Journal of American Geriatrics Society

Siegler, Eugenia L.; Capezuti, Elizabeth; Maislin, Greg; Baumgarten, Mona; Evans, Lois; Strumpf, Neville

doi: 10.1111/j.1532-5415.1997.tb01503.xpmid: 9215327

OBJECTIVES: To describe the changes in psychoactive drug use in nursing homes after implementation of physical restraint reduction interventions and mandates of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87). METHODS:A secondary analysis was conducted using data from a controlled clinical trial that took place in three nursing homes: a control home, one that received an educational intervention, and one that received an educational/consultation intervention. All three homes were influenced by the OBRA mandates. Complete pre‐ and 6 months' post‐intervention data on use of psychoactive drugs and physical restraints were available for 446 resident subjects. Changes were first analyzed with the resident subject as the unit of analysis and then using the nursing home ward (n = 16) as the unit of analysis. RESULTS: While physical restraint use declined in the home that received the educational/consultation intervention, neither neuroleptic nor benzodiazepine use increased in any of the homes after the interventions. The percentage of residents taking neuroleptics declined in the control home (18.6% to 11.3%, P = .014). Benzodiazepine use, which was more prevalent than described previously in the literature, declined in all three homes (P < .001). Of those residents whose physical restraints were discontinued, only 2% were started on neuroleptics. When the effect of OBRA mandates on appropriateness of neuroleptic use was examined, the percentage of residents on neuroleptics who lacked an OBRA‐approved indication declined from 21.3% to 14.6% in the total sample, and from 39.9% to 8% in the control home. CONCLUSIONS: Interventions to reduce physical restraint did not lead to an increase in psychoactive drug use; further, reduction in both can occur simultaneously. OBRA mandates regarding psychoactive drug use were not uniformly effective, but appear, at minimum, to have increased awareness of the indications for neuroleptics.

Parker, Kara; Miles, Steven H.

doi: 10.1111/j.1532-5415.1997.tb01504.xpmid: 9215328

OBJECTIVES: To determine how bedrails cause death in order to suggest clinical and ergonomic changes to prevent such deaths and to promote research to improve the use and design of bed systems. DESIGN: A review of reports of adult deaths and injuries from bedrails contained in the United States Consumer Product Safety Commission Death Certificate File and its Reported Incidents File and its National Injury Information Clearinghouse Accident Investigations from 1993 to 1996. Deaths involving the use of vest restraints were excluded. We reconstructed, reenacted, and have graphically depicted major patterns of deaths. A review of the literature to 1966 was also done. RESULTS: The 74 deaths described are categorized into three types: (1) 70% were entrapments between the mattress and a rail so that the face was pressed against the mattress, (2) 18% were entrapment and compression of the neck within the rails, and (3) 12% were deaths caused by being trapped by the rails after sliding partially off the bed and having the neck flexed or the chest compressed. CONCLUSIONS: Deaths from bedrails are underrecognized and preventable clinical events that can occur in any medical setting. Preventing these events will require a unified redesign of the relationships between rails, mattresses, and beds, which are now often assembled and used as separate products. Clinicians can prevent many of these deaths by using bedrails much more judiciously, confirming the proper relationships between beds, rails and mattresses, and using alarms.

Rajkumar, Chakravarthi; Cameron, James D.; Christophidis, Nicholas; Jennings, Garry L.; Dart, Anthony M.

doi: 10.1111/j.1532-5415.1997.tb01505.xpmid: 9215329

OBJECTIVES: To study the relationship between left ventricular diastolic function and systemic arterial compliance in the older population. DESIGN: Cross‐sectional survey. PARTICIPANTS: A total of 67 older volunteer participants (aged 67 ± 5.4 years). MEASUREMENTS: Systemic arterial compliance (SAC) was measured using applanation tonometry and aortic velocimetry, and diastolic function was assessed using Doppler filling. Left ventricular mass was determined echocardiographically. RESULTS: There were significant univariate correlations between diastolic filling, as measured by E/A ratio, systemic arterial compliance (0.34, P < .01), and left ventricular mass (‐0.41, P < .001). In multiple regression analysis, using diastolic filling as the dependent variable and heart rate, age, left ventricular mass corrected for body surface area, systolic and diastolic blood pressures, and arterial compliance as independent variables, the major determinants of diastolic filling were heart rate, left ventricular mass, and diastolic blood pressure. Arterial compliance did not make a significant independent contribution. CONCLUSION: This study demonstrates a positive relationship between diastolic filling and arterial compliance in the older population. However, in multiple regression analysis, heart rate, diastolic blood pressure, and left ventricular mass were the independent predictors of diastolic filling (E/A), whereas arterial compliance was not. These findings imply that therapeutic modulation of aortic stiffness would not, of itself, contribute to improvement in diastolic function.

Fishkind, Deborah; Paris, Barbara E. C.; Aronow, Wilbert S.

doi: 10.1111/j.1532-5415.1997.tb01506.xpmid: 9215330

OBJECTIVE: To investigate the prevalence of and indications for digoxin use and the prevalence of beta blocker and calcium channel blocker use in older patients with pevious myocardial infarction or coronary artery disease (CAD), and the prevalence of use of diuretics, beta blockers, angiotensin‐converting enzyme (ACE) inhibitors, and calcium channel blockers in older patients with hypertension in an academic hospital‐based geriatrics practice. DESIGN: A retrospective analysis of charts from 528 unselected older patients, seen from June 1995 through July 1996 at an academic hospital‐based geriatrics practice, was performed to investigate the prevalence of digoxin use and indications for digoxin use, the prevalence of beta blocker and calcium channel blocker use in older patients with previous myocardial infarction or coronary artery disease (CAD), and the prevalence of use of diuretics, beta blockers, angiotensin‐converting enzyme (ACE) inhibitors, and calcium channel blockers in older patients with hypertension. SETTING: An academic hospital‐based, primary care geriatrics practice staffed by fellows in a geriatrics training program and full‐time faculty geriatricians. PATIENTS: A total of 416 women and 112 men, mean age 81 ± 8 years (range 58 to 101), were included in the study. MEASUREMENTS AND MAIN RESULTS: Ninety‐two of the 528 patients (17%) were taking digoxin. Recorded indications for digoxin were atrial fibrillation with or without congestive heart failure (CHF) in 39% of patients, CHF with sinus rhythm and abnormal left ventricular ejection fraction (LVEF) in 18% of patients, a clinical assessment of CHF with sinus rhythm and no recorded measurement of LVEF in 20% of patients, paroxysmal atrial fibrillation in 14% of patients, and coronary artery disease (CAD) in 9% of patients. Of 121 patients with previous myocardial infarction, 23 (19%) were prescribed beta blockers, and 54 (45%) were taking calcium channel blockers. Of 173 patients with CAD, 41 (24%) were treated with beta blockers, and 79 (46%) were taking calcium channel blockers. LVEF was not recorded in the charts of 90 of 121 patients (74%) with prior myocardial infarction and of 125 of 173 patients (72%) with CAD. Of 480 older patients with hypertension, 154 (37%) were treated with diuretics, 55 (13%) were treated with beta blockers, 160 (38%) were treated with ACE inhibitors, and 197 (47%) were treated with calcium channel blockers. CONCLUSIONS: In 528 older patients seen in an academic hospital‐based geriatrics practice, the prevalence of digoxin use was 19%. Appropriate indications for digoxin were documented clearly in the charts of 53 of 92 patients (57%). Calcium channel blockers were used more often than beta blockers in patients with previous myocardial infarction or CAD. Calcium channel blockers were the most frequently used antihypertensive drugs.

Garcia, Gloria V.; Freeman, Rosario V.; Supiano, Mark A.; Smith, Maria J.; Galecki, Andrzej T.; Halter, Jeffrey B.

doi: 10.1111/j.1532-5415.1997.tb01507.xpmid: 9215331

OBJECTIVE: This study was undertaken to understand the dynamics of glucose metabolism in healthy non‐diabetic subjects older than age 80 (old‐old) compared with subjects aged 61 to 79 (young‐old), as well as to compare healthy older subjects with impaired glucose tolerance (IGT) with older subjects with normal glucose tolerance (NGT). DESIGN: A cross sectional, observational study. SETTING: A university hospital clinical research center. PARTICIPANTS: There were 28 community‐dwelling adults, 10 older than age 80 and 18 aged 61 to 79. Thirteen of these people had NGT and 15 had IGT. Subjects were not taking any medication that interfered with glucose tolerance. MEASUREMENTS: Status of glucose tolerance was determined by an oral glucose tolerance test categorized as NGT or IGT according to WHO criteria. Insulin sensitivity (SI and glucose effectiveness (SG) were assessed using a tolbutamide‐assisted intravenous glucose tolerance test (IVGTT). The data were analyzed using the Minmod modeling program. Glucose tolerance (Kg) and the acute insulin response to glucose (AIRg) were calculated from the IVGTT. RESULTS: There were no significant differences between the young‐old and old‐old in body mass index or in plasma glucose, insulin, or C‐peptide levels in the fasting state or during the OGTT. Values for Kg, SI SG, and AIRg from the IVGTT were similar in the two age groups. When the subjects were classified by glucose tolerance status, the subjects with NGT had age, gender, and body mass index similar to the subjects with IGT. Older people with IGT had a lower Kg and tended to have higher fasting glucose and similar fasting insulin compared with people with NGT. IGT subjects had lower S) and tended to have lower SG. The AIRg in IGT subjects tended to be low rather than high when compared with older people with NGT. CONCLUSION: Otherwise healthy adults more than 80 years of age have measures of glucose metabolism similar to people aged 61 to 79. The presence of IGT in older adults is associated with insulin resistance, regardless of patient age. We hypothesize that the lack of pancreatic islet compensation for insulin resistance may contribute to impaired glucose tolerance in older adults.

Mattimore, Thomas J.; Wenger, Neil S.; Desbiens, Norman A.; Teno, Joan M.; Hamel, Mary Beth; Liu, Honghu; Califf, Robert; Connors, Alfred F.; Lynn, Joanne; Oye, Robert K.

doi: 10.1111/j.1532-5415.1997.tb01508.xpmid:

Anía, Basilio J.; Suman, Vera J.; Fairbanks, Virgil F.; Rademacher, Diana M.; III, L. Joseph Melton

doi: 10.1111/j.1532-5415.1997.tb01509.xpmid: 9215333

OBJECTIVE: To assess the incidence and clinical spectrum of anemia among older people. DESIGN: Inception cohort assembled and followed by medical records linkage until death or last clinical contact through January 1994. SETTING: Population‐based study in Olmsted County, Minnesota. PARTICIPANTS: All 618 Olmsted County men and women aged 65 years or more with anemia by World Health Organization criteria that was first recognized in 1986. MEASUREMENTS: Age‐ and sex‐adjusted incidence rates, corrected for prevalent anemia, and survival estimates using the Kaplan‐Meier method, with calculation of standardized mortality ratios for specific causes of death. RESULTS: The corrected annual incidence of anemia rose with age, and rates were higher in men (90.3 per 1000; 95% CI, 79.2–101.4) than women (69.1 per 1000; 95% CI, 62.3–75.8). In 465 cases (75%), anemia was detected in conjunction with a hospitalization, but admission was due to anemia in only 57 instances. Half of the cases were caused by blood loss, two‐thirds of these as a result of surgery. The cause of anemia was uncertain in 102 cases (16%). One‐third of the patients were transfused with a median of 3 units each. Overall survival was worse than expected but was better among those with anemia caused by blood loss. Mortality attributable to malignancy, mental disorders, circulatory and respiratory diseases, ill‐defined conditions, and injuries was significantly increased among these older patients with anemia. CONCLUSIONS: The incidence of anemia among older people is 4 to 6 times greater than that suspected clinically, rises with age, and is higher in men than in women. The apparent cause in half the cases is blood loss. Even mild anemia is associated with reduced survival, especially during the first year, but this could relate to underlying comorbid conditions.

Sinoff, Gary; Ore, Liora

doi: 10.1111/j.1532-5415.1997.tb01510.xpmid: 9215334

BACKGROUND AND PURPOSE: The Barthel Index for assessing activities of daily living (ADL) was developed particularly for young stroke patients, but it now has a wider application in the geriatric assessment profile. This study tests the validity of the Barthel Index by self‐report in the old‐old (≥ 75 years). If more than 10% of the studied population assessed themselves incorrectly (≥ 15‐point discrepancy), the test may have limitations. We set out to try to quantify and explain this discrepancy. METHODS: During a 3‐month period, we tested 126 old‐old patients, both geriatric medical inpatients and subjects from the community, in a cross‐sectional study. Using the Barthel Index, their functional status was assessed by self‐report and by observation of performance. A measure of the magnitude of discrepancy between the two methods (discrepancy score) was calculated as the difference between the self‐report and performance total scores. RESULTS: Comparing the self‐report with actual ADL performance scores, the mean score for self‐report was higher (90 vs 88). There was a low Kappa score in all areas of the scale (range 0.103–0.398). Twenty of the 126 patients (15.9%) scored 15 or more points in the discrepancy score. By running a multiple linear regression, we were able to explain only 21% of the variance in the discrepancy score (R2 = .21). Significant explanatory variables were the presence of cognitive impairment, source of patients from acute geriatric ward, and age (very old ≥ 85 years). CONCLUSION: For the purpose of this study, use of the Barthel Index by self‐reporting was found to have its limitations in the old‐old (≥ 75 years), particularly with regard to the very old (≥ 85 years) medical geriatric inpatients. Therefore, we suggest that the older people may have to be assessed by the rehabilatation services using a performance‐based measure or a different self‐report test for documenting their activities of daily living, bearing in mind that self‐reported and performance‐based measures capture physical abilities differently.

Goran, Michael I.; Toth, Michael J.; Poehlman, Eric T.

doi: 10.1111/j.1532-5415.1997.tb01511.xpmid: 9215335

OBJECTIVE: To cross‐validate existing equations in the literature for their accuracy and precision for estimating body fat in older people from anthropometric measures and height2/resistance, using the 4‐compartment model as a criteria method, and to propose new practical equations with improved accuracy and precision. DESIGN: Measurement of body composition in a cross‐sectional cohort of healthy men and women and comparison by cross‐validation techniques against existing prediction equations. SETTING: The study was performed on subjects admitted to a General Clinical Research Center. PARTICIPANTS: The subjects were 41 healthy women (68.2 ± 6.6 years; 64.1 ± 10.2 kg) and 41 healthy men (70.2 ± 7.0 years; 74.9 ±11.0 kg). MEASUREMENTS: The criteria method for total body composition was the 4‐compartment model based on measurement of total body density by underwater weight, total body water by isotope dilution, and total bone mineral from dual energy X‐ray absorptiometry. The other techniques examined for accuracy and validity were body fat estimates derived by skinfolds using the Durnin and Womersley Equations; waist circumference and age using the Lean Equations; and bio‐electrical resistance using five published equations, including two derived in the older population. RESULTS: When compared with data derived from the 4‐compartment model, the skinfold equation of Durnin and Womersley was cross‐validated successfully in women but not in men. The Baumgartner equation was the only bioelectrical resistance equation that met the criteria for successful cross‐validation in men and women, although in women the intercept (4.0 ±2.1 kg) was close to significantly different from zero (P = .06). Error in the estimates of body fat using the Durnin and Womersley and the Baumgartner equations was significantly and inversely related to fat mass (r = ‐.39 to r = ‐.56). In our data, the significant predictors of fat mass were hip circumference, calf skinfold, gender, body weight, height2/resistance, and biceps skinfold, explaining 84% of the variance. CONCLUSIONS: The Durnin and Womersley equation is accurate for women and the Baumgartner equation is accurate for both men and women if a correction of +4 kg is made in women; however, for both equations the error in the estimate is inversely related to fat mass. We suggest new anthropometric equations for estimating body fat in older people, which may improve accuracy and precision. The new equations will need to be tested in independent cross‐validation studies.

Whetten‐Goldstein, Kathryn; Sloan, Frank; Kulas, Elizabeth; Cutson, Toni; Schenkman, Margaret

doi: 10.1111/j.1532-5415.1997.tb01512.xpmid: 9215336

OBJECTIVE: To examine the burden of Parkinson's Disease (PD) on society, family, and the individual. SETTING: In‐home interviews in Central North Carolina. DESIGN: A cross‐sectional, descriptive study. PARTICIPANTS: A total of 109 people with PD. MEASURES: Standard instruments used to assess income, health status, health‐related costs, and household activities. SAMPLE: The sample was weighted toward individuals who were within the first 5 years of post‐PD diagnosis. RESULTS: The total per capita societal burden was approximately $6000 per year, the greatest single element of which was compensation for earnings loss for those less than age 65. Government insurance covered 85% of our sample. The largest components of family burden were the burden of providing informal caregiving and that of earnings loss. Spouses providing informal care did so a mean of 22 hours per week. Compared with a random sample of older people, our respondents spent much less time on house and yard work. CONCLUSION: The direct costs of the disease reflect a small portion of the burden. The hidden costs, in the form of lost wages, informal care, and changing roles are substantial. Their magnitude is even more important when we consider that the family generally lives on a fixed income, and the caregiver is an older aged spouse. Medical practitioners will best be able to intervene if they look holistically at the patient with this disease. When treating symptoms themselves, practitioners need to be aware of the high level of pain, fatigue, and depression associated with PD, even in the early stages. The results demonstrate clearly that family relationships are affected early, indicating the importance of providing early referrals to services such as home health, social workers/counseling, and well as PD support groups.