1075 articles - 08.09.10
1: Age Ageing. 2010 Sep 4; [Epub ahead of print]
Thomas S, Mackintosh S, Halbert J.
Rehabilitation and Aged Care, Flinders University, Repatriation General Hospital, Daws Road, Daw Park, Adelaide, South Australia 5041, Australia.
BACKGROUND: the 'Otago exercise programme' (OEP) is a strength and balance retraining programme designed to prevent falls in older people living in the community. The aim of this review was to evaluate the effect of the OEP on the risk of death and fall rates and to explore levels of compliance with the OEP in older adults. METHODS: a systematic review with meta-analysis. Clinical trials where the OEP was the primary intervention and participants were community-dwelling older adults (65+) were included. Outcomes of interest included risk of death, number of falls, number of injurious falls and compliance to the exercise programme. RESULTS: seven trials, involving 1503 participants were included. The mean age of participants was 81.6 (+/-3.9) years. The OEP significantly reduced the risk of death over 12 months [risk ratio = 0.45, 95% confidence interval (CI) = 0.25-0.80], and significantly reduced fall rates (incidence rate ratio = 0.68, 95% CI = 0.56-0.79). There was no significant difference in the risk of a serious or moderate injury occurring as the result of a fall (risk ratio = 1.05, 95% CI = 0.91-1.22). Of the 747 participants who remained in the studies at 12 months, 274 (36.7%) were still exercising three or more times per week. CONCLUSION: the OEP significantly reduces the risk of death and falling in older community-dwelling adults.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20817938&dopt=ExternalLink
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PMID: 20817938 [PubMed - as supplied by publisher]2: J Am Geriatr Soc. 2010 Aug 24; [Epub ahead of print]
van Deijck RH, Krijnsen PJ, Hasselaar JG, Verhagen SC, Vissers KC, Koopmans RT.
De Zorggroep, region Venlo (EBC), Venlo, the Netherlands.
OBJECTIVES: To study the practice of continuous palliative sedation (CPS) by Dutch nursing home physicians in 2007. DESIGN: A structured retrospective questionnaire. SETTING: Nationwide nursing home physician study in the Netherlands. PARTICIPANTS: One thousand two hundred fifty-four nursing home physicians received a questionnaire concerning their last case of CPS in 2007; 54% (n=675) responded. MEASUREMENTS: Characteristics of CPS and requests for euthanasia were measured. RESULTS: Three hundred sixteen patients were described. The majority had cancer or dementia. The most-reported refractory symptoms were pain (52%), anxiety (44%), exhaustion (44%), dyspnea (40%), delirium (24%), loss of dignity (18%), and existential distress (16%). In 98% of cases, CPS was aimed at symptom relief. Of patients with cancer, 17% had previously requested euthanasia. The mean starting dose of midazolam was 31 mg every 24 hours (range 0-240 mg/24 h), and the mean end dose was 48 mg every 24 hours (range 0-480 mg/24 h). CONCLUSION: In addition to physical symptoms, anxiety, exhaustion, loss of dignity, and existential distress are often mentioned as refractory symptoms in the decision to start CPS by nursing home physicians. Furthermore, close to one in five patients with cancer had made a previous request for euthanasia. The dosage range of midazolam in this study fits the recommendations of the Dutch national guideline on palliative sedation, although international studies show smaller dosage ranges. Finally, prospective research about the acceptability and assessment of nonphysical symptoms as indications for CPS is recommended.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20738435&dopt=ExternalLink
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PMID: 20738435 [PubMed - as supplied by publisher]3: Age Ageing. 2010 Sep;39(5):542-8.
Van Pottelbergh G, Van Heden L, Mathei C, Degryse J.
Department of Primary Health Care, Katholieke Universiteit Leuven, Leuven, Belgium. gijs.vanpottelbergh@med.kuleuven.be
CONTEXT: multiple studies of elderly patients show that the prevalence of chronic renal failure in people aged 65 years and older is dependent on the method used to calculate the glomerular filtration rate. We performed a systematic literature search with research question: What is the best method that could be applicable in clinical practice for evaluating renal function in the elderly? Studies using inulin, Cr-51-EDTA, Tc-DTPA or iohexol assays as the gold standard were included. METHODS: we searched the PubMed and EMBASE databases. Articles found were screened first by title and abstract and then by five criteria. Retained articles were scored using an adapted version of QUADAS. RESULTS: twelve articles had an identified population or subpopulation aged 65 years and older. The studies were heterogeneous with regard to the population investigated and the statistical procedures used to compare the methods and equations with the gold standard. The Cockcroft-Gault (CG) and MDRD equations and the serum cystatin C concentration produced the highest correlations with the gold standard. CONCLUSIONS: no accurate method to evaluate renal function in the elderly was found. Serum cystatin C concentration and the CG and MDRD formula might be valuable parameters, although there is insufficient evidence.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20716584&dopt=ExternalLink
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PMID: 20716584 [PubMed - in process]4: J Am Geriatr Soc. 2010 Jul;58(7):1263-71.
Espeland MA, Brunner RL, Hogan PE, Rapp SR, Coker LH, Legault C, Granek I, Resnick SM; Women's Health Initiative Study of Cognitive Aging Study Group.
Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, NC 27157, USA. mespelan@wfubmc.edu
OBJECTIVES: To determine whether small decrements in global cognitive function that conjugated equine estrogen (CEE) therapies have been shown to produce in older women persist after cessation and extend to specific cognitive domains. DESIGN: Randomized controlled clinical trial. SETTING: Fourteen clinical centers of the Women's Health Initiative. PARTICIPANTS: Two thousand three hundred four women aged 65 to 80 free of probable dementia at enrollment. INTERVENTION: CEE 0.625 mg/d with or without medroxyprogesterone acetate (MPA, 10 mg/d) and matching placebos. MEASUREMENTS: Annual administrations of a battery of cognitive tests during and after the trial. RESULTS: Assignment to CEE-based therapies was associated with small mean relative decrements in global cognitive function and several domain-specific cognitive functions during the trial, which largely persisted through up to 4 years after the trial. The strongest statistical evidence was for global cognitive function (0.07-standard deviation decrements during (P=.007) and after (P=.01) the trial. For domain-specific scores, the mean decrements were slightly smaller, were less significant, and tended to be larger for CEE-alone therapy. CONCLUSION: CEE-based therapies, when initiated after the age of 65, produce a small broad-based decrement in cognitive function that persists after their use is stopped, but the differences in cognitive function are small and would not be detectable or have clinical significance for an individual woman. Differences in effects between cognitive domains suggest that more than one mechanism may be involved.
Publication Types: Research Support, N.I.H., Extramural Research Support, N.I.H., Intramural
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20649689&dopt=ExternalLink
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PMID: 20649689 [PubMed - in process]5: Age Ageing. 2010 Sep;39(5):617-23. Epub 2010 Jul 16.
Shah SM, Carey IM, Harris T, DeWilde S, Hubbard R, Lewis S, Cook DG.
Division of Community Health Sciences, St George's University of London, London, UK.
OBJECTIVES: to enhance identification of older nursing and residential home residents in a national sample and describe their chronic disease prevalence. DESIGN: cross-sectional analysis of an established primary care database (The Health Improvement Network). SETTING: 326 English and Welsh general practices. SUBJECTS: 435,568 patients aged > or = 65. Care home residents were identified by either a Read code for care home residence or multiple care home residence markers (postcode linkage, household size identifier and location of consultation). COMPARISONS: nursing and residential home residents were compared with a community control group with no markers of care home residence using age and sex standardised chronic disease prevalence ratios. MAIN OUTCOME MEASURES: chronic disease prevalence using definitions from the national primary care contract. RESULTS: 11,547 (2.7%) older people were identified as care home residents, of whom only 4,403 (38.1%) were directly identified by their primary care record. Mean age for nursing and residential homes was 84.9 and 86.1 years compared to 74.7 for controls. Prevalence ratios for dementia were 14.8 (95% CI 13.4-16.4) for nursing and 13.5 (12.4-14.8) for residential homes compared to controls. Stroke and severe mental illness were commoner in nursing and residential homes but hypertension, respiratory and cancer diagnoses were slightly less common. Recorded disease prevalences in nursing and residential homes were similar. CONCLUSIONS: recording of care home residence is limited in primary care and this is a barrier to routine monitoring of this group. Higher dementia and stroke prevalence in care home residents confirms high clinical need, but the small differences in disease prevalence between nursing and residential homes have implications for delivering medical and nursing care to residential homes. Lower prevalence of some chronic diseases suggests incomplete recording or case finding. Routine flagging of care home residents in health care systems is a potential tool for improving monitoring and outcomes.
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20639514&dopt=ExternalLink
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PMID: 20639514 [PubMed - in process]6: J Am Geriatr Soc. 2010 Jul;58(7):1299-310. Epub 2010 Jun 23.
Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC.
Division of Endocrinology and Metabolism, Department ofMedicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, MD 21287, USA. rrastogi@jhmi.edu
OBJECTIVES: To systematically review and quantitatively synthesize the effect of vitamin D therapy on fall prevention in older adults. DESIGN: Systematic review and meta-analysis. SETTING: MEDLINE, CINAHL, Web of Science, EMBASE, Cochrane Library, LILACS, bibliographies of selected articles, and previous systematic reviews through February 2009 were searched for eligible studies. PARTICIPANTS: Older adults (aged > or = 60) who participated in randomized controlled trials that both investigated the effectiveness of vitamin D therapy in the prevention of falls and used an explicit fall definition. MEASUREMENTS: Two authors independently extracted data, including study characteristics, quality assessment, and outcomes. The I(2) statistic was used to assess heterogeneity in a random-effects model. RESULTS: Of 1,679 potentially relevant articles, 10 met inclusion criteria. In pooled analysis, vitamin D therapy (200-1,000 IU) resulted in 14% (relative risk (RR)=0.86, 95% confidence interval (CI)=0.79-0.93; I(2)=7%) fewer falls than calcium or placebo (number needed to treat =15). The following subgroups had significantly fewer falls: community-dwelling (aged <80), adjunctive calcium supplementation, no history of fractures or falls, duration longer than 6 months, cholecalciferol, and dose of 800 IU or greater. Meta-regression demonstrated no linear association between vitamin D dose or duration and treatment effect. Post hoc analysis including seven additional studies (17 total) without explicit fall definitions yielded smaller benefit (RR=0.92, 95% CI=0.87-0.98) and more heterogeneity (I(2)=36%) but found significant intergroup differences favoring adjunctive calcium over none (P=.001). CONCLUSION: Vitamin D treatment effectively reduces the risk of falls in older adults. Future studies should investigate whether particular populations or treatment regimens may have greater benefit.
Publication Types: Research Support, N.I.H., Extramural
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20579169&dopt=ExternalLink
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PMID: 20579169 [PubMed - in process]7: J Am Geriatr Soc. 2010 Jul;58(7):1353-69. Epub 2010 Jun 1.
Papaleontiou M, Henderson CR Jr, Turner BJ, Moore AA, Olkhovskaya Y, Amanfo L, Reid MC.
Department of Medicine, Saint Peter's University Hospital, New Brunswick, NJ, USA.
This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80-7/1/09) with a mean study population age of 60 and older. Forty-three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60-73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain-producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5-156 weeks), and only five (12%) lasted longer than 12 weeks. In meta-analyses, effect sizes were -0.557 (P<.001) for pain reduction, -0.432 (P<.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36-item Health Survey was 0.191 (P=.17) for the physical component score and -0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short-term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long-term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20533971&dopt=ExternalLink
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PMID: 20533971 [PubMed - in process]8: J Am Geriatr Soc. 2010 Jun;58(6):1148-52. Epub 2010 May 7.
Hustey FM, Palmer RM.
Emergency Services Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. husteyf@ccf.org
OBJECTIVES: To determine whether the implementation of an Internet-based communication system improves the amount of essential information conveyed between a skilled nursing facility (SNF) and the emergency department (ED) during patient care transitions. DESIGN: Interventional; before and after. SETTING: ED of an urban teaching hospital with approximately 55,000 visits per year and a 55-bed subacute free-standing rehabilitation facility (the SNF). PARTICIPANTS: All patients transferred from the SNF to the ED over 16 months. INTERVENTION: An Internet-based communication network with SNF-ED transfer form for communication during patient care transitions. MEASUREMENTS: Nine elements of patient information assessed before and after intervention through chart review. Secondary outcomes: changes in efficiency of information transfer and staff satisfaction. RESULTS: Two hundred thirty-four of 237 preintervention and all 276 postintervention care transitions were reviewed. The Internet communication network was used in 78 (26%) of all care transitions, peaking at 40% by the end of the study. There was more critical patient information (1.85 vs 4.29 of 9 elements; P<.001) contained within fewer pages of transfer documents (24.47 vs 5.15; P<.001) after the intervention. Staff satisfaction with communication was higher among ED physicians after the intervention. CONCLUSION: The use of an Internet-based system increased the amount of information communicated during SNF-ED care transitions and significantly reduced the number of pages in which this information was contained.
Publication Types: Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20487072&dopt=ExternalLink
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PMID: 20487072 [PubMed - in process]9: Age Ageing. 2010 Jul;39(4):451-8. Epub 2010 May 18.
Boxer RS, Kleppinger A, Brindisi J, Feinn R, Burleson JA, Kenny AM.
Center on Aging, University of Connecticut Health Center, Farmington, 06030, USA.
OBJECTIVE: this analysis was to investigate the effects of dehydroepiandrosterone (DHEA) on cardiovascular risk factors in older women with frailty characteristics. DESIGN, SETTING AND PARTICIPANTS: the study was a double-blind, randomised, placebo-controlled trial of 99 women (mean 76.6 +/- 6.0 year) with the low DHEA-S level and frailty. INTERVENTION: participants received 50 mg/day DHEA or placebo for 6 months; all received calcium (1,000-1,200 mg/day diet) and supplement (combined) and cholecalciferol (1,000 IU/day). Women participated in 90-min twice weekly exercise regimens, either chair aerobics or yoga. MAIN OUTCOME MEASURES: assessment of outcome variables included hormone levels (DHEA-S, oestradiol, oestrone, testosterone and sex hormone-binding globulin (SHBG)), lipid profiles (total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglycerides), body composition measured by dual energy absorptiometry, glucose levels and blood pressure (BP). RESULTS: eighty-seven women (88%) completed 6 months of study; 88% were pre-frail demonstrating 1-2 frailty characteristics and 12% were frail with > or =3 characteristics. There were significant changes in all hormone levels including DHEA-S, oestradiol, oestrone and testosterone and a decline in SHBG levels in those taking DHEA supplements. In spite of changes in hormone levels, there were no significant changes in cardiovascular risk factors including lipid profiles, body or abdominal fat, fasting glucose or BP. CONCLUSION: research to date has not shown consistent effects of DHEA on cardiovascular risk, and this study adds to the literature that short-term therapy with DHEA is safe for older women in relation to cardiovascular risk factors. This study is novel in that we recruited women with evidence of physical frailty.
Publication Types: Research Support, N.I.H., Extramural Research Support, U.S. Gov't, Non-P.H.S.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20484057&dopt=ExternalLink
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PMID: 20484057 [PubMed - in process]10: J Am Geriatr Soc. 2010 May;58(5):950-66. Epub 2010 Apr 6.
Polinski JM, Bhandari A, Saya UY, Schneeweiss S, Shrank WH.
Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts 02120, USA. jpolinski@partners.org
In the months before and years since Medicare Part D's implementation in January 2006, many have been concerned with beneficiaries' ability to benefit from the complex program. A systematic review of published Medline and gray literature from January 1, 2005, to August 20, 2009, was undertaken to evaluate Medicare beneficiaries' knowledge about Part D and how this knowledge informed decisions regarding enrollment and plan choice. Thirty articles that reported original results describing seniors' knowledge of the Part D benefit, decision to enroll, or selection of plans; results from patient surveys addressing these issues; or results that analyzed enrollment data or plan selection patterns were included. Of these 30 articles, 10 described beneficiaries' knowledge, 12 described enrollment and plan choices, and eight described knowledge and choice. Across studies and years, beneficiaries' knowledge of the Part D program and benefit structure and design was poor, particularly with regard to the coverage gap and the low-income subsidy. Beneficiaries had great difficulty choosing the lowest-cost Part D plans and were disinclined to switch plans to improve their benefits. Knowledge deficits, enrollment problems, and plan choice difficulties were most pronounced during Part D implementation in early 2006 but persisted in subsequent years of the benefit. Beneficiaries' knowledge and choices should be monitored on an ongoing basis to inform potential changes to the Part D program.
Publication Types: Research Support, N.I.H., Extramural
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20406313&dopt=ExternalLink
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PMID: 20406313 [PubMed - in process]11: J Am Geriatr Soc. 2010 Apr;58(4):777-82.
LaMantia MA, Scheunemann LP, Viera AJ, Busby-Whitehead J, Hanson LC.
Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA. mlamanti@unch.unc.edu
Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't Review
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20398162&dopt=ExternalLink
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PMID: 20398162 [PubMed - indexed for MEDLINE]12: J Am Geriatr Soc. 2010 Apr;58(4):650-7.
Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, Lee SJ.
San Francisco VA Medical Center, and Department of Medicine, University of California San Francisco, San Francisco, California, USA. lee.jennings@ucsf.edu
OBJECTIVES: Although osteoporosis treatment can dramatically reduce fracture risk, rates of treatment after hip fracture remain low. In-hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. The objective of this study was to examine rates of in-hospital treatment with a combination of calcium and vitamin D (Cal+D) and antiresorptive or bone-forming medications in patients hospitalized for hip fractures DESIGN: Observational cohort. SETTING: Three hundred eighteen hospitals in the United States. PARTICIPANTS: Fifty-one thousand three hundred forty-six patients aged 65 and older hospitalized for osteoporotic hip fracture. MEASUREMENTS: In-hospital administration of Cal+D and antiresorptive or bone-forming medications. RESULTS: Three thousand four hundred five patients (6.6%) received Cal+D anytime after a procedure to correct femoral fracture; 3,763 patients (7.3%) received antiresorptive or bone-forming medications. Only 1,023 patients (2.0%) were prescribed ideal therapy, receiving Cal+D and an antiresorptive or bone-forming medication. Treatment rates remained low across virtually all patient-, provider-, and hospital-level characteristics. The strongest predictor of treatment with Cal+D was the receipt of an antiresorptive or bone-forming medication (adjusted odds ratio=5.50, 95% confidence interval=4.84-6.25), but only 27.2% of patients who received these medications also received Cal+D. CONCLUSION: Rates of in-hospital initiation of osteoporosis treatment for patients with hip fracture are low and may represent an opportunity to improve care.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20398147&dopt=ExternalLink
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PMID: 20398147 [PubMed - indexed for MEDLINE]13: J Am Geriatr Soc. 2010 Mar;58(3):472-9.
Downey L, Engelberg RA.
Division of Pulmonary and Critical Care, Department of Medicine, Harborview Medical Center, School of Medicine, University of Washington, Seattle, Washington 98104, USA. ldowney@u.washington.edu
OBJECTIVES: To compare quality-of-life (QOL) ratings of terminally ill patients with and without cancer over time. DESIGN: Secondary analysis of prospective data from a randomized clinical trial. SETTING: Trial conducted with terminally ill patients in Seattle, Washington, testing the efficacy of massage and guided meditation in improving patients' QOL. PARTICIPANTS: One hundred sixty-seven trial participants, of whom 127 provided follow-up data and died before data analysis. MEASUREMENTS: At enrollment, participants reported demographic characteristics, symptom distress, QOL, and primary life-limiting diagnosis. At enrollment and at follow-up interviews after every two study-provided treatment sessions, participants rated their perceived quality of life on a scale from 0 (no quality of life) to 10 (perfect quality). At the end of the study, the investigators added measures of patient's survival status, number of days between study enrollment and death, and receipt of hospice services to the data set. RESULTS: Multilevel models showed significantly steeper QOL declines for patients with cancer than for those without after adjustment for time between study enrollment and death. Over a 4-month before-death period, the average patient without cancer was estimated to experience a QOL decline of approximately 0.6 on a scale from 0 to 10, compared with a 1.2-point decline for patients with cancer. CONCLUSION: Patients with cancer face more-precipitous end-of-life challenges to quality of life than do other terminally ill persons. Therefore, clinicians must address QOL issues-not just symptom burden and distress. By introducing and discussing expected QOL declines at the end of life, clinicians may help to prepare, support, and reassure patients and their families.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20398115&dopt=ExternalLink
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PMID: 20398115 [PubMed - indexed for MEDLINE]14: J Am Geriatr Soc. 2010 Mar;58(3):427-34.
Yueh B, Collins MP, Souza PE, Boyko EJ, Loovis CF, Heagerty PJ, Liu CF, Hedrick SC.
Department of Otolaryngology/Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA. byueh@umn.edu
OBJECTIVES: To evaluate the effect of hearing screening on long-term hearing outcomes in a general population of older veterans. DESIGN: Hearing loss in the elderly is underdetected and undertreated. Routine hearing screening has been proposed, but it is not clear whether screening identifies patients who are sufficiently motivated to adhere to treatment. A four-arm randomized clinical trial was conducted to compare three screening strategies with no screening in 2,305 older veterans seeking general medical care. SETTING: Veterans Affairs Puget Sound Health Care System. INTERVENTIONS: The screening strategies were a tone-emitting otoscope, a widely used questionnaire about hearing handicap, and a combination of both tools. MEASUREMENTS: Hearing aid use 1 year after screening. RESULTS: Of participants who underwent screening with the tone-emitting otoscope, questionnaire, and combined testing, 18.6%, 59.2%, and 63.6%, respectively, screened positive for hearing loss (P<.01 for test of equality across three arms). Patients proceeded to formal audiology evaluation 14.7%, 23.0%, and 26.6% of the time in the same screening arms, compared with 10.8% in the control arm (P<.01 for test of equality across four arms). Hearing aid use 1 year after screening was 6.3%, 4.1%, and 7.4% in the same arms, compared with 3.3% in the control arm (P<.01). Hearing aid users experienced significant improvements in hearing-related function and communication ability. CONCLUSION: In older veterans, screening for hearing loss led to significantly more hearing aid use. Screening with the tone-emitting otoscope was more efficient. The results are most applicable to older populations with few cost barriers to hearing aids.
Publication Types: Comparative Study Randomized Controlled Trial Research Support, U.S. Gov't, Non-P.H.S.
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20398111&dopt=ExternalLink
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PMID: 20398111 [PubMed - indexed for MEDLINE]15: J Am Geriatr Soc. 2010 Feb;58(2):242-7. Epub 2010 Jan 26.
Gouin-Thibault I, Levy C, Pautas E, Cambus JP, Drouet L, Mahe I, Bal Dit Sollier C, Horellou MH, Golmard JL, Siguret V.
Laboratoire d'Hematologie, Assistance Publique Hopitaux de Paris, Hopital Charles Foix, 7 avenue de la Republique, 94205 Ivry sur Seine, France. isabelle.gouin@cfx.aphp.fr
OBJECTIVES: To determine the effect of patient characteristics and of specific guidelines that were developed for managing warfarin therapy in older adults and included in an in-house computer program on anticoagulation quality. DESIGN: Thirteen-month observational study. SETTING: Acute care, extended care, and rehabilitation geriatric wards of a teaching hospital in Paris, France. PARTICIPANTS: Hospitalized patients (N=307, mean age 86.1 +/- 6.1) treated with warfarin with a therapeutic international normalized ratio range of 2.0 to 3.0. INTERVENTION: Patients were assigned according to care unit to the computer-generated dosing group (CGD) or the standard management group (SM; usual physician-based care). MEASUREMENTS: Relationships between anticoagulation quality criteria and covariates (age, sex, warfarin indication, treatment phase, follow-up duration, model of care). RESULTS: According to multivariate analysis, only model of care and follow-up duration independently influenced anticoagulation control; the proportion of time within therapeutic INR range 2.0 to 3.0 was significantly greater in the CGD group than in the SM group (59% vs 48%, P=.004). When a wider INR range was analyzed (1.8-3.2), the proportion of time within range was 73% versus 64% (P=.006). Use of the computer was associated with fewer days with INRs greater than 3, a smaller percentage of INRs of 4 or greater, a longer time to the first INR of 4.0 or greater, and a smaller mean number of INRs per month than SM (all P<.01). CONCLUSION: Initiation regimen and long-term rules that have specifically been developed and included in a computerized dosage program improve quality of anticoagulation in elderly inpatients, allowing them to benefit from a quality of care as high as that of younger ambulatory patients.
Publication Types: Controlled Clinical Trial
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20374400&dopt=ExternalLink
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PMID: 20374400 [PubMed - indexed for MEDLINE]16: J Am Geriatr Soc. 2010 Feb;58(2):364-70.
Arbaje AI, Maron DD, Yu Q, Wendel VI, Tanner E, Boult C, Eubank KJ, Durso SC.
Division of Geriatric Medicine and Gerontology, Department of Medicine, School of Medicine, Johns Hopkins University, 5505 Hopkins Bayview Circle, Baltimore, MD 21224, USA. aarbaje@jhmi.edu
Older adults often receive suboptimal care during hospitalizations and transitions to postacute settings. Inpatient geriatric services have been shown to increase care quality but have not improved patient outcomes consistently. Acute Care for the Elderly units improve patient outcomes but are resource intensive. Transitional care has been shown to reduce hospital readmissions and healthcare costs. This article describes the Geriatric Floating Interdisciplinary Transition Team (Geri-FITT), a model that combines the strengths of inpatient geriatric evaluation and comanagement and transitional care models by creating an inpatient comanagement service that also delivers transitional care. The Geri-FITT model is designed to improve the hospital care of older adults and their transitions to postacute settings. In Geri-FITT, a geriatrician-geriatric nurse practitioner team assesses patients, comanages geriatric syndromes, provides staff education, encourages patient self-management, communicates with primary care providers, and follows up with patients soon after discharge. This pilot cohort study of Geri-FITT included hospitalized patients aged 70 and older on four general medicine services (two Geri-FITT, two usual care) at an academic medical center (N=717). The study assessed the effect of Geri-FITT on patients' care transition quality (Care Transitions Measure) and their satisfaction with hospital care (four questions). The results indicate that Geri-FITT is associated with slightly higher, though not statistically significantly so, quality care transitions and greater patient satisfaction with inpatient care. Geri-FITT may be a feasible approach to enhancing inpatient management and transitional care for older adults. Further study of its effect on these and other outcomes in other healthcare settings seems warranted.
Publication Types: Controlled Clinical Trial Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20370860&dopt=ExternalLink
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PMID: 20370860 [PubMed - indexed for MEDLINE]17: J Am Geriatr Soc. 2010 Feb;58(2):357-63.
Moore M, Williams B, Ragsdale S, Logerfo JP, Goss JR, Schreuder AB, Phelan EA.
Divisions of Gerontology and Geriatric Medicine, School of Public Health and Community Medicine, University of Washington, 325 9th Avenue, Box 359755, Seattle, WA 98104, USA. phelane@u.washington.edu
Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital-based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age-, sex-, and race-matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall-related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow-up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall-related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow-up; differences in fall-related healthcare use according to study group from baseline to follow-up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real-world clinical practice settings on key outcomes, including injurious falls, downstream fall-related healthcare use, and costs.
Publication Types: Controlled Clinical Trial Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20370859&dopt=ExternalLink
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PMID: 20370859 [PubMed - indexed for MEDLINE]18: J Am Geriatr Soc. 2010 Apr;58(4):658-63. Epub 2010 Mar 22.
Boonen S, Klemes AB, Zhou X, Lindsay R.
Bone Research Unit, Department of Experimental Medicine, Leuven University, Leuven, Belgium. steven.boonen@uz.kuleuven.ac.be
OBJECTIVES: To quantify the effect of age on the incidence of osteoporosis-related fractures and of risedronate treatment on fracture risk in different age groups in women with postmenopausal osteoporosis. DESIGN: Data from four randomized, double-blind, placebo-controlled, Phase III studies were pooled and analyzed. PARTICIPANTS: The analysis population (N=3,229) consisted of postmenopausal women with osteoporosis as determined on the basis of prevalent vertebral fractures, low bone mineral density (BMD), or both. INTERVENTION: Patients had received risedronate 5 mg daily or placebo for 1 to 3 years. MEASUREMENTS: The endpoints of interest were the incidence of osteoporosis-related fractures, clinical fractures, nonvertebral fractures, and morphometric vertebral fractures. The effect of age on fracture risk and treatment benefit was examined using Cox regression models with age and treatment as explanatory variables. The 3-year fracture risk was estimated for patients in each treatment group at a given age. RESULTS: Irrespective of treatment, fracture risks were greater in older patients (P<.001). On average, for every 1-year increase in age, a patient's risk for osteoporosis-related fracture increased 3.6% (95% confidence interval=2.3-5.0%). Irrespective of age, risedronate treatment reduced fracture risk 42%. Risedronate-treated patients had fracture risks similar to those of placebo-treated patients 10 to 20 years younger. CONCLUSION: Patients treated with risedronate have a significantly lower fracture risk, similar to that of untreated patients 10 to 20 years younger.
Publication Types: Meta-Analysis Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20345865&dopt=ExternalLink
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PMID: 20345865 [PubMed - indexed for MEDLINE]19: J Am Geriatr Soc. 2010 Apr;58(4):783-7. Epub 2010 Mar 22.
Berry SD, Ngo L, Samelson EJ, Kiel DP.
Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts 02131, USA. sarahberry@hrca.harvard.edu
Clinical studies often face the difficult problem of how to account for participants who die without experiencing the study outcome of interest. In a geriatric population with considerable comorbidities, the competing risk of death is especially high. Traditional approaches to describe risk of disease include Kaplan-Meier survival analysis and Cox proportional hazards regression, but these methods can overestimate risk of disease by failing to account for the competing risk of death. This report discusses traditional survival analysis and competing risk analysis as used to estimate risk of disease in geriatric studies. Furthermore, it illustrates a competing risk approach to estimate risk of second hip fracture in the Framingham Osteoporosis Study and compares the results with traditional survival analysis. In this example, survival analysis overestimated the 5-year risk of second hip fracture by 37% and the 10-year risk by 75% compared with competing risk estimates. In studies of older individuals in which a substantial number of participants die during a long follow-up, the cumulative incidence competing risk estimate and competing risk regression should be used to determine incidence and effect estimates. Use of a competing risk approach is critical to accurately determining disease risk for elderly individuals and therefore best inform clinical decision-making.
Publication Types: Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov't
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20345862&dopt=ExternalLink
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PMID: 20345862 [PubMed - indexed for MEDLINE]20: J Am Geriatr Soc. 2010 Mar;58(3):557-63. Epub 2010 Feb 22.
Perry M, Draskovic I, van Achterberg T, van Eijken M, Lucassen P, Vernooij-Dassen M, Olde Rikkert M.
Geriatric Medicine, 925, Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB, Nijmegen, the Netherlands. m.perry@ger.umcn.nl
OBJECTIVES: To construct a set of quality indicators (QIs) for dementia diagnosis and management in a primary care setting. DESIGN: RAND modified Delphi method, including a postal survey, a stakeholders consensus meeting, a scientific expert consensus meeting, and a demonstration project. SETTING: Primary care. PARTICIPANTS: General practitioners (GPs), primary care nurses (PCNs), and informal caregivers (ICs) in postal survey and stakeholders consensus meeting. Eight national dementia experts in scientific consensus meeting. Thirteen GPs in the demonstration project. MEASUREMENTS: Mean face validity and feasibility scores. Compliance rates using GPs' electronic medical record data. RESULTS: The initial set consisted of 31 QIs. Most indicators showed moderate or good face validity and feasibility scores. Consensus panels reduced the preliminary set used in the demonstration project to 24 QIs. The overall compliance to the QIs was 45.3%. Discriminative validity of the set was good; significant differences in adherence were found between GPs with high and low levels of patients aged 65 and older in their practice, with and without PCNs, and with positive and negative attitudes toward dementia (all P<.05). Based on the demonstration project, one QI was excluded. The final set consisted of 23 QIs; 15 QIs contained innovative quality criteria on collaboration between GPs and PCNs, referral criteria, and assessment of caregivers' needs. CONCLUSION: This new set of dementia QIs is feasible, reliable, and valid and can be used to improve primary dementia care. Because of the innovative quality criteria, the set is complementary to the existing dementia QIs.
Publication Types: Research Support, Non-U.S. Gov't Validation Studies
Links http://www.ncbi.nlm.nih.gov/entrez/queryd.fcgi?cmd=Retrieve&db=PubMed&list_uids=20210818&dopt=ExternalLink
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PMID: 20210818 [PubMed - indexed for MEDLINE]