Journal of American Geriatrics Society

Yoshikawa, Thomas T.

doi: 10.1111/jgs.12075pmid: N/A

Malone, Michael L.

doi: 10.1111/jgs.12074pmid: N/A

D'Arcy, Laura P.; Stearns, Sally C.; Domino, Marisa E.; Hanson, Laura C.; Weinberger, Morris

doi: 10.1111/jgs.12039pmid: 23252966

Objectives To determine whether community‐dwelling individuals and nursing home (NH) residents treated by a geriatrician were less likely to use the emergency department (ED) than individuals treated by other physicians. Design Retrospective cohort study using data from a national sample of older adults with a history of cardiovascular disease. Setting Ambulatory care or NH. Participants Fee‐for‐service Medicare beneficiaries aged 66 and older diagnosed with one or more geriatric conditions from 2004 to 2007 and followed for up to 3 years. Measurements Emergency department use was measured in Medicare inpatient and outpatient claims; geriatric care was measured as geriatrician visits in ambulatory or NH settings coded in physician claims. Results Multivariable analyses controlled for observed and unobserved subject characteristics that were constant during the study period. For community‐dwelling participants, one or more nonhospital geriatrician visits in a 6‐month period were associated with 11.3% lower ED use the following month (95% confidence interval (CI) = 7.5–15.0, N = 287,259). Participants who received primary care from geriatricians were less likely to have ED use than those who had traditional primary care. Results for participants who received consultative care from geriatricians were similar to those for participants who received primary care from geriatricians. Results for NH residents (N = 66,551) were similar to those for community‐dwelling participants. Conclusion Geriatric care was associated with an estimated 108 fewer ED visits per 1,000 community‐dwelling residents and 133 fewer ED visits per 1,000 NH residents per year. Geriatric consultative care in collaboration with primary care providers may be as effective in reducing ED use as geriatric primary care. Increased provision of collaborative care could allow the existing supply of geriatricians to reach a larger number of individuals.

Pines, Jesse M.; Mullins, Peter M.; Cooper, James K.; Feng, Lisa B.; Roth, Katalin E.

doi: 10.1111/jgs.12072pmid: 23311549

Objectives To describe trends in use of emergency departments (EDs) of older adults, reasons for visits, resource use, and quality of care. Design Analysis of the National Hospital Ambulatory Medical Care Survey. Setting U.S. emergency departments from 2001 to 2009. Participants Individuals aged 65 and older visiting U.S. EDs. Measurements Emergency departments (ED) visits by patients aged 65 and older were identified, and demographic, clinical, and resource use characteristics and outcomes were assessed. Results From 2001 to 2009, annual visits increased from 15.9 to 19.8 million, a 24.5% increase. Numbers of outpatients grew less than hospital admissions (20.2% vs 33.1%); intensive care unit admissions increased 131.3%. Reasons for visits were unchanged during the study; the top complaints were chest pain, dyspnea, and abdominal pain. Resource intensity grew dramatically: computed tomography 167.0%, urinalyses 87.1%, cardiac monitoring 79.3%, intravenous fluid administration 59.8%, blood tests 44.1%, electrocardiogram use 43.4%, procedures 38.3%, and radiographic imaging 36.4%. From 2005 to 2009, magnetic resonance imaging use grew 84.6%. The proportion receiving a potentially inappropriate medication decreased from 9.6% in 2001 to 4.9% in 2009, whereas the proportion seen in the ED, discharged, and subsequently readmitted to the hospital rose from 2.0% to 4.2%. Conclusion Older adults accounted for 156 million ED visits in the United States from 2001 to 2009, with steady increases in visits and resource use across the study period. Hospital admissions grew faster than outpatient visits. If changes in primary care do not affect these trends, facilities will need to plan to accommodate increasingly greater demands for ED and hospital services.

Jimenez, Daniel E.; Cook, Ben; Bartels, Stephen J.; Alegría, Margarita

doi: 10.1111/jgs.12063pmid: 23252464

Objectives To apply the Institute of Medicine definition of healthcare disparities, to measure disparities in different aspects of episodes of mental health care and to identify disparities in types of mental health services used. Design Four 2‐year longitudinal datasets from Panels 9 to 13 (2004–2009) of the Medical Expenditure Panel Surveys were combined. Setting Large‐scale surveys of families and individuals and their medical providers across the United States. Participants One thousand six hundred fifty‐eight participants (981 white, 303 black, and 374 Latino) aged 60 and older with probable mental healthcare needs. Measurements Mental healthcare need was defined as a Kessler‐6 Scale score >12 and a Patient Health Questionnaire‐2 score >2. Five aspects of mental healthcare episodes were analyzed: treatment initiation, adequacy of care, duration of care, number of visits, and expenditures. Whether episodes of care included only prescription drug fills, only outpatient visits, or both was assessed. Results Treatment initiation and adequacy were lower for blacks and Latinos than whites. Latinos experienced episodes of longer duration, more visits, and higher expenditures. Blacks and Latinos had significantly lower rates of episodes that consisted of only medication refills. Blacks had significantly greater rates of episodes with only outpatient care visits. Latinos had significantly higher rates of medication plus outpatient visits. Conclusion Low mental health treatment initiation and poor adequacy suggest the need for culturally appropriate interventions to engage older blacks and Latinos in mental health care. The surprising findings in blacks (higher rates of outpatient care visits) and Latinos (higher rates of medication plus outpatient visits) highlight the complexities of the older adult population and suggest new avenues for disparities research.

Saczynski, Jane S.; Go, Alan S.; Magid, David J.; Smith, David H.; McManus, David D.; Allen, Larry; Ogarek, Jessica; Goldberg, Robert J.; Gurwitz, Jerry H.

doi: 10.1111/jgs.12062pmid: 23311550

Objectives To examine whether the total burden of comorbidity and pattern of co‐occurring conditions varies in individuals with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HF‐P) or HF with reduced LVEF (HF‐R). Design Cross‐sectional cohort study. Setting Four participating health plans within the National Heart, Lung, and Blood Institute–sponsored Cardiovascular Research Network. Participants All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses. Measurements Participants with a LVEF of 50% or greater were classified as having HF‐P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases. Results Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF‐P (mean age 79.6; 60% female). More than three‐quarters of the sample had three or more co‐occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF‐P had a slightly higher burden of comorbidity than those with HF‐R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co‐occurred did not vary in participants with preserved or reduced systolic function. Conclusion There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF.

Abbo, Elmer D.; Yuen, Trevor C.; Buhrmester, Luke; Geocadin, Romergryko; Volandes, Angelo E.; Siddique, Juned; Edelson, Dana P.

doi: 10.1111/jgs.12068pmid: 23311551

Objectives To determine whether poor functional status is associated with worse outcomes after attempted cardiopulmonary resuscitation (CPR). Design Retrospective study of individuals who experienced cardiac arrest stratified according to dependence in activities of daily living (ADLs) and residential status (nursing home (NH) or community dwelling). Setting Two hundred thirty‐five hospitals throughout North America. Participants Adult inpatients aged 65 and older who had experienced a cardiac arrest as reported to the Get with the Guidelines—Resuscitation registry between 2000 and 2008. Measurements Primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge. Results Twenty‐six thousand three hundred twenty‐nine individuals who experienced cardiac arrest met inclusion criteria. NH residents dependent in ADLs had a lower odds than community‐dwelling independent participants of achieving ROSC (odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.63–0.85), whereas participants dependent in ADLs from either residential setting had lower odds of survival (community‐dwelling: OR = 0.76, 95% CI = 0.63–0.92; NH: OR = 0.79, 95% CI = 0.64–0.96) after adjusting for participant and arrest characteristics. Duration of resuscitation and doses of epinephrine or vasopressin were similar between groups and had no significant effect on ROSC or survival, although participants dependent in ADLs were more likely to have a do‐not‐resuscitate (DNR) order placed after ROSC. Overall, median time to signing a DNR order after resuscitation was 10 hours (interquartile range 2–70). Conclusion Functional and residential status are important predictors of survival after in‐hospital cardiac arrest. Contrary to the hypothesis but reassuring from a quality‐of‐care perspective, less‐aggressive attempts at resuscitation do not appear to contribute to poorer outcomes in individuals dependent in ADL, regardless of residential status.

Stessman, Jochanan; Jacobs, Jeremy M.; Stessman‐Lande, Irit; Gilon, Dan; Leibowitz, David

doi: 10.1111/jgs.12060pmid: 23301799

Objectives To examine the relationship between resting pulse rate (RPR) and longevity in individuals aged 70 to 90. Design The Jerusalem Longitudinal Cohort Study (1990–2010) is a prospective longitudinal study of a representative cohort born in 1920–21. Setting Home‐based comprehensive assessment in 1990, 1998, and 2005. Participants Individuals aged 70 (n = 453), 78 (n = 856), and 85 (n = 1,044), with follow‐up to age 90. Measurements Comprehensive assessment included average RPR, beta‐blocker usage, and physical activity level. Mortality data were collected from the Ministry of Interior from 1990 to 2010. Methods Cox proportional hazards ratios (HRs) were determined for RPR (continuous variable), adjusting for sex, education, diabetes mellitus, ischemic heart disease, congestive heart failure, hypertension, kidney disease, anemia, physical activity, body mass index, self‐rated health, dementia, beta‐blocker use, and an interaction term for RPR by beta‐blocker use. Results Mean RPR was 75.1 ± 9.9 at 70, 74.5 ± 10.9 at 78, and 68.5 ± 10.5 at 85 in women and 74.3 ± 10.7 at 70, 73.1 ± 11.2 at 78, and 65.2 ± 10.5 at 85 in men, with a significant decline from 78 to 85 for both sexes. In participants not taking beta‐blockers followed up from 70 to 77, 78 to 84, and 85 to 90, mean RPR was lower in survivors than nonsurvivors for women (75.8 ± 9.2 vs 83.5 ± 10.9, P < .001; 75.2 ± 9.8 vs 79.9 ± 12.6, P = .004; 71.5 ± 9.9 vs 74.6 ± 10.7, P = .02, respectively) and men (75.2 ± 10.3 vs 75.2 ± 10.9, P = .98; 73.5 ± 10.1 vs 77.2 ± 12.1, P = .005; 67.1 ± 9.5 vs 70.4 ± 11.7, P = .01, respectively). Adjusted HRs for mortality per 10‐beat increase in RPR during follow‐up were 1.13 (95% confidence interval (CI) = 0.87–1.47) for 70 to 77, 1.35 (95% CI = 1.11–1.65) for 78 to 84, and 1.17 (95% CI = 1.01–1.37) for 85 to 90. Conclusion RPR declines in the oldest old, and this decline is associated with greater longevity. It may serve as a simple prognostic marker in the oldest old.

Garimella, Pranav S.; Paudel, Misti L.; Ensrud, Kristine E.; Marshall, Lynn M.; Taylor, Brent C.; Fink, Howard A.; Fink, Howard A.

doi: 10.1111/jgs.12073pmid: 23311552

Objectives To examine the association between body size and composition and erectile dysfunction (ED) in older men. Design Cross‐sectional analysis of the Osteoporotic Fractures in Men study. Setting Six U.S. clinical sites. Participants Community‐dwelling men aged 65 and older. Measurements Body composition measures using anthropometry (body weight, body mass index (BMI)) and dual X‐ray absorptiometry (total body fat percentage, trunk fat percentage, ratio of trunk and total body fat). ED was assessed using the single‐item Massachusetts Male Aging Study (MMAS) scale and the five‐item International Index of Erectile Function questionnaire (IIEF‐5). Results In men completing the MMAS scale (n = 4,108), prevalence of complete ED was 42%. In sexually active men completing the IIEF‐5 questionnaire (n = 1,659), prevalence of moderate to severe ED was 56%. In multivariate‐adjusted analyses reporting prevalence ratios (PRs) and 95% confidence intervals (CIs), the prevalence of MMAS‐defined complete ED was significantly greater in men in the highest quartile of body weight (PR = 1.24, 95% CI = 1.16–1.34), total body fat percentage (PR = 1.25, 95% CI = 1.13–1.40), and trunk fat percentage (PR = 1.24, 95% CI = 1.15–1.38), and was greater in men with a BMI greater than 30.0 kg/m2 than in those with BMI of 22.0 to 24.9 kg/m2 (PR = 1.17, 95% CI = 1.05–1.31). Associations appeared similar for IIEF‐5–defined moderate to severe ED in analyses adjusted for age and study site. Conclusion In a cohort of older men, high body weight, BMI, and total body fat percentage were independently associated with greater prevalence of moderate to severe and complete ED. Future studies should investigate whether interventions to promote weight loss and fat loss will improve erectile function in older men.

Rochon, Paula A.; Gruneir, Andrea; Gill, Sudeep S.; Wu, Wei; Fischer, Hadas D.; Bronskill, Susan E.; Normand, Sharon‐Lise T.; Austin, Peter C.; Seitz, Dallas P.; Bell, Chaim M.; Fu, Longdi; Lipscombe, Lorraine; Anderson, Geoffrey M.; Gurwitz, Jerry H.