bluuebunny/crossref_metadata_2025_split huggingface dataset:
Seriously Ill Hospitalized Adults: Do We Spend Less on Older Patients?
Authors: Hamel Mary Beth , Phillips Russell S. , Teno Joan M. , Lynn Joanne , Galanos Anthony N. , Davis Roger B. , Connors Alfred F. , Oye Robert K. , Desbiens Norman , Reding Douglas J. , Goldman Lee ,   for the SUPPORT Investigators
Published: April 2015

OBJECTIVETo determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age‐related differences in resource use are explained by patients' severity of illness and preferences for life‐extending care.STUDY DESIGNProspective cohort study.SETTINGFive geographically diverse academic acute care medical centers participating in the SUPPORT Project.PATIENTSA total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6‐month mortality of 50%.MEASUREMENTSResource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs.RESULTSThe median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $7161 lower, respectively. These differences persisted after further adjustment for patients' preferences for life‐extending care.CONCLUSIONSCompared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource‐intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life‐extending care.
Memory Complaints and Memory Impairment in Older Individuals
Authors: Jonker Cees , Launer Lenore J. , Hooijer Chris , Lindeboom Jaap 
Published: April 2015

OBJECTIVE: To examine whether subjective memory complaints, measured with a series of four questions, are associated with performance on cognitive tests.DESIGN: Cross‐sectional study of individuals, 65 to 85 years of age, who lived in the community of Amsterdam.PARTICIPANTS: Individuals were selected randomly within 5‐year age strata from the patient lists of 30 general practitioners. Of the 4051 participants, 2537 nondepressed and nondemented respondents were included in the analysis.MEASURES: Four categories of subjective memory complaints were developed on the basis of answers to questions about the presence or absence of memory complaints and memory‐related problems in daily functioning. Tests of cognitive function were derived from the subscales of the CAMCOG.MAIN RESULTS: Individuals with complaints and memory‐related problems performed more poorly on tests of memory and memory‐related functions. This relationship was strengthened after adjusting for age, sex, and premorbid verbal intelligence, all of which were related to complaint status and to performance on cognitive tests.CONCLUSION: Simple questions about memory function are related to memory performance in nondepressed, nondemented community‐dwelling older people. Subjective memory complaints may be a promising indicator of memory impairment that signals the need for follow‐up. J Am Geriatr Soc 44:44–49, 1996.
Differences in the Signs and Symptoms of Hyperthyroidism in Older and Younger Patients
Authors: Trivalle Christophe , Doucet Jean , Chassagne Philippe , Landrin Isabelle , Kadri Nadir , Menard Jean‐François , Bercoff Eric 
Published: April 2015

OBJECTIVES: To determine if aging modifies the clinical presentation of hyperthyroidism and the signs of thyrotoxicosis in older people.DESIGN: Prospective cohort study.SETTING: A French university hospital.SUBJECTS: Eighty‐four new patients with overt hyperthyroidism confirmed chemically between January 1992 and January 1993. Controls were 68 older euthyroid patients matched to the older hyperthyroid patients.MEASUREMENTS: Comparison of 19 classical signs of hyperthyroidism between 34 older patients (≥70 years; mean age 80.2) and 50 younger patients (≤50 years; mean age 37.4). Older patients were also compared with controls (mean age 81.3).RESULTS: Three signs were found in more than 50% of older patients: tachycardia, fatigue, and weight loss. Seven signs were found significantly less frequently in older patients (P < .001): hyperactive reflexes, increased sweating, heat intolerance, tremor, nervousness, polydipsia, and increased appetite. Only anorexia (32% vs 4%) and atrial fibrillation (35% vs 2%) were more found frequently in older people (P < .001). A goiter was present in 94% of the younger and in 50% of the older patients (P < .001). The mean number of clinical signs found in the older subjects was significantly smaller than the number found in younger patients (6 vs 10.8; P < .001). Comparison with older controls showed three signs that were highly associated with thyrotoxicosis in older people: apathy (Odd ratio (OR): 14.8), tachycardia (OR: 11.2), and weight loss (OR: 8.7).CONCLUSION: This study confirms the paucity of clinical signs of hyperthyroidism in older adults. These results suggest the necessity of routine screening for thyroid disease in this age group. J Am Geriatr Soc 44:50–53, 1996.
Frailty and Hospitalization of Long‐Term Stay Nursing Home Residents
Authors: Fried Terri R. , Mor Vincent 
Published: April 2015

OBJECTIVE: To determine the relationship between characteristics of older, long‐term stay nursing home patients and hospitalization.DESIGN: A cohort study.SETTING: One hundred three proprietary nursing homes.PARTICIPANTS: All residents of these nursing homes aged 65 or older admitted between January 1, 1991, and December 30, 1993, who had no transitions out of the nursing home during the first 6 months of their stay.MEASUREMENTS AND MAIN RESULTS: Among the cohort of 3782 residents, 931 (25%) were hospitalized at least once during the second 6 months of their nursing home stay. In a logistic regression model, severe functional impairment (adjusted odds ratio (AOR) 1.20, 95% confidence interval (CI) 1.01, 1.43), worsening ADL self‐performance (AOR 1.22, 95% CI 1.04, 1.43), presence of a decubitus ulcer (AOR 1.62, 95% CI 1.17, 2.24), presence of a feeding tube (AOR 2.03, 95% CI 1.54, 2.67), primary diagnosis of congestive heart failure (AOR 1.61, 95% CI 1.11, 2.34), and primary diagnosis of respiratory disease (AOR 1.77, 95% CI 1.24, 2.54) were associated with hospitalization. No form of advance directive was associated with a lower rate of hospitalization.CONCLUSIONS: Physically frail patients, who may be the least likely to benefit from hospitalization, are the most likely to be hospitalized. The lack of an association between “Do‐not‐hospitalize” orders and lower rates of hospitalization suggests that there are substantial barriers to providing acute care in the nursing home. The association between recent functional decline, primary diagnoses of congestive heart failure and respiratory disease, and hospitalization indicates, however, that certain patient groups may be targeted successfully to reduce hospitalization rates.
National Trends in the Initial Hospitalization for Heart Failure
Authors: Croft Janet B. , Giles Wayne H. , Pollard Robert A. , Casper Michele L. , Anda Robert F. , Livengood John R. 
Published: April 2015

OBJECTIVES: Heart failure is a major health care burden among older adults, but information on recent trends has not been available. We compare rates, sociodemographic characteristics, and discharge outcomes of the initial hospitalization for heart failure in the Medicare populations of 1986 and 1993.DESIGN: Information reported on the Medicare hospital claims record during initial hospitalization for heart failure was compared for patients aged 65 and older hospitalized in 1986 (N = 631,306) and those aged 65 and older hospitalized in 1993 (N = 803,506).RESULTS: Age‐standardized hospitalization rates (per 1000 person‐years) for any diagnosis of heart failure were higher in 1993 than in 1986 (white: 24.6 vs 22.4, black: 26.1 vs 22.4, respectively). Age‐specific results suggested an earlier onset of heart failure in black adults. In 1993, compared with 1986, higher proportions of heart failure patients were discharged to another care facility (white: 23.9% vs 16.8%, black: 17.6% vs 10.5%, respectively) or to health service care at home (white: 11.3% vs 6.0%, black: 12.4% vs 6.5%, respectively). In contrast, in‐hospital mortality was lower in 1993 than in 1986 (white: 10.4% vs 13.3%, black: 8.9% vs 11.1%, respectively).CONCLUSION: The increased numbers of hospitalizations for heart failure and the likelihood that these patients will require advanced nursing care after discharge have important implications for future national health care expenditures and resources.
Depression and Mortality in Medically Ill Older Adults
Authors: Ganzini Linda , Smith David M. , Fenn Darien S. , Lee Melinda A. 
Published: April 2015

OBJECTIVE: To determine if major depressive disorder influences the survival of older, medically ill veterans.DESIGN: Thirty month follow‐up of an inception cohort.SETTING: An academically‐affiliated Veterans Affairs Medical Center.PARTICIPANTS: One hundred veterans, half of whom have a depressive disorder, recruited from inpatient medical and surgical units in 1990–1991. At initial evaluation all participants were older than age 65, cognitively intact, and medically but not terminally ill.MEASUREMENTS: Severity of medical illness, functional status, social support and presence of depression were measured at initial evaluation, presence of depression was measured 4 to 6 months after initial evaluation, and survival status was determined at 30 months. Retrospective medical record review was used to determine if patients received depression treatment and to explore whether depressed persons received life‐sustaining medical treatment less often than nondepressed persons.RESULTS: At 30 months, 36 of the 100 subjects had died. Only two factors predicted mortality: severity of medical illness and depression. The survival of subjects who had recovered from depression at 4 to 6 months was intermediate to never depressed and continuously depressed subjects. Somatic treatment of depression did not alter outcome. There was no significant difference between depressed and nondepressed in how often life‐sustaining medical treatments were withheld or withdrawn.CONCLUSION: Presence of major depression in medically‐ill older hospitalized veterans continues to be a risk factor for death 30 months after diagnosis.
Questionable Dementia: Clinical Course and Predictors of Outcome
Authors: Devanand D.P. , Folz Mara , Gorlyn Marianne , Moeller James R. , Stern Yaakov 
Published: April 2015

OBJECTIVE: To evaluate the clinical course and predictors of outcome in outpatients with cognitive impairment who do not meet criteria for dementia at initial evaluation.DESIGN: Naturalistic longitudinal study.METHODS: Cognitively impaired patients in a memory disorders clinic who fell between the “normal” and “dementia” categories were defined broadly as “questionable dementia” (QD). Of 127 consecutive QD patients, 75 were followed for a minimum of 1 year (mean 2.5 years, SD 1.7). Baseline neuropsychological testing was conducted in 62 of these 75 QD patients.RESULTS:: At the final follow‐up time‐point, 41.3% met diagnostic criteria for dementia (27 of 31 patients with dementia had possible or probable Alzheimer's Disease, AD), 44% were rated as not demented, and 14.7% remained as “uncertain” dementia. Increased age was associated with the final diagnosis of dementia, but duration of follow‐up, Clinical Dementia Rating, and modified Mini Mental State (mMMS) scores were not predictive. Low scores on the mMMS delayed recall subtest, consistent long‐term retrieval on the Selective Reminding Test, category naming for animals, and the WAIS‐R digit symbol, picture arrangement, and block design subtests were predictive of the final diagnosis of dementia (all P ≤.01). mMMS delayed recall showed 66.7% sensitivity and 71.4% specificity, the other five neuropsychological subtests together showed 66.7% sensitivity and 66.7% specificity, and the six tests together showed 81% sensitivity and 76.9% specificity. Similar predictive accuracy was obtained for the final diagnosis of AD.CONCLUSIONS: In QD patients, poor performance on the mMMS delayed recall item may be a useful predictor of the diagnosis of dementia (and AD) on follow‐up. Combining a screening instrument like the mMMS with specific neuropsychological tests may provide good predictive accuracy. In QD patients, the observed heterogeneity in diagnostic outcome, with most patients in the “dementia” and “no dementia” categories at follow‐up, enhances the feasibility of evaluating early markers with predictive accuracy for dementia and AD.
HM‐PAO (CERETEC) SPECT Brain Scanning in the Diagnosis of Alzheimer's Disease
Authors: Bergman H. , Chertkow H. , Wolfson C. , Stern J. , Rush C. , Whitehead V. , Dixon R. 
Published: April 2015

OBJECTIVE: To evaluate the accuracy of Single Photon Emission Computed Tomography (SPECT) scanning in the diagnosis of Alzheimer's Disease (AD) and its capacity to improve the diagnostic accuracy of conventional clinical evaluation.DESIGN: Comparison of SPECT scanning of AD and normal subjects with the criterion standard of clinical diagnosis confirmed by 1‐year repeated evaluation.SETTING: A memory clinic in a tertiary care university hospital.PATIENTS: One hundred twenty patients were evaluated upon entering the Jewish General Hospital (McGill University) Memory Clinic. Fifty‐eight patients were diagnosed as having AD and 17 as having vascular dementia. Twenty unmatched controls (recruited mainly through newspaper advertisements) were normal, and 25 had cognitive impairment without dementia (not included in the statistical analysis).MAIN OUTCOME MEASURES: Comparison of visual inspection of SPECT, based on the system of classification developed by Holman et al., using B pattern alone as positive or B (bilateral posterior temporal and/or parietal cortex deficits) or C (bilateral posterior temporal and/or parietal deficits with additional defects) pattern and B or C or D (unilateral posterior temporal and/or parietal defects with or without additional defects) as positive compared with clinical diagnosis after repeated evaluations. Sensitivity and specificity, as well as positive predictive value (PPV) and negative predictive value (NPV) based on the prevalence of AD in a memory clinic setting of 30% or 50%, were calculated.RESULTS: With B pattern as positive, the sensitivity of SPECT was 21% whereas the specificity was 80%. With B or C as positive, the sensitivity was 29% and the specificity was 75%. With B or C or D as positive, the sensitivity was 55% and the specificity was 65%. With a 30% prevalence, the PPV with B pattern as positive was 31% whereas the NPV was 30%. The PPV with B or C as positive was 33% while the NPV was 29%, and the PPV with B or C or D as positive was 40% whereas the NPV was 23%. With a 50% prevalence, the PPV with B pattern as positive was 51% and the NPV 49.6%; the PPV with B or C as positive was 54% and the NPV 48.6%; the PPV with B or C or D as positive was 61% while NPV was 41%.CONCLUSION: The sensitivity and specificity were too low for SPECT to be useful as a diagnostic test for AD. The poor positive and negative predictive values in our tertiary care clinic mean that SPECT is not useful in “ruling‐in” or “ruling‐out” AD in that setting. In fact, clinical evaluation is more accurate.
Implementation of the Patient Self‐Determination Act (PSDA) in Nursing Homes in New York City
Authors: Mezey Mathy , Mitty Ethel , Rappaport Michael , Ramsey Gloria 
Published: April 2015

OBJECTIVE: To examine implementation of the Patient Self Determination Act (PSDA), verbal directives, procedures for determination of resident' decision‐making capacity, and role of ethics committees in nursing homes in New York City.DESIGN: Telephone survey.PARTICIPANTS: Social workers in 109 (69%) nursing homes in New York City.MEASUREMENT: An 80‐item instrument addressing: (1) social worker knowledge of the PSDA; (2) informing residents about advance directives (living wills and durable power of attorney for health care [health care proxies]); (3) determination of decision‐making capacity to be informed about advance directives; (4) estimates of advance directives executed; (5) perceptions of PSDA effect; (6) ethics committees; (7) follow‐up and documentation; and (8) staff and community education.MAIN RESULTS: Virtually all social workers in nursing homes stated that they made what they perceived to be a “serious effort” to inform residents about advance directives and to have residents execute directives (preferentially a health care proxy). More residents were thought to have executed a directive pursuant to the PSDA law than before the Act went into effect. Social workers in most homes informed residents about directives through face‐to‐face discussions. Most homes, however, did not inform residents who were thought to lack decision‐making capacity about their right to execute a directive. Only 37% of homes had written procedures to determine a resident's decision‐making capacity to be informed about directives; most homes relied on physician and social work assessments. Voluntary homes differed significantly from proprietary homes in that they were larger, more likely to have an ethics committee, and more aggressive in their implementation of the PSDA. Forty‐five percent of homes with an ethics committee had written procedures for determination of resident decision‐making capacity compared with 26% of homes without a committee. Overall, 24% of residents were thought to have executed an advance directive. The number of directives per bed did not vary significantly by facility size, ownership, religious affiliation, or whether they did or did not have an ethics committee.CONCLUSIONS: The fact that social workers in nursing homes speak with most residents about advance directives has the potential to improve resident understanding around end of life decisions. The practice of not informing residents about advance directives when they are perceived to lack decision‐making capacity is problematic given that most homes have no clear procedures for determining residents' cognitive capacity to execute a directive. There is a need to replicate the benefits achieved by homes with ethics committees in implementing the PSDA in other homes.
Assessing Capacity to Participate in Discussions of Advance Directives in Nursing Homes: Findings from a Study of the Patient Self Determination Act
Authors: Bradley Elizabeth , Walker Leslie , Blechner Barbara , Wetle Terrie 
Published: April 2015

OBJECTIVE: To better understand the implementation of the Patient Self‐Determination Act (PSDA) in long‐term care, with a focus on the informing process as it affects advance directives.DESIGN: Retrospective cohort study of nursing home admissions, using medical record reviews, and a companion qualitative survey using key informant interviews.SETTING: Eleven nursing homes in Connecticut.PARTICIPANTS: A total of 600 residents randomly selected from six randomly chosen nursing homes and 19 key informants selected from five purposely sampled nursing homes in Connecticut.MEASURES: Institutional compliance with the PSDA requirement to provide written information about advance directives at admission and aspects of the informing process, including to whom the information is given.RESULTS: Compliance with the PSDA requirement to provide information at admission is high (90.7 of admissions in the post‐PSDA cohort received information within 1 week of admission). However, in nearly 70% of admissions in which information was provided, someone other than the residents received the information. Staff often cited the resident's cognitive impairment as a reason for excluding residents from this informing process. However, even among those residents judged to be alert and oriented at admission, someone other than the resident received the information 47.7% of the time.CONCLUSIONS: Substantial numbers of residents may be inappropriately excluded from participating in discussions because of difficulties in determining decisional capacity to discuss future treatment wishes. The research highlights the difficulties of enhancing resident participation and autonomy in long‐term care through procedural regulations such as the PSDA. More reliable methods of determining resident decisional capacity are needed to integrate the full intent of the PSDA into clinical practice in long‐term care.
Disability in Older Adults: Evidence Regarding Significance, Etiology, and Risk
Authors: Fried Linda P. , Guralnik Jack M. 
Published: April 2015

OBJECTIVES: This article synthesizes and assesses current evidence about the importance of physical disability to older adults. It then considers the applications of research findings to clinical geriatrics practice.RESULTS: Physical disability is a major adverse health outcome associated with aging. Certain subgroups of older adults, including individuals with mobility difficulty, with preclinical functional changes, and persons who are hospitalized, are at particularly high risk of becoming disabled or experiencing disability progression. The major underlying causes of physical disability are chronic diseases, including both acute events, such as hip fracture and stroke and slowly progressive diseases such as arthritis and heart disease. These diseases appear to have task‐specific effects; understanding this may assist in setting treatment and prevention goals. Comorbidity, particularly certain combinations of chronic diseases, is a strong risk factor for disability in itself. Recent trials indicate that clinical interventions may be able to prevent onset or progression of disability.CONCLUSIONS: Available evidence now suggests clinical approaches to both treatment and prevention of disability and directions for defining optimal clinical care for the future.