bluuebunny/crossref_metadata_2025_split huggingface dataset:
Psychopathological Features in Alzheimer's Disease: Course and Relationship with Cognitive Status
Authors: Holtzer Roee , Tang Ming‐Xin , Devanand D. P. , Albert Steven M. , Wegesin Domonick J. , Marder Karen , Bell Karen , Albert Marilyn , Brandt Jason , Stern Yaakov 
Published: September 2003

OBJECTIVES: To examine the course, clinical correlates, and relationship between cognitive status and psychopathological features in patients with probable Alzheimer's disease (AD) followed over a 5‐year period.DESIGN: Cohort study with follow‐up of 5 years.SETTING: Patients were recruited at three sites: 91 patients at Columbia Medical Center, 84 at Johns Hopkins School of Medicine, and 61 at Massachusetts General Hospital.PARTICIPANTS: Patients diagnosed with probable AD (n = 236) enrolled in a longitudinal study (Predictors study).MEASUREMENTS: Wandering/agitation, physical aggression, hallucinations, and delusions were evaluated at 6‐month intervals using the Columbia Scale for Psychopathology in Alzheimer's Disease. Descriptive analyses were used to provide estimates of prevalence and course of psychopathological features. General estimating equations determined the odds of having any of the four psychopathological behaviors as a function of cognitive status. Markov analyses provided 6‐month transition probabilities for psychopathological behaviors given patients' cognitive status and the presence or absence of such behaviors in the previous evaluation.RESULTS: For wandering/agitation, prevalence (39–57%) and persistence increased as a function of time and decrement in cognitive status. Physical aggression was less prevalent (6–22%) and increased as a function of cognitive decline but tended to persist only in the more severely impaired patients. Delusions (34–49%) reached a peak at the second year and then declined. The odds of delusions were maximal with intermediate decline but remained persistent regardless of cognitive status. Hallucinations, despite some fluctuations, were relatively stable during the follow‐up period (8–17%) and moderately persistent.CONCLUSION: Psychopathological features, particularly wandering/agitation and delusions, in AD were common throughout the disease course. The natural history and persistence of the four psychopathological features varied. These findings provide important information to clinicians and caregivers regarding the course, predictability, and possible treatment of psychopathological behaviors in patients with probable AD.
Life‐Sustaining Treatments: What Do Physicians Want and Do They Express Their Wishes to Others?
Authors: Gallo Joseph J. , Straton Joseph B. , Klag Michael J. , Meoni Lucy A. , Sulmasy Daniel P. , Wang Nae‐yuh , Ford Daniel E. 
Published: September 2003

OBJECTIVES: To assess whether older physicians have discussed their preferences for medical care at the end of life with their physicians, whether they have established an advance directive, and what life‐sustaining treatment they wish in the event of incapacity to make these decisions for themselves.DESIGN: Mailed survey to a cohort of physicians.SETTING: Physicians who were medical students at the Johns Hopkins University in graduating classes from 1946 to 1964.PARTICIPANTS: Physicians who completed the advance directive questionnaire (mean age 68).MEASUREMENTS: Questionnaires were sent out to known surviving physicians of the Precursors Study, an on‐going study that began in 1946, asking physicians about their preferences for life‐sustaining treatments.RESULTS: Of 999 physicians who were sent the survey, 765 (77%) responded. Forty‐six percent of the physicians felt that their own doctors were unaware of their treatment preferences or were not sure, and of these respondents, 59% had no intention of discussing their wishes with their doctors within the next year. In contrast, 89% thought their families were probably or definitely aware of their preferences. Sixty‐four percent reported that they had established an advance directive. Compared with physicians without advance directives, physicians who established an advance directive were more likely to believe that their doctors (odds ratio (OR) = 3.42, 95% confidence interval (CI) = 2.49–4.69) or family members (OR = 9.58, 95% CI = 5.33–17.23) were aware of their preferences for end‐of‐life care and were more likely to refuse treatments than those without advance directives.CONCLUSION: This survey of physicians calls attention to the gap between preferences for medical care at the end of life and expressing wishes to others through discussion and advance directives, even among physicians.
Hospice Usage by Minorities in the Last Year of Life: Results from the National Mortality Followback Survey
Authors: Greiner K. Allen , Perera Subashan , Ahluwalia Jasjit S. 
Published: September 2003

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use.DESIGN: Secondary analysis of the 1993 National Mortality Followback Survey (NMFS), a nationally obtained sample using death certificates and interviews with relatives (proxy respondents) to provide mortality, social, and economic data and information about healthcare utilization in the last year of life for 23,000 deceased individuals.SETTING: Hospice care.PARTICIPANTS: Individuals aged 15 and older who died in 1993. Subjects were included in this analysis if they died of nontraumatic causes (N = 11,291).MEASUREMENTS: Hospice use was dichotomized by proxy responses indicating use or nonuse of home or inpatient hospice services. The percentage of individuals using hospice services in the last year of life was calculated.RESULTS: Unadjusted bivariate results found that African Americans were less likely to use hospice than whites (odds ratio (OR) = 0.59; P < .001) and that those without a living will (LW) (OR = 0.23; P < .001) and without a cancer diagnosis (OR = 0.28; P < .001) were less likely to use hospice. The negative relationship between African Americans and hospice use was unaffected when controlled for sex, education, marital status, existence of a LW, income, and access to health care. Logistic models revealed that presence of a LW diminished the negative relationship between African Americans and hospice use, but the latter remained significant (OR = 0.83; P = .033). A subanalysis of subjects aged 55 and older showed a significant interaction between access to care and race/ethnicity with respect to hospice use (P = .044). Inclusion of income in this multivariable logistic model attenuated the relationship between African‐American race/ethnicity and hospice use (OR = 0.77), and the difference between whites and African Americans became only marginally statistically significant (P = .060).CONCLUSION: In the 1993 NMFS, hospice use was negatively associated with African‐American race/ethnicity independent of income and access to healthcare. The relationship is not independent of age, insurance type, or history of stroke. For subjects aged 55 and older, access to healthcare may be an important confounder of the negative relationship between African‐American race/ethnicity and hospice use. Consistent with previous studies, this analysis found that African Americans were less likely to use LWs than whites. The reduced importance of African‐American race/ethnicity on hospice use with the inclusion of presence of a LW in logistic models suggests that similar cultural processes may shape differences between African Americans and whites in advance care planning and hospice use.
The Effects of Implementation of the Agency for Health Care Policy and Research Urinary Incontinence Guidelines in Primary Care Practices
Authors: Bland Deirdre R. , Dugan Elizabeth , Cohen Stuart J. , Preisser John , Davis Cralen C. , McGann Paul E. , Suggs Patricia K. , Pearce Katherine F. 
Published: September 2003

OBJECTIVES: To determine whether a multifaceted intervention based on the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for Urinary Incontinence would increase primary care physician screening for and management of urinary incontinence (UI).DESIGN: Group randomized trial, conducted from 1996 to 1997.SETTING: Internal medicine and family medicine community practices.PARTICIPANTS: Forty‐one primary care practices, including 57 physicians and their staff and 1,145 patients aged 60 and older.INTERVENTION: Twenty of the 41 primary care practices in North Carolina were randomized to a composite intervention that included a 3‐hour continuing medical education accredited course, training in management of UI, patient educational materials, and on‐site physician and office support. The remaining 21 practices served as “usual care” controls. Telephone surveys of UI status and quality of life were obtained from 1,145 patients before the intervention. At 1 year, patients and physicians were contacted by telephone and mail to determine the effect of the educational intervention.MEASUREMENTS: Patients completed telephone surveys to assess screening for UI, UI status, treatment interventions, and quality of life. Physicians completed surveys related to UI treatment and practice patterns.RESULTS: Baseline and endpoint telephone surveys were completed by 668 of 1,145 (58%) of patients, who were cared for by 45 physicians (10 internists, 35 family medicine). Physician screening rates for UI were 22% for those patients who did not report UI. UI was reported by 39.5% of patients at baseline, of whom 30% reported being asked about UI by their primary care physician during the study. Rates of assessment and management of existing UI were low in both the control and intervention groups. Additional historical questioning indicated that 54.2% reported that they had ever undergone assessment, including history, urinalysis, or testing, or had had management of their UI by any physician.CONCLUSION: Attempts at increasing screening and management of UI by primary care physicians using the AHCPR standardized guidelines using a multifaceted system of educational and logistical support were not successful. These guidelines may not be the best approach to treating UI in the primary care setting.
Effects of Exercise Training Added to Ongoing Hormone Replacement Therapy on Bone Mineral Density in Frail Elderly Women
Authors: Villareal Dennis T. , Binder Ellen F. , Yarasheski Kevin E. , Williams Daniel B. , Brown Marybeth , Sinacore David R. , Kohrt Wendy M. 
Published: September 2003

OBJECTIVES: To determine whether exercise training added to ongoing hormone replacement therapy (HRT) increases bone mineral density (BMD) in physically frail elderly women.DESIGN: Prospective controlled trial.SETTING: University‐based research center.PARTICIPANTS: Twenty‐eight women on HRT, aged 75 and older with physical frailty.INTERVENTIONS: Participants were assigned to 9 months of supervised (EXER) or home (HOME) exercise. The EXER program started with physical therapy and gradually incorporated resistance and endurance training. The HOME program consisted of flexibility exercises.MEASUREMENTS: Changes in BMD and body composition.RESULTS: There were larger increases in lumbar spine BMD in response to EXER than with HOME (3.5% vs 1.5%, P = .048), with a trend for larger increases in total body BMD (1.5% vs 0.2%, P = .058). There were no significant between‐group differences in hip BMD. The EXER group had decreases in weight (−2.2 ± 0.3 kg, P = .010) and fat mass (−2.7 ± 0.4 kg, P = .018) and increases in muscle strength (9–30%, P < .05).CONCLUSION: In physically frail elderly women on HRT, relatively vigorous exercise training significantly increased lumbar spine BMD. The improved BMD and strength in response to exercise could reduce fracture risk in frail women already on HRT.
Low Total Cholesterol and Increased Risk of Dying: Are Low Levels Clinical Warning Signs in the Elderly? Results from the Italian Longitudinal Study on Aging
Authors: Brescianini Sonia , Maggi Stefania , Farchi Gino , Mariotti Sergio , Di Carlo Antonio , Baldereschi Marzia , Inzitari Domenico , For The ILSA Group  
Published: September 2003

OBJECTIVES: To analyze the relationship between serum total cholesterol (TC) and all‐cause mortality, taking into account various potential confounders.DESIGN: Population‐based prospective cohort study.SETTING: Older Italians residing in the general community.PARTICIPANTS: Four thousand five hundred twenty‐one men and women aged 65–84.MEASUREMENTS: Vital status data were available for 1992–95. The hazard ratios of dying for subjects in the second, third, and fourth quartiles compared with the first quartile of TC were computed using Cox proportional hazards, adjusting for lifestyle factors, anthropomorphic and biochemical measures, preexisting medical conditions, and frailty indicators.RESULTS: Blood samples were obtained from 3,295 (73%) of the participants, of whom 399 died during almost 3 years of follow‐up. Low TC was associated with a higher risk of death. Those with TC in the second, third, and fourth quartiles (TC>189 mg/dL or 4.90 mmol/L) had lower hazard ratios (HRs) of death than subjects in the first quartile (0.57, 95% confidence interval (CI) = 0.38–0.87; 0.56, 95% CI = 0.36–0.88; and 0.53, 95% CI = 0.33–0.84, respectively). Few subjects taking lipid‐lowering drugs (LLDs) were in the lowest quartile of cholesterol, suggesting that these individuals have low TC values for reasons other than LLD use.CONCLUSION: Subjects with low TC levels (<189 mg/dL) are at higher risk of dying even when many related factors have been taken into account. Although more data are needed to clarify the association between TC and all‐cause mortality in older individuals, physicians may want to regard very low levels of cholesterol as potential warning signs of occult disease or as signals of rapidly declining health.
Risk Factors for Nosocomial Pneumonia in a Geriatric Hospital: A Control‐Case One‐Center Study
Authors: Rothan‐Tondeur Monique , Meaume Sylvie , Girard Laurence , Weill‐Engerer Sébastien , Lancien Evelyne , Abdelmalak Soha , Rufat Pierre , Le Blanche Alain‐Ferdinand 
Published: September 2003

OBJECTIVES: To determine the risk factors (RFs) and the incidence of nosocomial pneumonia (NP).DESIGN: Control/case study conducted from January 1 to April 15, 1999. Prospective enrollment.SETTING: Geriatric university hospital with long‐, intermediate‐, and short‐term care facilities.PARTICIPANTS: Inpatients aged 65 and older with NP.MEASUREMENTS: NP diagnosis relied on at least two clinical signs of respiratory infection and on chest radiography. Each NP case was randomly paired with two controls and followed up for 30 days to determine complication and mortality rates. RFs between cases and controls were compared (chi‐square test, odds ratio (OR), 95% confidence interval, significance level P = .05). RFs that were significant in univariate analysis were tested using multivariate analysis and logistic regression.RESULTS: Seventy‐five cases of NP were diagnosed in 2,142 patients. The average incidence rate was 3.5% (short‐term facilities = 0.5%; intermediate‐term facilities = 8.3%; long‐term care facilities = 5.3%). The complication rate was 58.1%. The most frequent complications were recurrent NP, heart and respiratory failure, phlebitis, and pressure ulcers. The NP mortality rate was 12.2%. The independent RFs of NP were a history of NP during the previous 6 months (OR = 4.50) and oxygen therapy (OR = 16.15), P < .001. Additional RFs were severe malnutrition, heart failure, prescription of antibiotics during the month preceding the emerging NP, eating dependency, and feeding by nasogastric tube.CONCLUSION: The main RF for NP is a history of pneumonia. NP prevention in geriatrics should rely on early management of respiratory infections and malnutrition, surveillance of oxygen therapy and enteral feeding, rational use of antibiotics, and adaptation to the patient's dependency.
Dementia after Delirium in Patients with Femoral Neck Fractures
Authors: Lundström Maria , Edlund Agneta , Bucht Gösta , Karlsson Stig , Gustafson Yngve 
Published: September 2003

Objectives: To investigate whether delirium in older patients with femoral neck fractures is associated with an increased risk of developing dementia and a higher mortality rate.Design: A 5‐year prospective follow‐up study.Setting: Department of Orthopedic Surgery at the University Hospital in Umeå, Sweden.Participants: Seventy‐eight nondemented patients aged 65 and older operated on for femoral neck fractures were followed for 5 years.Measurements: The patients were assessed using the Organic Brain Syndrome (OBS) Scale pre‐ and postoperatively. Medical and social data were collected from the patients, their caregivers, and medical records, and the survivors were visited and assessed with the OBS Scale and the Mini‐Mental State Examination in their homes 5 years after the fracture.Results: Thirty of 78 (38.5%) nondemented patients with a femoral neck fracture developed dementia within a 5‐year period. Twenty of 29 (69%) who were delirious postoperatively developed dementia, compared with 10 of 49 (20%) who were not delirious during their hospital stay (P < .001). Twenty‐one (72.4%) of those with postoperative delirium died within 5 years, compared with 17 of 49 (34.7%) of those who remained lucid postoperatively (P = .001).Conclusion: Delirium in nondemented femoral neck fracture patients is associated with the development of dementia and a higher mortality rate. Patients with preoperative or postoperative delirium should therefore be assessed not only for the etiology of the delirium but also for any underlying organic brain disorder. Questions that remain unanswered are whether postoperative delirium is a marker of undetected dementia and whether postoperative delirium contributes to the development of dementia.
The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months
Authors: Visvanathan Renuka , Macintosh Caroline , Callary Mandy , Penhall Robert , Horowitz Michael , Chapman Ian 
Published: September 2003

OBJECTIVES: To identify predictors and consequences of nutritional risk, as determined by the Mini Nutritional Assessment (MNA), in older recipients of domiciliary care services living at home.DESIGN: Baseline analysis of subject characteristics with low MNA scores (<24) and follow‐up of the consequences of these low scores.SETTING: South Australia.PARTICIPANTS: Two hundred fifty domiciliary care clients (aged 67–99, 173 women).MEASUREMENTS: Baseline history and nutritional status were determined. Information about hospitalization was obtained at follow‐up 12 months later.INTERVENTION: Letters suggesting nutritional intervention were sent to general practitioners of subjects not well nourished.RESULTS: At baseline, 56.8% were well nourished, 38.4% were at risk of malnutrition, and 4.8% were malnourished (43.2% not well nourished). Independent predictors of low MNA scores (<24) were living alone, and the physical and mental component scales of the 36‐item Short Form Health Survey. Follow‐up information was obtained for 240 subjects (96%). In the ensuing year not well‐nourished subjects were more likely than well‐nourished subjects to have been admitted to the hospital (risk ratio (RR) = 1.51, 95% confidence interval (CI) = 1.07–2.14), have two or more emergency hospital admissions (RR = 2.96, 95% CI = 1.15–7.59), spend more than 4 weeks in the hospital (RR = 3.22, 95% CI = 1.29–8.07), fall (RR = 1.65, 95% CI = 1.13–2.41), and report weight loss (RR = 2.63, 95% CI = 1.67–4.15).CONCLUSION: The MNA identified a large number of subjects with impaired nutrition who did significantly worse than well‐nourished subjects during the following year. Studies are needed to determine whether nutritional or other interventions in people with low MNA scores can improve clinical outcomes.
A Model for Managing Delirious Older Inpatients
Authors: Flaherty Joseph H. , Tariq Syed H. , Raghavan Srinivasan , Bakshi Sanjeev , Moinuddin Asif , Morley John E. 
Published: September 2003

Although multiple models of care exist to prevent the development of delirium in hospitalized patients, models for the management of patients for whom delirium is unpreventable or who already have delirium on admission to the hospital are needed.This article describes the development, management, and economics of a new model of care for patients with delirium, called the Delirium Room (DR). The DR is a specialized 4‐bed unit that provides 24‐hour intensive nursing care and is completely free of physical restraints. Another important feature of the 4‐bed DR is that it is an integral part of a 22‐bed acute care for the elderly (ACE) unit. As such, patients in the DR benefit from features of the ACE unit: a change in the physical environment of the medical floor to promote mobility and function and discourage bedrest, comprehensive geriatric care that identifies and addresses problems that can lead to a decline in function, and use of a daily multidisciplinary team meeting.This article also presents descriptive data on a group of delirious patients managed in the DR with the intention of giving baseline data for other ACE units that are considering opening a DR or for future prospective studies in this area.
Medical Care of the Terminally Ill is More Than Symptom Management
Authors: Rainone Francine 
Published: September 2003

PURPOSE: To provide clinicians with a concise review of the literature applicable to clinical management of the dying patient.BACKGROUND: Various clinical trials,1 epidemiologic studies, and personal accounts have documented that a large part of the suffering of the terminally ill is preventable and ameliorable. Broadcast media2 and creative artists3 have also highlighted the fact that physicians are poorly prepared to recognize and address symptom management at the end of life.
Estimation of Glomerular Filtration Rate in Older Patients with Chronic Renal Insufficiency: Is the Modification of Diet in Renal Disease Formula an Improvement?
Authors: Lamb Edmund J. , Webb Michelle C. , Simpson David E. , Coakley Anthony J. , Newman David J. , O'Riordan Shelagh E. 
Published: September 2003

OBJECTIVES: To evaluate a new formula for glomerular filtration rate (GFR), derived from the Modification of Diet in Renal Disease (MDRD) study in older people.DESIGN: An observational study of the performance of the MDRD formula compared with other formulae and creatinine clearance (ClCr) as measures of the GFR.SETTING: Volunteers were recruited via outpatient clinics.PARTICIPANTS: Fifty‐two patients (27 men, 25 women: mean age 80, range 69–92) with a variety of medical diagnoses. Mean GFR was 53.3 mL/min/1.73 m2 (range 15.9–100.2). Exclusion criteria included renal replacement therapy/renal transplantation and cognitive impairment.MEASUREMENTS: 51Chromium ethylenediaminetetraacetic acid (51Cr EDTA) was used as the reference method against which the formulaic estimates of GFR were compared using bias plot and regression analyses.RESULTS: The MDRD and Cockcroft and Gault formulae (both coefficient of determination (R2) = 0.84) gave the best fit with GFR, followed by the Jelliffe formula (R2 = 0.81), ClCr (R2 = 0.73) and the Baracskay formula (R2 = 0.56). ClCr (−1.2%) demonstrated minimal bias compared with the MDRD (8.0%) and Cockcroft and Gault (−10.4%) formulae. However, imprecision compared with 51Cr EDTA was lowest for the Cockcroft and Gault formula, with 50% of estimates lying between −9.5 and −0.5 mL/min/1.73 m2 of measured 51Cr EDTA clearance. This compares with −6.7 and 10.1 mL/min/1.73 m2 for ClCr and 0.0 and 12.7 mL/min/1.73 m2 for the MDRD formula.CONCLUSION: Calculated estimates of GFR are an improvement over ClCr estimation. On balance, the MDRD formula does not improve the estimate of GFR compared with the Cockcroft and Gault formula in older Caucasian patients with chronic renal insufficiency.