bluuebunny/crossref_metadata_2025_split huggingface dataset:
Emergency Triage to Intensive Care: Can We Use Prognosis and Patient Preferences?
Authors: Hanson Laura C. , Danis Marion , Lazorick Suzanne 
Published: April 2015

OBJECTIVE: To identify predictors of 6‐month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions.DESIGN: Historical cohortSETTING: A 600‐bed university hospitalPATIENTS: 263 consecutive patients triaged in the emergency room to receive intensive careMEASUREMENTS AND MAIN RESULTS: Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6‐month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described.Six‐month mortality was 19 percent, and increased with increasing APS, age ≤ 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P ≤ 0.01). In multivariate analysis, APS, age ≤ 80 and performance status were independent predictors of 6‐month mortality. Only APS predicted mortality in hospital.The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%).CONCLUSIONS: Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.
Long‐Term Urethral Catheterization Increases Risk of Chronic Pyelonephritis and Renal Inflammation
Authors: Warren John W. , Muncie Herbert L. , Hebel J. Richard , Hall‐Craggs Mary 
Published: April 2015

OBJECTIVE: To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors.DESIGN: Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy.SETTING: A 240‐bed long‐term care facility.PARTICIPANTS: All residents ≤ 65 years old who died and were autopsied during a 2‐year period.MEASUREMENTS: Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti‐inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones.RESULTS: The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized >90 days during their last year of life and zero (0/65) when catheterized ≤90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized >>90 days and 18 percent (12/65) when ≤90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension.CONCLUSION: Chronic pyelonephritis and chronic renal inflammation are associated with long‐term catheterization.
Patterns of Predeath Service Use by Dementia Patients with a Family Caregiver
Authors: Collins Clare , Ogle Karen 
Published: April 2015

OBJECTIVE: To describe site of death and patterns of predeath service use (hospital, nursing home, and in‐home services) among persons with dementia who have a family caregiver.DESIGN: Family caregivers who experienced the death of their relative while participating in a 5‐year longitudinal study were surveyed retrospectively about service use patterns in the 90 days before the death of their relative.SETTING: Community.SUBJECTS: Eighty‐two family caregivers of a person with dementia who experienced the death of their relative while participating in a longitudinal study (n = 326) were included in this analysis. All participants were providing care to a relative with dementia in the home at entry into the study.MAIN OUTCOME MEASURES: Survey items were used to identify site of death and measure use of the following services in the 90 days before death: hospital, nursing home, skilled nursing services, home health aides, and physician home visits.RESULTS: Sixty‐nine percent of the caregivers were spouses, and 28% were adult children. Family caregivers had been providing care for an average of 6 years (SD = 3.9) before the death of their relative. The most frequent setting for patient death was home (42%), followed by nursing home (32%) and hospital (26%). The average number of days spent at home in the 90 days before death by the sample was more than 60 days. Thirty‐four percent of the dementia patients were cared for exclusively in the home in the 90 days before death, and 34% spent more than half of the 90 days before death at home. Hospital stays were brief, and less than one‐fourth of the sample spent all of the 90 days before death in an institutional setting. Twenty‐one percent of the sample used no in‐home services in the 90 days before death, 48% of the sample did not use skilled nursing services, and only 27% received a physician home visit.CONCLUSIONS: The results of this study suggest that dementia patients who have a family caregiver receive a significant proportion of their care at home in the 90 days before death. A hospice approach may help address the needs for assistance of families who provide terminal care in the home for a relative with dementia.
Causes of Weight Loss in a Community Nursing Home
Authors: Morley John E. , Kraenzle Dale 
Published: April 2015

Objective: To determine the causes of weight loss in nursing home residents.Design: Retrospective chart review of all weights over the previous 6 months and an in‐depth examination of all residents who lost 5 or more pounds over that period.Setting: A for‐profit community nursing home in an urban area.Subjects: All residents who had been in the nursing home for 3 or more months. Their mean age was 80.1 years, and 89% were female.Results: Weight loss of 5 pounds or more occurred in 19% of subjects. Only 15% of subjects had lost 5% of body weight, and 4% had lost more than 10% of their body weight. Depression accounted for 36% of the weight loss. Other causes of anorexia included medications, psychotropic drug reduction, swallowing disorders, paranoia, dementia with apraxia, gallstones, and obsessive‐compulsive disorder. Increased energy utilization as a cause of weight loss was seen in two residents who wandered incessantly, one with tardive dyskinesia and one with chronic obstructive pulmonary disease. Dehydration was the cause of weight loss in two residents, and one resident had intentional weight loss for obesity. Cancer was the cause of weight loss in two residents. Four of 30 residents had more than one cause of weight loss. One of 25 tube‐fed residents displayed weight loss.Conclusions: A single cause of weight loss can be identified in most nursing home residents. Depression is the most common cause of weight loss. Psychotropic drug reduction may cause weight loss. The majority of causes of weight loss in a community nursing home are potentially treatable.
Caudal Epidural Blocks for Elderly Patients with Lumbar Canal Stenosis
Authors: Ciocon Jerry O. , Galindo‐Ciocon Daisy , Amaranath L. , Galindo Diana 
Published: April 2015

Objective: To determine the efficacy of caudal epidural blocks (CEB) in relieving pain and the duration of pain relief with CEB in elderly patients suffering from degenerative lumbar canal stenosis (LCS).Design: This study was a descriptive, prospective study with a 10‐month follow‐up.Participants and Setting: Thirty patients, 76 ± 6.7 years of age, with leg discomfort with or without back pain and with LCS documented by magnetic resonance imaging (MRI) within 1 year of the study, were recruited from the outpatient clinic of the Cleveland Clinic Florida. None of the subjects had received CEB or surgery for their leg discomfort and none had relief of pain by analgesics alone.Measurements and Interventions: Subjects received a total of three doses of 0.5% Xylocaine with 80 mg Depo‐Medrol into the caudal epidural space through the sacral hiatus at weekly intervals. The Roland 5‐point pain rating scale was utilized before and at 2‐month intervals up to 10 months after the CEB was administered. MRI was used to identify the degree of LCS.Results: The degree of LCS on admission was moderate in 66.7% (n = 20) of the patients, mild in 23.3% (n = 7), and severe in the remaining 10% (n = 3). Patients had LCS involving 2.4 ± 0.49 lumbar vertebrae. The degree of LCS is directly correlated with the pain level before CEB. After CEB, the pain level changed from 3.43 ± 0.82 to 1.5 ± 0.86 (P < 0.0000), with a significant relief of pain up to 10 months (the end of observation). The duration of pain relief ranged from 4 to 10 months (P < 0.0001).Conclusion: CEB offers significant pain relief and appears to be a reasonable therapeutic option among elderly patients with LCS. This alternative seems particularly important among patients with poor response to drug therapy and who are either poor surgical risks or who have refused surgery.
Fracture Risk in Patients with Alzheimer's Disease
Authors: Melton L. Joseph , Beard C. Mary , Kokmen Emre , Atkinson Elizabeth J. , O'Fallon W. Michael 
Published: April 2015

Objective: To assess the risk of fracture following onset of Alzheimer's disease.Design: Retrospective (historical) cohort study.Setting: Population‐based in Rochester, Minnesota.Participants: All 543 Rochester residents with onset of Alzheimer's disease during the 10‐year period, 1975–84, and an equal number of age‐ and sex‐matched controls from the community.Measurements: Fractures were assessed through review of each subject's complete (inpatient and outpatient) medical records in the community.Main Results: Rochester residents with Alzheimer's disease were no more likely to have a history of fracture prior to onset than were matched controls from the same population. During the year of onset, there was a 2‐fold excess of fractures at various sites among those with Alzheimer's disease. The risk ratio for any fracture subsequently was 1.1 (95% CI 0.9, 1.3), and this slight increase was accounted for entirely by a 2.7‐fold increase in the risk of hip fracture (95% CI 1.8, 4.2).Conclusions: Fracture risk was not increased before the onset of Alzheimer's disease, although there was an excess of fractures around the time that Alzheimer's disease came to clinical attention. Fracture risk was not elevated thereafter except for a substantial increase in the risk of hip fracture. This suggests a link with certain falls rather than generalized disuse osteoporosis.
Voluntary Active Euthanasia and Physician‐Assisted Suicide in Dutch Nursing Homes: Are the Requirements for Prudent Practice Properly Met?
Authors: Muller M. T. , Van der Wal G. , van Eijk J. Th. M. , Ribbe M. W. 
Published: April 2015

Objective: To acquire data about and an understanding of the way in which Dutch nursing home physicians (NHPs) who administer voluntary active euthanasia and/or physician‐assisted suicide (EAS) cope with the requirements for prudent practice. These requirements include: the patient must experience his or her suffering as unbearable and hopeless; the wish to die must be well considered and persistent; the request must be voluntary; the NHP must consult at least one other physician; the physician is not allowed to issue a certificate testifying to natural death and is obliged to keep records.Design, Setting, Participants, Measurements: See preceding paper.Results: Sixty‐nine NHPs (12%) indicated that they had administered EAS on at least one occasion. The state of the patient was described by the NHP as utterly hopeless in 88% of cases and as utterly unbearable in 64% of the cases. The period of time between the first discussion of the subject and the actual administration varied from less than a day to more than a year. The most frequently given reasons for the request were unbearable suffering (53%) and hopeless suffering (49%). The majority of the NHPs (85%) indicated that it was the patient who first broached the subject of EAS. Eighty‐five percent of the NHPs also requested a consultation with another physician. In the majority of cases this second opinion was given by another NHP (63%); over 50% of these NHPs worked in the same nursing home. Ninety‐one percent of the physicians consulted were convinced that the request was well considered, and 93% found that there was no alternative treatment available. The nurses involved were consulted informally: 94% were questioned about the request for EAS and 93% about the physician's intention to comply. Seventy‐five percent of the respondents said they had made some sort of written notes regarding the last time they had administered EAS. The number of certificates testifying to death by natural causes fell after 1988. In 41% of the cases all requirements were met.Conclusion: The results of this study indicate that Dutch NHPs observe all the requirements for EAS in 41% of cases. In the remaining cases, shortcomings were found: NHPs allowed too little time between the first discussion and the actual administration; they did not always keep written records; or they signed a death certificate testifying that the patient had died a natural death.
Resident Training in Nursing Home Care: Survey of Successful Educational Strategies
Authors: Counsell Steven R. , Katz Paul R. , Karuza Jurgis , Sullivan Gail M. 
Published: April 2015

OBJECTIVE: To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs.DESIGN: A mail survey with three follow‐up mailings.PARTICIPANTS: Directors of accredited internal medicine and family practice residency programs.MEASUREMENTS: Open‐ and closed‐ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested.MAIN RESULTS: Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill‐based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended.CONCLUSIONS: Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.
The Relationship between Disease and Function and Perceived Health in Very Frail Elders
Authors: Mulrow Cynthia D. , Gerety Meghan B. , Cornell John E. , Lawrence Valerie A. , Kanten Deanna N. 
Published: April 2015

Objective: To study associations between disease and observed function and self‐perceived health in very frail elders.Design and Setting: Cross‐sectional survey of nine nursing homes in San Antonio, TX.Participants: 194 elderly long‐stay nursing home residents dependent in at least two ADLs and without severe cognitive impairment.Measures: Burden of disease (BOD) was chart abstracted using a standardized protocol that assessed types and severities of 59 categorizations of chronic and acute medical conditions. Observed function and self‐perceived health status were assessed independently by the Katz Activities of Daily Living scale (ADL) and the Sickness Impact Profile (SIP), respectively.Results: Summary BOD scores had a low, but statistically significant, univariate correlation with ADL scores (r = 0.21, P = 0.003) and no significant correlation with SIP scores (R = −0.008). Multiple linear regression analyses, including the 24 most frequent disease categories, showed that disease explained significant amounts of ADL (r2 = 0.25, P = 0.001) and borderline significant amounts of SIP (r2 = 0.16, P = 0.11). Models including both disease and sociodemographic, cognitive, and affective variables showed disease added significant incremental explanation beyond the other factors to ADL (incremental r2 = 0.14, P = 0.04), but not to SIP (incremental r2 = 0.08, P > 0.10).Conclusions: Disease, observed function, and self‐perceived health status are separate, but interrelated entities, with disease having a stronger relationship to observed function than self‐perceived health. Comprehensive assessment of frail elders may need to include all three areas, and studies that focus on one area should take into account the other two as potential important covariates.
A Longitudinal Study of Risk Factors Associated with the Formation of Pressure Ulcers in Nursing Homes
Authors: Brandeis Gary H. , Ooi Wee Lock , Hossain Monir , Morris John N. , Lipsitz Lewis A. 
Published: April 2015

Objective: To determine risk factors associated with the formation of stage II—IV pressure ulcers in nursing homes.Design: Since the incidence rate for pressure ulcer formation varies among nursing homes, the homes were divided into tertiles based on these rates. Pooled logistic regression was used to model which factors are associated with the formation of pressure ulcers in both high and low incidence homes.Setting: 78 National HealthCorp nursing homes.Subjects: We studied 4232 nursing home residents free of pressure ulcers on admission to a nursing facility and at 3‐months follow‐up. All remained in the home for at least 3 additional months to a maximum of 21 months.Measurements: The effects of age, gender, race, antipsychotic drug use, urinary incontinence, fecal incontinence, body mass index, diabetes mellitus, disorientation, ambulation, physical restraints, activities of daily living of bathing, feeding, or transferring, and nursing home bed size on the formation of a stage II—IV pressure ulcer while the subject was a resident in the nursing home were studied.Main Results: Significant factors associated with the formation of pressure ulcers in high incidence homes (21‐month incidence = 19.3%) were ambulation difficulty (OR = 3.3; CI = 2.0, 5.3), fecal incontinence (OR = 2.5; CI = 1.6, 4.0), diabetes mellitus (OR = 1.7; CI = 1.2, 2.5), and difficulty feeding oneself (OR = 2.2; CI = 1.5, 3.3). In the low incidence homes (21‐month incidence = 6.5%), significant factors associated with pressure ulcer incidence were ambulation difficulty (OR = 3.6; CI = 1.7, 7.4), difficulty feeding oneself (OR = 3.5; CI = 2.0, 6.3), and male gender (OR = 1.9; CI = 1.2, 3.6).Conclusions: Although low and high incidence homes share similar risk factors, such as ambulation and feeding activities of daily living, the main difference was that diabetes and fecal incontinence played a major role only in high risk homes, while male gender was an important discriminator only in low incidence homes. Yet, it is unclear if these factors explain the three‐fold difference in the incidence rates for pressure ulcers in these facilities. Baseline or resident clinical characteristic differences of any one factor between the high and low incidence homes varied by no more than 5%. While we identified certain conditions which are associated with pressure ulcer formation, there may be unknown or unmeasured facility effects in addition to the characteristics of a given resident in a particular home.
A Prospective Study of Dehydroepiandrosterone Sulfate and Cognitive Function in an Older Population: The Rancho Bernardo Study
Authors: Barrett‐Connor Elizabeth , Edelstein Sharon L. 
Published: April 2015

Objective: To determine whether low plasma dehydroepiandrosterone sulfate (DHEAS) levels predict poor cognitive function in the elderly.Design: A prospective, population‐based study with periodic clinical evaluations and 100% follow‐up for vital status.Setting: Rancho Bernardo, CaliforniaPatients: 270 men and 167 women (80% of surviving, local, age‐eligible subjects) from the Rancho Bernardo cohort who had plasma obtained for DHEAS assays in 1972 to 1974 and screening for dementia in 1988 to 1991.Measurements: DHEAS levels were measured by radioimmunoassay. There were five interviewer‐administered standard screening tests of cognitive function: Mini‐Mental Status Examination, Buschke selective reminding test, Trails B, category fluency, and Heaton Visual Reproduction test.Results: DHEAS levels were higher in men than women and decreased with age in both sexes. There were no significant differences in age‐adjusted DHEAS levels in the percent of men or women with categorically impaired performance on any test. When analyzed as a continuous variable, DHEAS levels were significantly correlated with only one test, the Bushke, and only in women. Low baseline DHEAS levels were not associated with any mention of dementia on death certificates or with non‐participation of survivors. Low levels of DHEAS predicted mortality in men more than in women such that men were more likely to have died before cognitive function testing than women.Conclusion: The single DHEAS‐memory association, restricted to women, is most likely to be spurious, consequent to multiple comparisons. We cannot exclude a true effect of low DHEAS, restricted to women and reflecting their better survival than men.