharge, and adverse outcomes.
Idpathic CD4+ T Lymphopenia in Older Persons
Authors: Kaiser Fran E. , Morley John E.
Published: April 2015

OBJECTIVE: Survey of the association of idiopathic CD4+T cell lymphocytopenia in older persons with protein energy undernutrition and unusual infections/colonizations.

METHOD: Retrospective chart analysis.

RESULTS: Five subjects aged 61 to 87 years, with unusual organisms and/or either marasmus or kwashiorkor, were noted to have absolute CD4+and CD8+T cell lymphocytopenia. All were HIV negative.

CONCLUSION: T cell lymphocytopenia may not be a uncommon finding in malnourished older persons, but additional studies to determine its prevalence need to be undertaken. Its role in disease and impact on therapeutic response needs to be further explored.
Assessing Health‐Related Quality of Life in Elderly Outpatients: Telephone Versus Face‐to‐Face Administration
Authors: Weinberger Morris , Nagle Becky , Hanlon Joseph T. , Samsa Gregory P. , Schmader Kenneth , Landsman Pamela B. , Uttech Kay M. , Cowper Patricia A. , Cohen Harvey J. , Feussner John R.
Published: April 2015

OBJECTIVE: While health‐related quality of life (HRQOL) is increasingly being used as an outcome in clinical trials, it is unknown whether HRQOL assessments are influenced by the method of administration. Within the context of a randomized, controlled trial evaluating a pharmacist intervention for elderly outpatients prescribed at least five medications, we compared telephone and face‐to‐face administration of the SF‐36, a widely used HRQOL measure.

DESIGN: Survey

SETTING: General Medicine Clinic, Veterans Affairs Medical Center

PATIENTS: At entry, participants in the randomized trial received continuous care from a general medicine clinic physician, were>65 years of age, and were prescribed>5 regularly scheduled medications. Patients were excluded if they were cognitively impaired and had no caregiver available to participate in the study as a proxy or if they resided in a nursing home.

MEASUREMENTS: Subjects completed the SF‐36 by telephone at doseout and face‐to‐face at clinic visits within 1 month (mean = 16.7 days).

MAIN RESULTS: Telephone administration required significantly less time than face‐to‐face interviews (10.2 vs 14.0 minutes, P < 0.001). Although systematic differences between modes of administration were generally small, there were substantial nonsystematic discrepancies for all eight SF‐36 scales (mean absolute difference scores ranged from 10.8 to 30.1). Discrepancies were greatest for emotional role functioning, physical role functioning, social functioning, and bodily pain; these four scales also demonstrated low to moderate correlations (.33 to .58).

CONCLUSIONS: The two modes of administration may not produce interchangeable results. Researchers should be cautious when mixing modes of administration to elderly patients. J Am Geriatr Soc 42: 1295–1299, 1994.
Constipation in the Elderly: Influence of Dietary, Psychological, and Physiological Factors
Authors: Towers Adele L. , Burgio Kathryn L. , Locher Julie L. , Merkel Ira S. , Safaeian Mehry , Wald Arnold
Published: April 2015

OBJECTIVE: To identify dietary, psychological, and physiological characteristics of older individuals with chronic constipation, compared with a control group of individuals without constipation, and identify correlates of colonic transit time.

DESIGN: Cohort study.

SETTING: University hospital and affiliated clinics.

PARTICIPANTS: Eighteen constipated and 18 control subjects who were nondemented, ambulatory, community‐dwelling outpatients over the age of 60 years.

MEASURES: Measures included a 1‐week food diary, diet questionnaire, bowel diary, the Hopkins Symptom Checklist (SCL‐90R), colonic transit study, and medical history, including queries about activity, medications, medical illnesses, and bowel symptoms.

MAIN RESULTS: Constipated subjects reported consuming fewer meals per day compared with control subjects (P < 0.01) and a tendency to consume fewer calories (P = 0.07). There were no differences between groups on fiber or fluid intake or any of the other dietary parameters. However, slow colonic transit was significantly related to low caloric intake (P < 0.0001), higher percent of protein in the diet (P < 0.05), low fluid intake (P < 0.05), and to psychological symptoms of somatization, obsessive‐compulsiveness, depression, anxiety, and the global severity index (P < 0.05). Transit times were unrelated to crude or dietary fiber intake, activity level, or age.

CONCLUSIONS: The data suggest that constipation in this older population is related to caloric intake rather than fiber consumption or other dietary qualities. Psychological distress is associated with slowed colonic transit and should be investigated further as a possible etiologic factor in constipation.
Past Personal History of Dysphoria, Social Support, and Psychological Distress Following Conjugal Bereavement
Authors: Hays Judith C. , Kasl Stanislav , Jacobs Selby
Published: April 2015

OBJECTIVE: This study describes the course and risk factors of psychological distress following bereavement, controlling for factors often omitted from studies of grief: psychiatric history, social support, and coping choices of the bereaved.

PARTICIPANTS: Spouses of patients hospitalized for serious illness or elective surgery were systematically screened and followed longitudinally through the recovery or death of the hospitalized patient. Of 440 respondents, 154 were bereaved within 2 months.

DESIGN AND SETTING: Spouses were interviewed in their homes by trained interviewers at intake and 2, 6, 13, and 25 months postintake.

MEASUREMENTS: Dependent variables were measured with the CES‐D (depressive symptoms) and the PERI (general anxiety and hopelessness/helplessness) scales. Independent variables were measured with the SADS‐L (past personal history of dysphoria) and the Lazarus' Ways of Coping scale as well as sociodemographic measures.

MAIN RESULTS: Lifetime prevalence of a brief period of dysphoric mood among spouses before the patient's illness was 22%; past personal history of dysphoric mood was related to female sex, smaller networks, and more depression and anxiety during the hospitalization of their spouses. Newly widowed persons with a past history of dysphoria perceived their networks to be relatively nonsupportive, but devoted similar amounts of coping effort to seeking social support and reported similar amounts of social interaction compared with persons with no history of dysphoria. Persons with a past history of dysphoria reported elevated levels of depressive symptoms, general anxiety, and hopelessness/helplessness through 25 months postbereavement, yet their recovery trajectory was similar to those without a past history of dysphoria.

CONCLUSIONS: It was concluded that a past history of subsyndromal symptomatology in conjunction with a stressful life event such as bereavement increases one's vulnerability to excess psychological distress.
Causes of Death Associated with Alzheimer Disease: Variation by Level of Cognitive Impairment Before Death
Authors: Kukull W. A. , Brenner D. E. , Speck C. E. , Nochlin D. , Bowen J. , McCormick W. , Teri L. , Pfanschmidt M. L. , Larson E. B.
Published: April 2015

OBJECTIVE: To describe causes of death for patients with Alzheimer disease (AD) and other dementing illnesses enrolled in a population‐based Alzheimer disease patient registry (ADPR) and to describe the variation in causes by the level of cognitive impairment before death in probable AD cases.

SETTING: The ADPR enrolls and diagnoses newly recognized potential dementia cases occurring in a large, stable health maintenance organization. To date, 654 cases have been enrolled and followed annually to monitor cognitive decline and verify initial diagnosis.

DESIGN: Longitudinal descriptive study.

PATIENTS: ADPR enrollees who have died.

MEASUREMENTS: Death certificates were obtained for all who died (total n = 104, probable AD = 55); reported causes of death were reviewed by a physician to determine the underlying cause. AD patients were categorized according to their Mini‐Mental State Exam score (cognitive impairment) within 12 months of death as (a) mildly (21+), (b) moderately (15–20), or (c) severely (0–14) impaired, and underlying cause and all reported causes of death for each group were tabulated.

MAIN RESULTS: Among probable AD patients, pneumonia and AD were most often recorded on death certificates when cognitive impairment within the year prior to death had reached the severe level; heart disease, stroke, and other common causes of death predominated in AD patients who were less cognitively impaired.

CONCLUSIONS: When AD cases were followed from first diagnosis to death, the causes of death varied by level of cognitive impairment. Illnesses potentially amenable to treatment caused death at all levels of disease, but more so early in the course of AD. Cognitive impairment may make patients less able to recognize and report symptoms of medical problems, thereby complicating efforts to intervene.
Older Adults' Perceptions of their Health and Functioning in Relation to Sleep Disturbance, Falling, and Urinary Incontinence
Authors: Kutner Nancy G. , Schechtman Kenneth B. , Ory Marcia G. , Baker Dorothy I. ,   FICSIT Group
Published: April 2015

OBJECTIVE: To investigate variation in older adults' perceived health and functioning that is associated with self‐reported sleep disturbance, falling, and urinary incontinence, controlling for self‐reported depression, ambulation difficulty, number of chronic conditions, and subjects' sociode‐mographic characteristics.

DESIGN: Multicenter prospective study (FICSIT).

SETTING: Persons age 70 and older living in the community evaluated at baseline.

PARTICIPANTS: 239 women, 113 men; mean age = 77.

MEASUREMENTS: Sleep disturbance score based on EPESE questions, recent falls history (Y/N), incontinent episodes (Y/N), CES‐D score, SIP Ambulation score, and 4 MOS SF‐36 scale scores.

RESULTS: Women were significantly more likely than men to report multiple conditions (sleep disturbance, falling, incontinence) and to report lower levels of functioning as measured by 3 of 4 SF‐36 scales. In regression analyses, sleep disturbance and urinary incontinence were significant predictors of perceived limitation in usual role activities because of physical health problems. Depression and ambulation measures significantly predicted scores on all 4 SF‐36 scales.

CONCLUSIONS: Our analysis suggests that it is important to address depressive symptomatology and ambulation difficulty—which in turn are related to sleep disturbance, falling, and urinary incontinence —in efforts to enhance older adults' perceived health and functioning.
Cognitive Function in Old and Very Old Residents of a Residential Facility: Relationship to Age, Education, and Dementia
Authors: Osterweil Dan , Mulford Patty , Syndulko Karl , Martin Maria
Published: April 2015

OBJECTIVE: To determine if age, education, and dementia status affect neuropsychological performance in old and very old frail residential care subjects.

DESIGN: Descriptive study of performance at the time of preadmission assessment.

SETTING: Jewish Home for the Aging, Reseda, California.

PARTICIPANTS: 201 applicants to the Jewish Home for the Aging residential care setting. Mean age was 84.7 years; SD was 5.6. Ninety‐five subjects were 84 years of age or younger, while 106 were age 85 and older. There were 141 nondemented, 21 demented, and 39 were possibly demented applicants. Levels of education were as follows: 0–4 years: n = 25; 5–8: n = 69; 9–12: n = 77; and, 13–20: n = 23.

MEASUREMENTS: Independent variables were age, education, and dementia status. Outcome measures were Folstein MMSE, Inglis P‐A Learning Test, Digit Span, Cube Copying, selected Boston Diagnostic Aphasia Exam subtests.

RESULTS: Subjects with 0 to 4 years of education scored more poorly on cognitive tests than other subjects. The very old tended to score more poorly than the old. Neuropsychological tests discriminated between those with normal cognitive function, possible dementia, and established dementia. About one‐third of nondemented elderly scored below the traditional impairment cut‐off of 24 points on the Mini‐Mental State Exam.

CONCLUSIONS: Questions are raised about how to interpret the poorer cognitive performance of very old and often frail subjects, especially in long‐term‐care settings where there are fewer demands upon residents whose impairments might otherwise cause them more functional difficulty.
Disability and Severe Gastrointestinal Hemorrhage. A Prospective Study of Community‐Dwelling Older Persons
Authors: Pahor Marco , Guralnik Jack M. , Salive Marcel E. , Chrischilles Elizabeth A. , Manto Andrea , Wallace Robert B.
Published: April 2015

OBJECTIVE: To describe the occurrence of severe gastrointestinal bleeding in community‐dwelling older persons and to examine whether disability is a risk factor for this life‐threatening condition independent of other known predictors.

DESIGN: Prospective cohort survey.

SETTING: Three communities of the Established Populations for Epidemiologic Studies of the Elderly (EPESE).

PARTICIPANTS: 8205 persons age ≥68 years.

MEASUREMENTS: The hospital discharge diagnoses provided by the Medicare Provider Analysis and Review files and the death certificates were prospectively surveyed for 3 years. Those with at least 1 discharge diagnosis of gastrointestinal bleeding and who received a blood transfusion or died were identified as cases of severe gastrointestinal hemorrhage. Physical disability, cognitive function, smoking and alcohol intake habits, body mass index, blood pressure, chronic conditions, number of hospital admissions in past year and medications taken were assessed at baseline.

RESULTS: The occurrence rate of severe gastrointestinal bleeding was 10.8 per 1000 person‐years (241 events/22,277 person‐years). In proportional hazards regression models, compared with no disability, ≥ 1 disabilities in the Rosow‐Breslau scale (RR = 2.1, 95% CI = 1.5–2.9), and ≥1 ADLs limitations (RR = 3.1, 95% CI = 2.1–4.6) independently predicted gastrointestinal hemorrhage after adjusting for age, gender, body mass index, comorbidity, number of hospital admissions, blood pressure, intake of coumarin, corticosteroids, aspirin and other nonsteroidal antiinflammatory drugs.

CONCLUSIONS: In this prospective analysis, disability is an independent predictor of gastrointestinal hemorrhage. Further studies are needed to explain the mechanisms by which disability may cause gastrointestinal hemorrhage. Because physical disability is potentially modifiable, strategies to lower the risk of gastrointestinal bleeding should be evaluated.
Differences in the Treatment of Patients with Acute Myocardial Infarction According to Patient Age
Authors: Rosenthal Gary E. , Fortinsky Richard H.
Published: April 2015

OBJECTIVE: To identify age‐related differences in the treatment of patients with acute myocardial infarction.

DESIGN: Retrospective cohort study.

SETTING: Two university‐affiliated medical centers with integrated clinical programs.

PATIENTS: 329 patients admitted with acute myocardial infarction in 1988–1990 for whom complete medical records were available. Study exclusions included patients transferred from other hospitals specifically to undergo angiography or other cardiac procedures, nursing home residents, patients with metastatic cancer or dementia, and patients in whom “do not resuscitate” orders were written during the first 2 hospital days.

MEASUREMENTS: Medical records were reviewed to determine socio‐demographic data, comorbidity, admission severity of illness, medications, the use of specific diagnostic and therapeutic modalities during and after hospitalization, treatment limitations, and patient outcomes.

MAIN RESULTS: Chronological age of patients was related to the use of several diagnostic and therapeutic modalities. Using logistic regression to adjust for comorbidity, severity, infarct size and location, and other covariates, patients 75 years and older were 12 times less likely to receive thrombolytic therapy, 8 times less likely to undergo coronary angiography, and 7 times less likely to undergo coronary angioplasty than patients less than 65 years of age. However, age was not related to the use of other modalities, including echocardiography or gated blood pool scanning, pulmonary artery catheterization, and transvenous pacing. Finally, in a logistic regression model, the risk of in‐hospital death was 4 times greater for patients 75 years and older than patients less than 65 years.

CONCLUSIONS: Physicians' management of patients with acute myocardial infarction differed greatly according to patient age for some diagnostic and therapeutic modalities, but not for others. These findings indicate that generalizations about age‐related practice variations should not be based on analysis of a single procedure. Moreover, judgments about the appropriateness of age‐related differences in management require knowledge of the relative effectiveness of management strategies in older and younger patients.
Improving Treatment of Late Life Depression in Primary Care: A Randomized Clinical Trial
Authors: Callahan Christopher M. , Hendrie Hugh C. , Dittus Robert S. , Brater D. Craig , Hui Siu L. , Tierney William M.
Published: April 2015

OBJECTIVE: Facilitate primary care physicians' compliance with recommended standards of care for late life depression by reducing barriers to recognition and treatment.

DESIGN: Randomized controlled clinical trial of physician‐targeted interventions.

SETTING: Academic primary care group practice caring for an urban, medically indigent patient population.

PATIENTS/PARTICIPANTS: Patients aged 60 and older who exceeded the threshold on the Centers for Epidemiologic Studies Depression Scale (CES‐D) and the Hamilton Depression Rating Scale (HAM‐D) and their primary care physicians.

INTERVENTION: Physicians of intervention patients were provided with patient‐specific treatment recommendations during 3 special visits scheduled specifically to address the patient's symptoms of depression. In general, physicians were encouraged to establish a diagnosis of depression and educate their patient about the diagnosis, discontinue medications that can cause or exacerbate depressive symptoms, initiate antidepressants when appropriate, and consider referral to psychiatry. Guidelines for prescribing antidepressants were provided. Control physicians received no intervention, and control patients received usual care.

MAIN OUTCOME MEASURES: Frequency of recording a depression diagnosis, stopping medications associated with depression, initiating antidepressant medication, and psychiatry referral; mean changes in HAM‐D and Sickness Impact Profile (SIP) scores.

RESULTS: One hundred three physicians and 175 patients were involved in the clinical trial. Physicians of intervention patients were more likely to diagnose depression and prescribe antidepressants (P < 0.01). There were no differences between the groups in the frequency of stopping medications associated with depression or referrals to psychiatry. Medications with the strongest cause and effect relationship to depression were infrequently used in this cohort of patients. Although both groups showed improvement in HAM‐D and SIP scores, we were unable to demonstrate significant differences in HAM‐D or SIP scores between the 2 groups.

CONCLUSIONS: Intensive screening and feedback of patient‐specific treatment recommendations increased the recognition and treatment of late life depression by primary care physicians. However, we were unable to demonstrate significant improvement in depression or disability severity among intervention patients despite the informational support provided to their physicians. Efforts to improve the functional status of these patients may require more integrated interventions and more aggressive attempts to target psychosocial stressors traditionally outside the purview of primary care.
Indicators of Quality Medical Care for the Terminally Ill in Nursing Homes
Authors: Keay Timothy J. , Fredman Lisa , Taler George A. , Datta Soma , Levenson Steven A.
Published: April 2015

PURPOSE: To identify medical care indicators for nursing home terminal care.

DATA SOURCES: Studies examining care of terminally ill patients were identified using computer, bibliography, and expert searches; input from nursing home medical directors in Maryland; and input from expert geriatricians.

STUDY SELECTION: More than 900 articles, books, and abstracts from meetings covering medical care for terminally ill patients were reviewed. Information from more than 100 publications is included.

DATA EXTRACTION: Indicators of medical care for terminally ill patients, which can be used to quantify performance with respect to standards, guidelines, and options, were identified initially through review of the literature.

DATA SYNTHESIS: Indicators were refined by input from medical directors of Maryland long‐term care facilities and subsequent review by expert geriatricians.

CONCLUSIONS: Minimum standards for which 100% performance is expected are communication of advance directives, attention to pain control, and attention to relief of dyspnea. Performance indicators for medical care guidelines and options in terminal care of nursing home patients are also described.
Estrogen Replacement Therapy and Memory in Older Women
Authors: Robinson David , Friedman Leah , Marcus Robert , Tinklenberg Jared , Yesavage Jerome
Published: April 2015

OBJECTIVE: To study the relationship between estrogen hormone replacement therapy and recall of proper names and words in cognitively intact older women.

DESIGN: A case‐control study using subjects matched on age and education.

PARTICIPANTS: From a group of 278 older (age range 55 to 93 years) community‐dwelling women volunteers for memory research, 72 older women taking estrogen replacement therapy were matched on age and education with a group of 72 women not taking estrogen.

MEASUREMENTS: Dependent measures were performances on: a proper name recall test and a word recall test.

RESULTS: Proper name recall was significantly better in those receiving estrogen (mean = 4.3; SD = 3.3) than in those not receiving estrogen (mean = 3.1; SD = 2.5), P = 0.01. There was also significantly greater variance in the name recall scores of the group taking estrogen than in the group not taking estrogen. For word recall, there was no significant difference between those subjects taking estrogen (mean = 6.4; SD 3.8) and those not taking estrogen (mean = 5.8; SD 3.7), P > 0.10.

CONCLUSIONS: Estrogen use was associated with enhanced recall of proper names. Previous failures to find differences associated with estrogen use may reflect the memory measures used or an increased inter‐individual variability of the estrogen‐taking group, as was observed in the present study. Interpretation of these results should be tempered by their retrospective nature.
Postprandial Hypotension in 499 Elderly Persons in a Long‐Term Health Care Facility
Authors: Aronow Wilbert S. , Ahn Chul
Published: April 2015

OBJECTIVE: To present baseline data from a prospective study of postprandial hypotension in 499 elderly persons in a long‐term health care facility.

DESIGN: Analyses of baseline data for a prospective study.

SETTING: A large long‐term health care facility where 499 ambulatory or wheelchair‐bound residents were studied.

PATIENTS: The 499 residents were ≥ 62 years of age, mean age 80 ± 9 years (range 62–100), 71% female, 29% male, 66% white, 27% black, 7% Hispanic, 68% ambulatory, and 32% wheelchair‐bound.

MEASUREMENTS AND MAIN RESULTS: The mean maximal decrease in postprandial systolic and diastolic blood pressures was 15 ± 6 mm Hg/6 ± 2 mm Hg. The mean maximal decrease in postprandial systolic blood pressure occurred 15 minutes after eating in 13% of residents, 30 minutes after eating in 20% of residents, 45 minutes after eating in 26% of residents, 60 minutes after eating in 30% of residents, and 75 minutes after eating in 11% of residents. Of 499 residents, 118 (24%) had a maximal decrease in postprandial systolic blood pressure of ≥20 mm Hg. The mean maximal decrease in postprandial systolic blood pressure was 24 ± 5 mm Hg in residents with syncope in the prior 6 months and 14 ± 5 mm Hg in residents without syncope (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was 21 ± 5 mm Hg in residents with falls in the preceding 6 months and 13 ± 4 mm Hg in residents without falls (P < 0.0001). The mean maximal decrease in postprandial systolic blood pressure was significantly greater in residents treated with angiotensin‐converting enzyme inhibitors, calcium channel blockers, diuretics, nitrates, digoxin, and psychotropic drugs than in residents not treated with these drugs. The mean maximal decrease in postprandial systolic and diastolic blood pressures was not significantly different in elderly blacks, Hispanics, and whites.

CONCLUSIONS: A more severe reduction in postprandial systolic blood pressure correlates with a history of syncope or falls in the previous 6 months. Long‐term follow‐up is being planned to determine whether a marked reduction in postprandial systolic blood pressure in elderly persons correlates with a higher incidence of falls, syncope, new coronary events, new stroke, and total mortality.
Effects of Resistive and Balance Exercises on Isokinetic Strength in Older Persons
Authors: Judge James O. , Whipple Robert H. , Wolfson Leslie I.
Published: April 2015

OBJECTIVE: To determine the safety and efficacy of 3 months of resistive training of multiple lower extremity muscle groups compared with balance training in persons over 75 years.

DESIGN: Randomized 3‐month clinical trial. Subjects (n = 110, mean age 80) were randomized to 4 groups in a 2 × 2 design (control, resistive, balance, combined resistive/balance).

INTERVENTIONS: Resistive training involved knee extension and flexion, hip abduction and extension, and plantar and dorsiflexion using simple resistive machines and sandbags. Balance training consisted of exercises to improve postural control. The control group attended 5 health‐related discussion sessions.

MEASUREMENTS: Summed isokinetic moments (N m) of 8 leg movements: hip, knee and ankle flexion/extension, and hip abduction/adduction. Secondary outcomes were gait velocity and chair rise time.

MAIN RESULTS: Summed peak moment increased in both resistive exercise‐trained groups (13% increase in the resistive group and 21% in the combined training group, P < 0.001). The effect of resistance training was significant (MANOVA F = 21.1, P < 0.001), but balance training did not improve strength, and there was no interaction (positive or negative) between balance and resistive training. Maximal gait velocity and chair rise time did not improve. Eleven subjects (20%) had musculoskeletal complaints related to resistive training, but all were able to complete the program with modifications.

CONCLUSION: Resistive training using simple equipment is an effective and acceptable method to increase overall leg strength in older persons. Resistive or balance training did not improve maximal gait velocity or chair rise time in this sample of relatively healthy older persons.
Dehydration and Death During Febrile Episodes in the Nursing Home
Authors: Weinberg Andrew D. , Pals Jean K. , Levesque Paul G. , Beal Lorraine F. , Cunningham Thomas J. , Minaker Kenneth L.
Published: April 2015

OBJECTIVE: To determine the incidence of early hypernatremic dehydration among residents of a nursing home care unit (NHCU) presenting with significant febrile episodes (FE).

DESIGN: Prospective cohort analytic study. FE were defined as temperature (T) > 100°F oral (o) or 101°F rectal (r) for ≥ 24 hours.

SETTING: NHCU in a Veterans Administration hospital.

PATIENTS: A total of 130 residents of the NHCU were monitored for FE during a 4‐month study period.

MAIN OUTCOME MEASURES: Blood urea nitrogen (BUN)/creatinine (Cr) (abnormal ≥ 25) and serum sodium (Na)(abnormal ≥ 146 mmol/L) were drawn within 24–48 hours of the onset of all FE; documentation of impaired oral intake (OI) by staff; necessity of transfer to acute medical wards and mortality were recorded.

RESULTS: There were 48 FE among 42 residents (39 M, 3 F; mean age 75 ± 11.3). Maximum recorded T during the FE ranged from 100.1°F–102.2°F o and 101.2°F‐105.3°F r. Laboratory values were available for 40/48 FE. Twenty‐three percent (9/40) had elevated BUN/Cr ratios, 25% (10/40) had elevated serum Na, and 12.5% (5/40) had both. In patients noted to have impaired OI (n = 11) as documented by staff, increased serum Na or BUN/Cr ratio was observed in 82% (9/11). A random control group of 37 nonacutely ill, nonfebrile NHCU residents (33 M, 4 F; mean age 75 ± 10.1) having routine annual laboratory tests revealed only 1 resident (age 95) with an elevated Na of 146 and BUN/Cr ratio of 26 and 1 resident with an increased BUN/Cr ratio of 28. None of the controls had any staff documentation of impaired OI. Of the 5 deaths in the febrile group with laboratory data (total deaths = 6; 14%), 100% had either elevated serum Na and/or elevated BUN/Cr ratios, and 80% (4/5) had both. Comparing the febrile group with controls, BUN/Cr ratios were found to be significantly elevated in the febrile group (P < 0.05). Serum sodium values were also significantly elevated in the febrile group (P < 0.01).

CONCLUSIONS: Staff documentation of impaired OI was highly associated with either elevated serum Na or increased BUN/Cr ratios. These data show that many older NHCU patients with significant fevers often have early impaired OI and laboratory evidence of dehydration. These data indicate that staff should institute appropriate monitoring for dehydration at the time of earliest detection of fever in this population.
Safety Assessment for the Frail Elderly: A Comparison of Restrained and Unrestrained Nursing Home Residents
Authors: Schnelle John F. , Rae Priscilla G. Mac , Simmons Sandra F. , Uman Gwen , Ouslander Joseph G. , Rosenquist Lori L. , Chang Betty
Published: April 2015

Objective: To facilitate clinicians judgment concerning physical restraint decisions by identifying potentially reversible injury risk factors that differentiate representative samples of restrained and unrestrained nursing home residents.

Design: Comparison of restrained and unrestrained nursing home residents on a safety assessment for the frail elderly (SAFE) protocol.

Setting: Long‐term care facilities in the Greater Los Angeles Area.

Participants: One hundred eight physically restrained and 111 unrestrained nursing home residents.

Intervention: None.

Main Outcome Measures: (1) Internal, Interrater, and test/retest reliability of the overall SAFE protocol and of the four major factors measured by SAFE; (2) The relationship of SAFE scores to expert judgment of resident injury risk; (3) Differences between large samples of restrained and unrestrained residents on specific SAFE score factors.

Results: Two walking, one transition, and one judgment factor are reliably measured by the SAFE protocol. SAFE scores were significantly correlated with expert judgment of risk for injury and showed large differences between restrained and unrestrained residents, even after differences in ambulation ability between the two groups were accounted for.

Conclusion: The SAFE is a reliable protocol that measures behavioral factors related to falls and risk for injury among nursing home residents with a broad range of cognitive impairment. Factors that significantly differentiate restrained and unrestrained groups should be targeted for rehabilitation and remediation in physical restraint reduction efforts. Removing or changing restraints for the large sample (50%) of restrained residents who were not ambulatory will not significantly increase their mobility, since the majority of this group could not independently propel their wheelchairs. Increased mobility for the large group of both restrained and unrestrained residents will likely be realized only if restraint reduction programs are combined with interventions to improve both mobility and the specific behavioral performance factors measured by SAFE.
Mortality Differences Between Elderly Mexican Americans and Non‐Hispanic Whites in San Antonio, Texas
Authors: Espino David V. , Parra Ernesto O. , Kriehbiel Rod
Published: April 2015

Objective: To identify differences in causes of death between elderly Mexican Americans (MA) and non‐Hispanic whites (NHW).

Design: Retrospective death certificate review.

Subjects: Elderly Mexican Americans and non‐Hispanic Whites age 65 and over who died in Bexar County, Texas during 1989.

Measures: Data obtained from chart review included age, sex, race/ethnicity, and cause of death. Age‐adjusted and cause‐specific mortality rates, odds ratios (OR), and 95% confidence intervals (CI) were calculated.

Results: Mexican Americans were at greater risk of dying in nine of the thirty causes of death examined. The mortality rates of MA subjects were higher than those of NHW from death caused by diabetes (OR = 3.19, CI = 2.27–4.49), renal failure (OR = 2.06, CI = 1.44–2.94), congestive heart failure (OR = 1.50, CI = 1.44–2.94), and multiple systemic diseases (OR = 2.59, CI = 1.89–3.57). Among the male subjects, MA had a greater risk than NHW of dying from myocardial infarction (OR = 1.83, CI = 1.15–2.90), coronary disease (OR = 1.37, CI = 1.07–1.75) and septicemia/pyuria (OR = 2.12, CI = 1.09–4.10). Among female subjects, MA had a greater likelihood of dying from cirrhosis (OR = 3.03, CI = 1.00–9.29). For only one of the causes of death was the risk lower among MA than NHW: MA female subjects had a lesser chance of dying from the chronic obstructive pulmonary disease (COPD) than NHW females (OR = 0.36, CI = 0.18–0.72).

Conclusion: Mexican American elders have a greater risk of dying from non‐insulin dependent diabetes mellitus and renal failure than their NHW counterparts. Elderly MA men have a greater risk of dying from cardiovascular disease than their NHW counterparts. Mexican American women may have a greater risk of dying from cirrhosis, but a lower risk of dying from complications of COPD. Finally, death from ill defined causes, such as multiple systemic diseases, may be a major under‐acknowledged cause of death among older MA.
Pyrazolopyridine Derivative Acts as a Novel Cyclooxygenase Inhibitor: Antiplatelet Effect in Aged Patients with Ischemic Stroke
Authors: Satoh Kei , Yoshida Hidemi , Imaizumi Tada‐atsu , Koyama Masayuki , Hiramoto Makoto , Takamatsu Shigeru
Published: April 2015

Objective: To examine the antiplatelet effect of a novel pyrazolopyridine derivative (KC‐764) in geriatric patients with ischemic stroke.

Design: Randomized clinical trial of three graded dose levels.

Setting: A geriatric clinic attached to a nursing home.

Patients: Fifteen patients with a history of cerebral infarction with a mean age of 75±5 years (range, 65–83). Patients were divided into three groups and administered 10, 20, or 40 mg/day KC‐764 for 8 weeks.

Measurements: Platelet aggregation induced by arachidonate, ADP, collagen and platelet‐activating factor. Plasma or serum levels of thromboxane B2 and 6‐ketoprostaglandin F1α.

Main Results: Platelet aggregation was inhibited by KC‐764 administration and returned to the control level after discontinuation. Although plasma thromboxane B2 levels were markedly decreased, plasma 6‐ketoprostaglandin F1α was not affected. However, the dose of 10 mg/day was not sufficient to maintain an effective plasma level of KC‐764. There were no side effects or changes in laboratory findings.

Conclusions: We confirmed that KC‐764 at a dose of 20 to 40 mg/day is an effective antiplatelet agent and a good candidate for a trial to see if it is feasible for long‐term use for the prevention of ischemic stroke in high‐risk patients.
The Pace Pilot Study: 12‐Month Results and Implications for Future Primary Prevention Trials in the Elderly
Authors: Silagy Christopher A , McNeil John J , Donnan Geoffrey A , Tonkin Andrew M , Worsam Bernard , Campion Katrina
Published: April 2015

Objective: To document compliance with medication, dropout and drop‐in rates, and baseline cardiovascular event rates during the pilot phase of the PACE (Prevention with low‐dose Aspirin of Cardiovascular disease in the Elderly) study.

Design: Randomized, double‐blind, placebo‐controlled trial of low‐dose aspirin therapy.

Setting: Community‐based, in general practices and residential retirement villages, in Victoria, Australia.

Subjects: Four hundred persons aged 70 years and older (53% females), ambulatory and living independently, who volunteered to participate. None had significant vascular disease, peptic ulceration, hemorrhagic symptoms, or were currently taking non‐steroidal anti‐inflammatory drugs.

Main Outcome Measures: Compliance with medication (assessed by pill count and platelet function tests), self‐reported drop‐out and drop‐in rates, and incidence of cardiovascular events reported by participants and their general practitioners during a 12‐month period.

Results: Two fatal cardiovascular events, three non‐fatal coronary events, and eight non‐fatal cerebrovascular events were observed during the 12‐month period. These incidence figures were approximately 15%, 15%, and 40%, respectively, of those in the general population of the same age and sex, based on morbidity data available from the Australian Bureau of Statistics. Compliance to medication was excellent (87%), and premature withdrawal (other than for a study end point) was limited to 14.5%. Secondary ‘softer’ endpoints, such as transient ischaemic attack and unstable angina, necessitated patient withdrawal from randomized therapy and possibly contributed to the small number of primary ‘hard’ end points observed. The projected power of the main study to detect a 20% treatment effect on overall cardiovascular mortality in 15,000 subjects over a 4‐year period may, therefore, be substantially reduced.

Conclusions: These results suggest that any future primary prevention study of cardiovascular disease in the elderly examining the effect of low‐dose aspirin on overall cardiovascular mortality will likely need to use much larger numbers of patients or use a combined end point of fatal and non‐fatal ischemic events.
Long‐Term Care Facility Policies on Life‐Sustaining Treatments and Advance Directives in Canada
Authors: Choudhry Niteesh K. , Ma Joseph , Rasooly Iris , Singer Peter A.
Published: April 2015

OBJECTIVE: To describe the prevalence and content of long‐term care facility policies regarding the use of life‐sustaining treatments (cardiopulmonary resuscitation (CPR), artificial hydration and nutrition, dialysis, antibiotics for life‐threatening infections, transfer to acute care hospital) and advance directives in Canada.

DESIGN: Cross‐sectional mailed survey.

SETTING: Canadian long‐term care facilities with 25 beds or more listed in the 1991–92 Directory of Long Term Care Centres in Canada. Institutions listed as, “general hospitals,” “psychiatric hospitals,” “children's treatment centres,” “group homes,” or as purely residential facilities were excluded.

PARTICIPANTS: Chief Executive Officers or their designates.

MAIN OUTCOME MEASURES: Respondents' self‐reports regarding the existence of life‐sustaining treatment or advance directive policies and content analysis of the policies themselves.

RESULTS: Of 1472 long‐term care facilities, 1021 (69%) responded. Of these, 344 (34%) institutions had 397 policies regarding the use of life‐sustaining treatments or advance directives. Three hundred twenty facilities (31%) had 349 do‐not‐resuscitate (DNR) policies (40% on CPR alone and 60% on CPR plus other life‐sustaining treatments). Seventeen institutions (2%) each had one policy addressing life‐sustaining treatments other than CPR, and 31 institutions (3%) each had one policy addressing advance directives. Of the 397 policies, 171 (43%) required routine discussion with all patients, 156 (39%) mentioned futility, 331 (83%) indicated that the competent patient had the right to make a decision about life‐sustaining treatment, 265 (67%) indicated that the family of the incompetent patient had this right, 27 policies (7%) mentioned conflict resolution, 378 (95%) had an explicit requirement for recording the decision, 10 (3%) required explicit communication of the decision to the competent patient, 10 (3%) required such communication to the family of the incompetent patient, 260 (66%) required updating of the decision, and 213 (54%) mentioned rescinding or changing the decision.

CONCLUSIONS: Only one‐third of Canadian long‐term care facilities have do‐not‐resuscitate policies, and even fewer have policies on advance directives or life‐sustaining treatments other than CPR. The policies themselves could be improved by encouraging routine advance discussions, scrutinizing the use of the futility standard, stipulating procedures for conflict resolution, and explicitly requiring communication of the decision to competent patients or substitute decision makers of incompetent patients.
A Nutritional Index Predicting Mortality in the Nursing Home
Authors: Frisoni Giovanni B. , Franzoni Simone , Rozzini Renzo , Ferrucci Luigi , Boffelli Stefano , Trablucchi Marco
Published: April 2015

OBJECTIVE: To define a sensitive and specific index, based on nutritional indicators, predicting mortality in nursing home patients.

DESIGN: A prospective cohort study.

SETTING: A nursing home.

MEASUREMENTS: Anthropometric and laboratory nutritional indicators were assessed in 104 nursing home elderly residents (20 males, 84 females). Patients were aged 60 years and older and had relatively good somatic health and nutritional status. Mortality data were collected over an 18‐month follow‐up period. Discriminant analysis was used to compute an adimensional measure (index) that could predict mortality with the highest sensitivity and specificity.

RESULTS: Mortality was 0.20/year. A nonlinear, “U‐shaped” relationship of cholesterol levels with mortality was found. A prognostic index based on cholesterol, lymphocyte count, mid‐arm circumference, hemoglobin, age, and gender was obtained. Higher values of this index were associated with progressively higher risks at 12 months and 18 months. Sensitivity and specificity calculated on 18‐month mortality were 80% and 78.4%, respectively.

CONCLUSIONS: This index, based on simple measures, can be a useful tool in the evaluation of health status of the elderly living in nursing homes.