bluuebunny/crossref_metadata_2025_split huggingface dataset:
The Doctor's Role in Discussing Advance Preferences for End‐of‐Life Care: Perceptions of Physicians Practicing in the VA
Authors: Markson Lawrence , Clark Jack , Glantz Leonard , Lamberton Victoria , Kern Donald , Stollerman Gene 
Published: April 2015

OBJECTIVES: Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision‐making. This study investigates (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision‐making process.DESIGN: Mail survey conducted in 1993.SETTING: The Department of Veterans Affairs.PARTICIPANTS: A national probability sample of 1050 VA internists, family physicians, and generalists.MEASUREMENTS AND MAIN RESULTS: Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preferences with at least one patient, and 19% had talked to more than 25. Seventy‐three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision‐making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings.Eighty‐two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs (14%).CONCLUSIONS: Physicians report that they are actively involved with their patients in making decisions about end‐of‐life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.
Managing Geriatric Syndromes: What Geriatric Assessment Teams Recommend, What Primary Care Physicians Implement, What Patients Adhere To
Authors: Shah P. Nina , Maly Rose C. , Frank Janet C. , Hirsch Susan H. , Reuben David B. 
Published: April 2015

OBJECTIVES: To evaluate the responses of primary care physicians and patients to recommendations from a commmunity‐based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment.DESIGN: Case series.SETTING: Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community‐based academic practice as the location for CGA.PARTICIPANTS: A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA
MEASUREMENTS: Physician implementation and patient adherence rates were ascertained during a face‐to‐face structured interview with the patient 3 months after CGA.RESULTS: Two hundred twelve of 528 (40%) CGA recommendations were clearly or possibly related to the target or target‐related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self‐care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician‐implemented recommendations and 46% for self‐care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low.CONCLUSIONS: When examining the process of care of community‐based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician‐initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self‐care recommendations.
The Relationship Between Endothelin‐1, Event‐Related P300 Potentials, and Prognosis in Cerebral Arteriosclerosis
Authors: Kügler Christian F.A. , Funk H. , Vlajic P. , Platt D. 
Published: April 2015

OBJECTIVES: To search for a potential role of endothelin‐1 (ET‐1), a potent vasoconstrictor and presumably neurotoxic 21‐amino acid peptide, for dysfunction of brain signal processing and cerebrovascular morbidity in nondemented patients with cerebral arteriosclerosis.DESIGN: Cross‐sectional study with longitudinal follow‐up.SETTING: University‐affiliated teaching hospital.PARTICIPANTS: A total of 106 nondemented patients with significant stenosis of either the internal carotid (cAD, cases; n = 63, mean age ± SD, 62 ± 7 years) or peripheral arteries (pAD, disease controls; n = 43, 60 ± 11 years) were investigated before carotid endarterectomy and bypass surgery, respectively. After a mean follow‐up of about 19 months, cerebrovascular morbidity of the cAD and pAD patients was evaluated by phone.MEASUREMENTS: Brain signal processing functions by event‐related visual P300 potentials; cerebrovascular events by a structured telephone interview; the extent of arteriosclerosis by venous ET‐1 concentration.RESULTS: Venous ET‐1 levels were elevated in both cAD and pAD patient groups, but to the same degree. In these patients, ET‐1 concentration was correlated slightly with diastolic blood pressure (r = .334, P = .0326, stepwise regression). Only in cAD patients with ET‐1 levels above the 75th percentile were P300 latencies markedly prolonged compared with their lower ET‐1 level counterparts. Furthermore, the P300 latencies of the cAD patients, but not of the pAD patients, correlated positively with venous ET‐1 concentration and inversely with pack years of smoking (r = .728, P = .0002; stepwise regression). In contrast to base‐line P300 abnormalities and classical risk factors (e.g., hypertension), high ET‐1 levels predicted an increased cerebrovascular morbidity of cAD, but not of pAD, patients (P = .0044; Mantel‐Cox test).CONCLUSIONS: In nondemented patients with cerebral arteriosclerosis, endothelin‐1 is associated with P300 abnormalities reflecting subclinical dysfunction of brain signal processing. In the long‐term, high venous ET‐1 levels also appear to predict a higher cerebrovascular morbidity of cAD patients even after carotid endarterectomy.
A Predictive Model for ADL Dependence in Community‐Living Older Adults Based on a Reduced Set of Cognitive Status Items
Authors: Gill Thomas M. , Williams Christianna S. , PhD Emily D. Richardson , Berkman Lisa F. , Tinetti Mary E. 
Published: April 2015

OBJECTIVE: To develop and validate a simple tool, based on a reduced set of Mini‐Mental State Examination (MMSE) items, that can be used to predict the onset of ADL dependence, and to compare the predictive accuracy of this new tool with that of the MMSE.DESIGN: Two prospective, population‐based cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort.SETTING: General community in New Haven, Connecticut.PARTICIPANTS: For the development cohort, 775 community‐living persons, 72 years of age and older, who were independent at baseline in their ADL function. For the validation cohort, 1038 comparable subjects.MEASUREMENTS: All subjects underwent a baseline interview and cognitive assessment in their homes by a trained research nurse using standard instruments. Self‐reported ADLs were ascertained at 1 year and 3 years for the development cohort and at 1 year and 2 1/2 years for the validation cohort.RESULTS: ADL dependence developed in 221 (28.5%) subjects in the development cohort. Although the rate of ADL dependence increased within each MMSE domain as the number of incorrect items increased, only orientation and short‐term memory remained significantly associated with ADL dependence in multivariable analysis. A predictive model, based on the presence of impairments in these two domains, was developed that stratified subjects into three risk groups. Rates of ADL dependence were 22% (neither domain impaired), 44% (one domain impaired), and 68% (both domains impaired) (P < .001). The corresponding rates in the validation cohort, in which 191 (18.4%) subjects developed ADL dependence, were 15%, 26%, and 45% (P < .001). The area under the ROC curves for the MMSE and the reduced item strategy were nearly identical at 0.63 and 0.62, respectively.CONCLUSIONS: A simple and valid six‐item strategy, based on the presence of impairments in orientation and short‐term memory, predicts the onset of ADL dependence as effectively as does the 30‐item MMSE. This new tool may be useful as part of a more comprehensive assessment when determining an older person's risk for developing ADL dependence.
Do Advance Directives Provide Instructions That Direct Care?
Authors: Teno Joan M , Licks Sandra , Lynn Joanne , Wenger Neil , Connors Alfred F. , Phillips Russell S. , O'Connor Mary Ann , Murphy Donald P. , Fulkerson William J. , Desbiens Norman , Knaus William A. 
Published: April 2015

OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision‐making in SUPPORT might arise, in part, from the content of the actual documents.DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life‐sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives.SETTINGS: Five teaching hospitals in the United States.PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self‐Determination Act. Patients were part of a randomized controlled trial to improve decision‐making and outcomes.RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life‐sustaining medical treatment, and only 22 of these directed forgoing life‐sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff.CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision‐making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.
The Process of Care in Preventive In‐Home Comprehensive Geriatric Assessment
Authors: Alessi Cathy A. , Stuck Andreas E. , Aronow Harriet U. , Yuhas Karen E. , Bula Christophe J. , Madison Rodger , Gold Marcia , Segal‐Gidan Freddi , Fanello Roslyn , Rubenstein Laurence Z. , Beck John C. 
Published: April 2015

OBJECTIVES: To describe the process of care of a program of in‐home comprehensive geriatric assessment (CGA) and to determine: (1) if there are major findings in all domains of CGA (medical, functional, mental health, and social/ environmental), (2) if there is a continued clinical yield when CGA is repeated annually, and (3) factors that affect patient adherence with recommendations from CGA.DESIGN: Descriptive prospective study of subjects allocated to the intervention group of a 3‐year randomized trial of preventive in‐home CGA.SETTING: Homes of participants living in an urban setting.PARTICIPANTS: Persons aged 75 years or older and living at home who received the intervention (N = 202 subjects, mean age 80.8 years, 70% female, 95% white, 64% living alone).INTERVENTION: Annual in‐home CGA and quarterly home visits by gerontologic nurse practitioners for 3 years.MEASUREMENTS: Detailed data were collected prospectively on clinical problems detected by CGA, and specific recommendations were made for these problems using an instrument developed explicitly for this project to study the CGA process. Subject adherence with these recommendations was also recorded.RESULTS: Major problems were identified in all domains of CGA; the most common problems were medical. In the first year, 76.7% of subjects had at least one major problem identified that was either previously unknown or suboptimally treated. One‐third of subjects had additional major problems identified during the second and third years. A constant number of therapeutic and preventive recommendations was made each year (11.5 per subject annually). Subject adherence varied by type of recommendation (ANOVA, F = 108.4, P <.001); adherence was better for referrals to a physician than for referrals to a non‐physician professional or community service or for recommendations involving self‐care activities (Scheffe's test, P < .001).CONCLUSION: In these community‐dwelling older people, there was a continued yield of problems identified and recommendations made when CGA was repeated annually for 3 years, supporting the practice of repeat CGA in older people in the community. Subject adherence with recommendations from CGA varied by type of recommendation, but further work is needed to determine additional factors that affect this adherence and to determine the association between the yield of CGA (i.e., problems identified, recommendations given and adherence with these recommendations) and important clinical outcomes.
Prospective Evaluation of Clinical Criteria to Select Older Persons with Acute Medical Illness for Care in a Hypothetical Home Hospital
Authors: Leff Bruce , Burton Lynda , Bynum Julie Walter , Harper Michael , Greenough William B. , Steinwachs Donald , Burton John R. 
Published: April 2015

OBJECTIVE: To evaluate criteria to select older persons who need hospitalization for common acute medical illnesses for care in a hypothetical home hospital.DESIGN: Prospective record review.SETTING AND PARTICIPANTS: Patients aged 65 and older admitted to the general medical service of a community‐ based university hospital.MEASUREMENTS: We developed illness‐specific selection criteria to identify older persons with certain acute medical conditions for treatment in a hypothetical home hospital. The selection criteria were reviewed prospectively against all community‐dwelling older patients admitted to the general medical service of a community‐based university hospital over a 4‐month period. We determined eligibility for home hospital admission based on information available at the time of admission and then tracked the patient's hospital course.RESULTS: One hundred fifty‐seven admissions of 143 patients were reviewed. The selection criteria identified 33% of patients admitted to the acute hospital with one of the three target diagnoses as eligible for a home hospital model of care had it been available. Eligible patients experienced shorter lengths of stay (3.7 vs 5.4 days, P =.012), fewer mean number of procedures performed (0.98 vs 1.70, P =.001), fewer mean number of complications (0.17 vs 0.56, P = .010), and fewer events that could be handled only in the acute hospital setting (P =.036). In addition, in logistic regression analysis, three criteria for home hospital ineligibility, pulmonary congestion associated with ischemic chest pain (odds ratio 6.85, 95% CI 2.64, 17.81), the presence of an acute coexisting illness requiring hospitalization independent of the target conditions (odds ratio 2.66, 95% CI 1.11, 6.41), and significant pulmonary congestion after initial treatment (odds ratio 14.4, 95% CI 1.77, 117.41) were significantly associated with items difficult to accomplish at home.CONCLUSIONS: Criteria can be delineated that identify older persons with acute medical illnesses who may be suitable for treatment in a home hospital.
Moderate Wine Consumption Is Associated with Decreased Odds of Developing Age‐Related Macular Degeneration in NHANES‐1
Authors: Obisesan Thomas O. , Hirsch Robert , Kosoko Omofolasade , Carlson Letitia , Parrott Marian 
Published: April 2015

OBJECTIVE: To determine the association between alcohol intake and the risk of developing age‐related macular degeneration (AMD).DESIGN: Case control study.PARTICIPANTS: The sample consisted of 3072 adults 45 to 74 years of age with macular changes indicative of AMD who participated in a nationally representative sample of the first National Health Nutrition and Examination Survey (NHANES‐1) between 1971 and 1975: (a) the ophthalmology data set and (b) the medical history questionnaire.MAIN OUTCOME MEASURES: Alcohol intake and the risk of developing AMD were measured. AMD was determined by staff at the National Eye Institute by fundoscopy examination using standardized protocol.RESULTS: Overall, 184 individuals (6%) had AMD. We observed a statistically significant but negative association between AMD and the type of alcohol consumed in a bivariate model (OR 0.86; 95% CI 0.73, 0.99). In the same model, age maintained a consistently strong association with AMD (OR 1.08; 95% CI 1.06–1.11; P < .001). Among the different types of alcohol consumed in NHANES‐1 (beer, wine, and liquor), the effect of wine, either alone (OR 0.66; 95% CI 0.55–0.79) or in combination with beer (OR 0.66; 95% CI 0.55–0.79) or liquor (OR 0.74; 95% CI 0.63–0.86), dominated the negative association observed between AMD and alcohol type. Additionally, a statistically significant and negative association between wine and AMD was noted after adjusting for the effect of age, gender, income, history of congestive heart failure, and hypertension (OR 0.81; 95% CI 0.67–0.99).CONCLUSION: Moderate wine consumption is associated with decreased odds of developing AMD. Health promotion and disease prevention activities directed at cardiovascular disease may help reduce the rate of AMD‐associated blindness among older people. The nature and pathophysiology of this association warrant further investigation.
The Effect of Zinc and Vitamin A Supplementation on Immune Response in an Older Population
Authors: Fortes Cristina , Forastiere Francesco , Agabiti Nerina , Fano Valeria , Pacifici Roberta , Virgili Fabio , Piras Giovanna , Guidi Luisa , Bartoloni Carlo , Tricerri Augusto , Zuccaro Piergiorgio , Ebrahim Shah , MD Carlo A. Perucci 
Published: April 2015

OBJECTIVE: To determine if either supplemental vitamin A, zinc, or both increases cell‐mediated immune response in an older population.DESIGN: A double‐blind, randomized, controlled trial of supplementation with vitamin A and zinc.SETTING: Casa Di Riposo Roma III, a public home for older people in Rome, Italy.SUBJECTS: The health and nutritional status of 178 residents were evaluated. One hundred thirty‐six residents agreed to participate in the trial and were randomized into four treatment groups, and 118 of these residents completed the trial.INTERVENTION: The four treatments consisted of: (1) Vitamin A (800 μg retinol palmitate); (2) Zinc (25 mg as zinc sulfate); (3) Vitamin A and Zinc (800 μg retinol palmitate and 25 mg as zinc sulfate); (4) Placebo capsules containing starch.MAIN OUTCOME MEASUREMENTS: Immune tests – counts of leucocytes, lymphocytes, T‐cell subsets, and lymphocyte proliferative response to mitogens – were measured before and after supplementation.RESULTS: Zinc increased the number of CD4+DR+ T‐cells (P = .016) and cytotoxic T‐lymphocytes (P = .005). Subjects treated with vitamin A experienced a reduction in the number of CD3+ T‐cells (P = .012) and CD4+ T‐cells (P = .012).CONCLUSIONS: These data indicate that zinc supplementation improved cell‐mediated immune response, whereas vitamin A had a deleterious effect in this older population. Further research is needed to clarify the clinical significance of these findings.
Major Depression in a Population of Demented and Nondemented Older People: Prevalence and Correlates
Authors: Forsell Yvonne , Winblad Bengt 
Published: April 2015

OBJECTIVE: To analyze the differences between variables associated with depression and symptoms of depression in demented and nondemented persons.DESIGN: A survey design was used.SETTING/PARTICIPANTS: A total of 1101 older persons registered in a district of Stockholm, Sweden, participated in the study.MEASUREMENTS: Subjects were given physical and psychiatric examinations by physicians, and informants interviews and medical records were assessed. Dementia was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM‐III‐R) criteria and major depression according to DSM‐IV. The variables studied were age, gender, marital status, institutionalization, Mini‐Mental State Exam score, disability in daily life, physical disorders with symptoms affecting daily life, and a previous history of depression (early and late).RESULTS: 27.8% of the patients in the study sample were demented according to DSM‐III‐R. Major depression was diagnosed in 3.9% of the nondemented and in 11.8% of the demented subjects. Some of the depressive symptoms, such as lack of energy, thinking/concentration difficulties, loss of interest, and psychomotor disturbance, were found more commonly in demented than in nondemented persons. Increased disability was associated with major depression both in demented and nondemented persons.CONCLUSION: In this study, the prevalence of depression was higher in demented than in nondemented persons. Among the factors that were studied, increased disability was associated with depression both in demented and nondemented persons. No differences were found regarding the other studied variables.
Balance and Gait Performance in an Urban and a Rural Population
Authors: Ringsberg Karin A. M. , Gärdsell Per , Johnell Olof , Jónsson Brynjolfur , Obrant Karl J. , Sernbo Ingemar 
Published: April 2015

OBJECTIVE: To compare the differences in standing balance and gait performance between two populations, correlated with age and physical activities of daily living.DESIGN: A cross‐sectional study.SETTINGS: Malmö, the third largest city in Sweden, and Sjöbo, a typical agricultural community 60 km east of Malmö.PARTICIPANTS: Participants were 570 men and women from the urban community (urban) and 391 from the rural community (rural), born in 1938, 1928, 1918, and 1908, and women born in 1948. The two cohorts were subdivided into true urbans, who had lived only in the city (n = 269), and true rurals, who had never lived in a city (n = 354).MEASUREMENTS: Information about workload, housing, spare time activities, medication, and illness during different decades of life was gathered using two questionnaires. The first questionnaire was sent to the home after agreement to participate, and the second was presented at the test session. The clinical measurements were standing balance, gait speed, and step length.RESULTS: The urban subjects had significantly (P <.001) impaired balance compared with rural subjects. This difference increased with increasing age. The urban subjects walked faster than the rural subjects (P <.001), and the urban subjects used fewer steps than their rural counterparts (P <.001). Spare time activities had a significant influence on the above tests, but, except for gait velocity (P =.011), workload was of minor importance according to analysis of covariance.CONCLUSION: Background factors such as usual daily activities of living and lifestyle seem to be of importance when evaluating and comparing different populations with respect to their balance and gait performance.