Journal of American Geriatrics Society

Arora, Vineet M.; Johnson, Martha; Olson, Jared; Podrazik, Paula M.; Levine, Stacie; DuBeau, Catherine E.; Sachs, Greg A.; Meltzer, David O.

doi: 10.1111/j.1532-5415.2007.01444.xpmid: 17979894

OBJECTIVES: To assess the quality of care for hospitalized vulnerable elders using measures based on Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs). DESIGN: Prospective cohort study. SETTING: Single academic medical center. PARTICIPANTS: Subjects aged 65 and older hospitalized on the University of Chicago general medicine inpatient service who were defined as vulnerable using the Vulnerable Elder Survey‐13 (VES‐13), a validated tool based on age, self‐reported health, and functional status. MEASUREMENTS: Inpatient interview and chart review using ACOVE‐based process‐of‐care measures referring to 16 QIs in general hospital care and geriatric‐prevalent conditions (e.g., pressure ulcers, dementia, and delirium); adherence rates calculated for type of care process (screening, diagnosis, and treatment) and type of provider (doctor, nurse). RESULTS: Six hundred of 845 (71%) older patients participated. Of these, 349 (58%) were deemed vulnerable based on VES‐13 score. Three hundred twenty‐eight (94%) charts were available for review. QIs for general medical care were met at a significantly higher rate than for pressure ulcer care (81.5%, 95% confidence interval (CI)=79.3–83.7% vs 75.8%, 95% CI=70.5–81.1%, P=.04) and for delirium and dementia care (81.5%, 95% CI=79.3–83.7 vs 31.4% 95% CI=27.5–35.2%, P<.01). According to standard nursing assessment forms, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P<.001 when compared with physicians), although in patients with functional limitations, nurse admission assessments of functional limitations often did not agree with reports of limitations by patients on admission. CONCLUSION: Adherence to geriatric‐specific QIs is lower than adherence to general hospital care QIs. Hospital care QIs that focus on screening may overestimate performance by detecting standard nursing or protocol‐driven care.

Estrada, Marcos; Kleppinger, Alison; Judge, James O.; Walsh, Stephen J.; Kuchel, George A.

doi: 10.1111/j.1532-5415.2007.01436.xpmid: 17979895

OBJECTIVES: To determine whether adjustment of muscle mass for height2 or for body mass represents a more‐relevant predictor of physical performance. DESIGN: Cross‐sectional study, using baseline data from a trial comparing upper‐ and lower‐body training. SETTING: Women recruited from the community and gynecological practices in Connecticut. PARTICIPANTS: One hundred eighty‐nine healthy older (aged 67.5 ± 4.8), active women receiving estrogen for osteoporosis over 2 years. MEASUREMENTS: Total and appendicular skeletal muscle (ASM) and fat mass (AFM) were determined using dual x‐ray absorptiometry. Physical performance, muscle strength, and fitness measures were obtained at baseline. RESULTS: Adjusting ASM for height2 identifies lean women who are sarcopenic according to published standards yet fails to identify overweight and obese women whose ASM adjusted for body mass is low. ASM divided by body mass (ASM/body mass) is a stronger physical performance predictor, explaining 32.5%, 13.5%, 11.6%, 6.3%, and 6.8% of the variance in maximum time on treadmill, 6‐minute walk, gait speed, 8‐foot walk, and single leg stance, respectively, whereas ASM divided by height in m2 (ASM/height2) explained only 2.9%, 0.2%, 2.0%, 0.04%, and 0.1%. Multivariate modeling demonstrated considerable overlap in aspects of ASM/body mass and AFM/body mass associated with performance, with ASM/body mass dominant. In contrast, ASM/height2 is a much stronger predictor of leg press 1 repetition maximum and maximum power. CONCLUSION: The results suggest that relative sarcopenia with ASM adjusted for body mass is a better mobility predictor, with absolute sarcopenia a better indicator of isolated muscle group function in healthy postmenopausal women receiving estrogen replacement.

Vestergaard, Peter; Rejnmark, Lars; Mosekilde, Leif

doi: 10.1111/j.1532-5415.2007.01420.xpmid: 17916118

OBJECTIVES: To study changes in mortality and causes of death in patients suffering a hip fracture between 1981 and 2001. DESIGN: Historic, register‐based cohort study. SETTING: Nationwide cohort study in Denmark. PARTICIPANTS: All 163,313 patients suffering a hip fracture between 1981 and 2001 in Denmark and 505,960 age‐ and sex‐matched controls. INTERVENTIONS: Osteosynthesis, arthroplasty, or other management for the hip fracture. MEASUREMENTS: Mortality and cause of death at 30 days and 1 year. RESULTS: The mean age of the patients with hip fracture increased (from 75.8 in 1981 to 78.1 in 2001, P<.01), and the proportion of men with hip fracture also increased (from 25.5% to 29.8%, P<.01). A statistically significant decrease was observed in crude 1‐year survival. Mortality increased in subjects with a hip fracture from 1981/85 to 1986/2001, whereas it decreased among controls. There was significantly greater mortality in patients undergoing arthroplasty (relative risk=1.05, 95% confidence interval=1.03–1.07) than in those undergoing osteosynthesis. Causes of death related to the trauma that caused the fracture explained most of the deaths (68–76%) within the first 30 days after the fracture. CONCLUSION: Significant demographic changes took place, with older people and more men experiencing hip fracture. After adjustment for age, sex, and comorbidity, survival was poorer in patients suffering a hip fracture than in controls. This calls for measures to improve survival.

Hardy, Susan E.; Perera, Subashan; Roumani, Yazan F.; Chandler, Julie M.; Studenski, Stephanie A.

doi: 10.1111/j.1532-5415.2007.01413.xpmid: 17916121

OBJECTIVES: To estimate the relationship between 1‐year improvement in measures of health and physical function and 8‐year survival. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Persons aged 65 and older (N=439). MEASUREMENTS: Six measures of health and function assessed at baseline and quarterly over 1 year. Participants were classified as improved at 1 year, transiently improved, or never improved for each measure using a priori definitions of meaningful change: gait speed (usual walking pace over 4 m), 0.1 m/s; Short Physical Performance Battery, 1 point; Medical Outcomes Study 36‐item Short Form Health Survey physical function, 10 points; EuroQol, 0.1 point; National Health Interview activity of daily living scale, 2 points; and global health change, two levels or reaching the ceiling. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, and hospitalization. RESULTS: Of the six measures, only improved gait speed was associated with survival. Mortality after 8 years was 31.6%, 41.2%, and 49.3% for those with improved, transiently improved, and never improved gait speed, respectively. The survival benefit for improvement at 1 year persisted after adjustment for covariates (hazard ratio=0.42, 95% confidence interval=0.29–0.61, P<.001) and was consistent across subgroups based on age, sex, ethnicity, initial gait speed, healthcare system, and hospitalization. CONCLUSION: Improvement in usual gait speed predicts a substantial reduction in mortality. Because gait speed is easily measured, clinically interpretable, and potentially modifiable, it may be a useful “vital sign” for older adults. Further research is needed to determine whether interventions to improve gait speed affect survival.

Garber, Alan J.; Clauson, Per; Pedersen, Claus B.; Kølendorf, Klaus

doi: 10.1111/j.1532-5415.2007.01414.xpmid: 17979896

OBJECTIVES: To compare the safety and efficacy of insulin detemir with that of neutral protamine Hagedorn (NPH) insulin in older (aged ≥65) and younger (aged 18–64) persons with type 2 diabetes mellitus (DM). DESIGN: Pooled, post hoc analysis of data from three open‐label, randomized studies. SETTING: Three multinational Phase III trials. PARTICIPANTS: Four hundred sixteen older and 880 younger persons with DM, treated for 22 to 26 weeks with basal insulin plus mealtime insulin or oral agents. MEASUREMENTS: Hemoglobin A1c (HbA1c), fasting plasma glucose, glucose variability, hypoglycemic episodes. RESULTS: Mean treatment difference for HbA1c (insulin detemir–NPH insulin) indicated that insulin detemir was not inferior to NPH insulin for both age groups (0.035%, 95% confidence interval (CI)=−0.114–0.183 and 0.100%, 95% CI=−0.017–0.217, for older and younger persons, respectively). Relative risk of all hypoglycemic episodes (insulin detemir/NPH insulin) was 0.59 (95% CI‐0.42–0.83) for older persons and 0.75 (95% CI‐0.59–0.96) for younger persons. Adverse events were similar between treatments. Fasting plasma glucose was similar between treatments (mean treatment difference 0.97 mg/dL, 95% CI=−8.01–9.95, and 4.69 mg/dL, 95% CI=−2.30–11.67, for older and younger persons, respectively). Mean treatment difference for weight was −1.02 kg (95% CI −1.61 to −0.42) and −1.13 (95% CI −1.58 to −0.69) for older and younger persons, respectively. CONCLUSION: Previously reported benefits of insulin detemir, particularly less hypoglycemia and less weight gain, compared with NPH insulin, were the same for older and younger persons with DM at similar levels of HbA1c.

Sand, Kelly L.; Lynn, Joanne; Bardenheier, Barbara; Seow, Hsien; Nace, David A.

doi: 10.1111/j.1532-5415.2007.01422.xpmid: 17979897

OBJECTIVES: To improve staff immunization rates for influenza in long‐term care facilities (LTCFs). DESIGN: A quality improvement project. SETTING: LTCFs ranging in size from 50 to 2,000 beds. PARTICIPANTS: Staff members at facilities. MEASUREMENTS: Change in staff influenza immunization rate. RESULTS: Of the 13 nursing homes involved, 11 improved their staff influenza immunization rates; nine improved more than 10%, and six improved to a rate greater than 55%, a level that corresponds to substantial protection against outbreaks. Staff education was essential but insufficient. Direct encouragement and dramatic informative endeavors helped, as did financial incentives, competitions, and requiring unambiguously worded consents for refusals. Paying staff members $150 each achieved improvement rapidly. CONCLUSION: Quality improvement increased staff immunization rates at LTCFs, which reduces the risk of an influenza outbreak. Based on the insights learned about effective changes, the project developed a change package for use by other LTCFs.

Phelan, Elizabeth A.; Balderson, Benjamin; Levine, Martin; Erro, Janet H.; Jordan, Luesa; Grothaus, Lou; Sandhu, Nirmala; Perrault, Patrick J.; LoGerfo, James P.; Wagner, Edward H.

doi: 10.1111/j.1532-5415.2007.01416.x

Gill, Thomas M.; Han, Ling; Allore, Heather G.

doi: 10.1111/j.1532-5415.2007.01421.xpmid: 17916117

OBJECTIVES: To determine whether the availability of bath aids may forestall the subsequent development of bathing disability. DESIGN: Prospective cohort study. SETTING: Greater New Haven, Connecticut. PARTICIPANTS: Five hundred one nondisabled (required no personal assistance in bathing) community‐living residents aged 73 and older. MEASUREMENTS: The availability of five bath aids (grab bars, bath seat, nonskid mat or abrasive strips, handheld shower spray, and long‐handled brush or sponge) was ascertained during a comprehensive home‐based assessment. Subsequently, participants were followed with monthly telephone interviews to determine the onset of persistent (i.e., present for at least 2 consecutive months) disability in bathing and were evaluated for disability in three bathing subtasks (bathing transfers, washing whole body, and drying whole body) during the next home‐based assessment, which was completed 18 months after the initial assessment. RESULTS: The presence of a bath seat was associated with a greater likelihood of developing persistent disability in bathing and disability in each of the three bathing subtasks, although these associations were not statistically significant after adjustment for potential confounders. Nonsignificantly greater risk was also observed for grab bars, handheld shower spray, and long‐handled brush or sponge. In the adjusted analysis, the presence of nonskid mats or abrasive strips was associated with a 23% lower risk (nonsignificant) of persistent bathing disability and a lower likelihood of developing disability in washing and drying one's whole body, with corresponding odds ratios of 0.28 (P=.003) and 0.38 (P=.030), respectively. CONCLUSION: In this longitudinal study, the presence of bath aids, with the exception of nonskid mats or abrasive strips, did not forestall the subsequent development of bathing disability. Because it may not be possible to fully account for the effects of self‐selection, clinical trials may be necessary to demonstrate the potential value of bath aids in community‐living older persons.

Vogels, Raymond L.C.; Oosterman, Joukje M.; Van Harten, Barbera; Scheltens, Philip; Van Der Flier, Wiesje M.; Schroeder‐Tanka, Jutta M.; Weinstein, Henry C.

doi: 10.1111/j.1532-5415.2007.01395.xpmid: 17727641

OBJECTIVES: To determine the frequency and pattern of cognitive dysfunction in outpatients with chronic congestive heart failure (CHF) and to identify the corresponding demographic and clinical correlates. DESIGN: Case‐control study. SETTING: Outpatient clinic in a community hospital. PARTICIPANTS: Sixty‐two outpatients with CHF, 53 controls diagnosed with cardiovascular disease uncomplicated by CHF (cardiac controls), and 42 healthy controls were investigated. MEASUREMENTS: Neuropsychological assessment included tests of mental speed, executive function, memory, language, and visuospatial function. Composite z‐scores for five cognitive domains and mean z‐score for overall cognitive performance were computed. The cutoff score to indicate cognitive impairment was defined as the overall healthy participants' cognitive z‐score minus 2 standard deviations. Independent demographic and clinical predictors of cognitive impairment were identified using linear regression analysis. RESULTS: Patients with CHF showed a pattern of general cognitive impairment, including impairment of executive function, memory, language, mental speed, and attention. Twenty‐five percent (P=.04) of patients with CHF were classified as cognitively impaired, compared with 15% of the cardiac controls and 4% of the healthy controls. Independent predictors of cognitive impairment in patients with CHF were estimated intelligence, New York Heart Association class, and presence of the apolipoprotein (Apo)E ɛ4 allele. CONCLUSION: Cognitive dysfunction is relatively common in patients with CHF, with deficits being most prominent in the domains of executive function, memory, language, and mental speed. Disease severity and ApoE genotype are likely to be important determinants for cognitive impairment in patients with chronic CHF.

Wilkins, Consuelo H.; Wilkins, Kenneth L.; Meisel, Marie; Depke, Marilyn; Williams, James; Edwards, Dorothy F.

doi: 10.1111/j.1532-5415.2007.01417.xpmid: 17916120

OBJECTIVES: To identify variables associated with diagnosing dementia in poor older adults by comparing older people with dementia who were diagnosed by their primary care physicians (PCPs) with those not diagnosed by their PCP. DESIGN: Observational study. SETTING: Community‐based, in‐home cognitive assessment program. PARTICIPANTS: Four hundred eleven adults aged 55 and older with cognitive impairment. MEASUREMENTS: Instrumental activities of daily living (IADLs), activities of daily living (ADLs), Mini‐Mental State Examination, Short Blessed Memory Orientation and Concentration Test, and Clinical Dementia Rating. RESULTS: Alzheimer's disease was the most common diagnosis in this group of primarily African‐American (73%) older people. Of the 411 participants, 232 (56%) were not diagnosed by their PCP. Participants without a previous diagnosis were older (mean age 81.7 vs 78.7, P=.01), more independent in IADLs (P<.001), and more likely to live alone (P=.001) than persons diagnosed by their PCP. Of the 201 who lived alone, 66% were not diagnosed with dementia by their PCP. Variables associated with PCP diagnosis were more severe cognitive impairment (P<.001), spouse caregiver (P=.009), younger age (P=.02) and care from a university‐based PCP (P=.04). CONCLUSION: Persons with dementia who were older and lived alone were less likely to be diagnosed by their PCP. Although persons not diagnosed by their PCP had less cognitive impairment, they had substantial impairment in activities, including handling finances, cooking, and managing medications.