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Background: Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster‐randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community‐dwelling older adults age ≥70 at increased fall injury risk. Methods: We assessed fall‐related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health‐related quality of life (HRQOL) using the EQ‐5D‐5L and EQ‐VAS. We used Poisson models to assess intervention effects on falls, fall‐related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. Results: For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93–1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80–1.08; p = 0.337) for self‐reported fractures, 0.89 (95% CI, 0.73–1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77–1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89–1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non‐significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ‐5D‐5L (intervention minus control) was 0.009 (95% CI, −0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, −0.006 to 0.015; p = 0.384) at 24 months. Conclusions: Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient‐, practice‐, and organization‐level operational strategies to increase the real‐world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. Clinicaltrials.gov identifier: NCT02475850. [ABSTRACT FROM AUTHOR]

The objective of this study was gather pilot data from informal caregivers regarding the potential for a training program to assist current or past caregivers in reentering the job market, and thus offering a pathway to economic resilience. In an effort that could foster a sustainable and competent caregiving market to help meet the needs of an aging America, whether training informal caregivers might help them transition into a paid caregiving or other health service role was explored. Caregivers (N = 55) of a chronically or terminally ill family member or friend in a suburban county near Chicago were interviewed. The interview guide addressed household economic effect of illness, emotional burden, and training program interest. Fifty-six percent of caregivers were interested in training to work outside the home, caring for people in other households, 84% indicated a desire to learn more about health care, and 68% reported a desire to explore job possibilities in health care. Eighty-two percent were experienced in working with an individual aged 50 and older. Informal caregivers' interest in a training program to bolster their qualifications for a role in the healthcare workforce, including the option of a formal caregiver position, supports the demand for such a program. Considering the need for healthcare workers to serve the growing elderly population and the desire of informal caregivers to find gainful employment, these informal caregivers could provide the impetus to invest in informal caregiver training. [ABSTRACT FROM AUTHOR]

The article discusses a population study of the survival trends in very old adults with advanced diffuse large B-cell lymphoma (DLBCL) receiving immunochemotherapy with the drugs rituximab and cyclophosphamide, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and cyclophosphamide, cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) from 1992-2009. Topics include race factors, research methodology, and survival rates since the introduction of rituximab in 2006.

Objectives To examine caregiver factors associated with unmet needs for care of older adults. Design Population-based surveys of caregivers and older adult care recipients in the United States in 2011. Setting 2011 National Health and Aging Trends Study and National Study of Caregiving. Participants Family caregivers (n = 1,996) of community-dwelling older adults with disabilities (n = 1,366). Measurements Disabled care recipient reports of unmet needs for care in the past month with activities of daily living ( ADLs; e.g., wet or soiled clothing), mobility (e.g., have to stay inside), or instrumental activities of daily living ( IADLs; e.g., medication errors). Caregiver reported sociodemographic characteristics, caregiving intensity and tasks performed, health, and psychosocial effects. Results Of the care recipients, 44.3% reported at least one unmet need for care in the past month (38.2% ADL related, 14.6% IADL related). Younger caregivers, caregiving sons, caregivers not living with care recipients, and having supplemental paid caregivers were associated with more unmet needs. Caregivers with recipients reporting two or more unmet needs were more likely to spend more than 100 hours per month caregiving, help with skin care and wounds, report caregiving as emotionally and physically difficult, and report restricted participation in valued activities (all P < .001). Conclusion Unmet ADL needs are prevalent among older adults with family caregivers. Caregivers experiencing high levels of burden, stress, and negative physical and psychosocial impacts may provide substandard or poor care to older adults, which may be a risk factor for neglect. Clinicians caring for disabled older adults should assess their unmet needs and the capacity of caregivers to address them. [ABSTRACT FROM AUTHOR]

Objectives The association between weight change and cognition is controversial. We examined the association between 20-year weight change and cognitive function in late life. Design Cohort study. Setting Study of Osteoporotic Fractures ( SOF). Participants One thousand two hundred eighty-nine older, community-dwelling women (mean baseline age 68 (65-81) and 88 (82-102) at cognitive testing). Measurements Study of Osteoporotic Fractures participants had body weight measured repeatedly over 20 years (mean 8 weights). Adjudicated cognitive status was classified as normal (n = 775) or mild cognitive impairment ( MCI)/dementia (n = 514) at Year 20. Logistic models were used to evaluate whether absolute weight change, rate of weight loss per year, presence of abrupt, unrecovered weight loss, and weight variability were associated with MCI or dementia. Results Women with greater rate of weight loss over 20 years had increased chance of developing MCI or dementia. In age/education/clinic-adjusted 'base' models, each 0.5 kg/yr decrease resulted in 30% increased odds of MCI/dementia (OR = 1.30 [95% CI: 1.14, 1.49]). After adjustment for age, education, clinic, depression, and walking speed, there was 17% (OR = 1.17 [95% CI: 1.02, 1.35]) increased odds of MCI/dementia for each 0.5 kg/yr decrease in weight. In base models, variability in weight was significant. Each 1% average deviation from each woman's predicted weight curve was associated with 11% increased odds of MCI/dementia (OR = 1.11 [95% CI: 1.04, 1.18]). The estimate was attenuated after full adjustment (OR = 1.06 [95% CI: 0.99, 1.14]). The presence of an abrupt weight decline was not associated with MCI/dementia. Conclusions Rate of weight loss over 20 years was associated with development of MCI or dementia in women surviving past 80 years, suggesting that nutritional status, social-environmental factors, and/or adipose tissue function and structure may affect cognitive function with aging. [ABSTRACT FROM AUTHOR]

Objectives The Meaningful Use initiative has made nearly $30 billion available through incentive programs to encourage provider adoption and use of electronic health records. The objective of this study was to evaluate the impact of outpatient physicians' participation in Meaningful Use on the quality of care provided to Medicare fee-for-service (FFS) enrollees . Design Retrospective cohort study. Setting One hundred percent inpatient and outpatient Medicare FFS claims covering the period January 2010 through December 2012. Participants 303,110 Medicare FFS enrollees from New York State. Measurements Hospitalizations and emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs), diabetic retinopathy screening, diabetic nephropathy screening, colorectal cancer screening, and influenza vaccinations. Results Physician participation in the Meaningful Use initiative was not associated with reductions in ACSC-related hospitalizations (0.0 percentage points, 95% confidence interval (CI): 0.0-0.1) or ED visits (0.0 percentage points, 95% CI: 0.0-0.1) relative to the comparison group. Meaningful Use participation was associated with higher odds of colorectal cancer screening (odds ratio (OR): 1.2, 95% CI: 1.1-1.4) relative to the comparison group, but not for diabetic retinopathy screening (OR: 1.1, 95% CI: 1.0-1.2), diabetic nephropathy screening (OR: 1.0, 95% CI: 0.8-1.2), or influenza vaccinations (OR: 1.1, 95% CI: 1.0-1.2). Similar results were found in secondary analyses of dually-eligible beneficiaries participating in both Medicare and Medicaid. Conclusion Physician participation in Meaningful Use was not associated with substantial improvements on six quality measures. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether the implementation of the Observational Pain Management Protocol (Protocol) can improve pain management for nursing home residents with dementia. Design A two-group, single-blinded, cluster-randomized controlled trial. Setting Seventeen nursing homes. Participants Hundred and twenty eight recruited residents with advanced dementia and pain-related diagnoses were allocated to either the control or the experimental conditions based on the randomized group allocated to their home. Interventions The Protocol, which includes assessing, interpreting, and verifying the participants' observed pain scores, initiating pain-relieving interventions according to the observed pain scores, and reassessment, was implemented in the experimental homes for 12 weeks to guide the pain management of the participants. Meanwhile, the control homes continued to employ their usual pain management strategies. Measurements These included the use of pain medications (measured by the Medication Quantification Scale) and non-pharmacological pain treatments in terms of types and frequency, as well as the participants' observational pain scores (assessed by Chinese-Pain Assessment IN Advanced Dementia). Results A significant increase in the frequency (95% CI: −0.13 to −0.09, P < .01) and type (95% CI: −0.05 to −0.02, P < .01) of non-pharmacological interventions used was seen in the experimental homes in comparison with the control homes. However, no statistically significant difference in the use of pain medications was observed. A significant reduction in the observational pain score (95% CI: −0.26 to −0.17, P < .001) was obtained only in the experimental home. Conclusion This study supports the view that the Protocol is of clinical utility in enhancing the use of non-pharmacological pain-relieving interventions among residents with advanced dementia, leading to a reduction in their observational pain-related behaviors. However, the Protocol did not have any effect on the use of pain medications. [ABSTRACT FROM AUTHOR]

Objectives To investigate the relationship between polypharmacy and frailty. Design Longitudinal, observational cohort study. Setting Saarland, Germany. Participants 3,058 community-dwelling adults aged between 57 and 84 years. Measurements Frailty was assessed according to the frailty phenotype, described by Fried et al. Polypharmacy and hyperpolypharmacy were defined as the concomitant use of five or more and 10 or more drugs, respectively. We assessed associations between polypharmacy and prevalent and incident frailty within 3 years of follow-up by logistic regression models controlled for multiple potential confounders including comorbidity. Additionally, cubic splines were used to assess dose-response associations. Results Polypharmacy was reported in 39.1% (n = 1,194), and hyperpolypharmacy in 8.9% (n = 273) of participants. Prevalent frailty was present in 271 (8.9%) participants; 186 (9.3%) of 1,998 non-frail participants with follow-up data became frail within 3 years. After adjustment, polypharmacy and hyperpolypharmacy were associated with prevalent frailty with adjusted odds ratios (95% confidence interval) of 2.30 (1.60-3.31) and 4.97 (2.97-8.32), respectively. Polypharmacy (odds ratio ( OR) 1.51 (1.05-2.16)) and hyperpolypharmacy ( OR 1.90 (1.10-3.28)) were also independent predictors of incident frailty. Furthermore, there was a moderate exposure-response relationship between the number of medicines and prevalent as well as incident frailty. Conclusion Our study showed that polypharmacy is associated with frailty. Further research should address the potential benefit of reducing of inappropriate polypharmacy and better pharmacotherapeutic management for preventing medication-associated frailty. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between homebound status and mortality. Design Cross-sectional. Setting Annual, in-person interviews. Participants A nationally representative sample of community-dwelling, Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study between 2011 and 2013 (N = 6,400). Measurements Two-year mortality and prevalence of homebound status in the year before death are described using three categories of homebound status: homebound (never or rarely left home in the last month), semihomebound (left home with assistance, needed help or had difficulty), and nonhomebound (left home without help or difficulty). Results In unadjusted analyses, 2-year mortality was 40.3% in homebound participants, 21.3% in those who were semihomebound and 5.8% in those who were nonhomebound. Homebound status was associated with greater 2-year mortality, adjusted for sociodemographic characteristics, comorbidities, and functional status (hazard ratio = 2.08; 95% confidence interval = 1.63-2.65, P < .001). Half of older community-dwelling Medicare beneficiaries were homebound in the year before death. Conclusion Homebound status is associated with greater risk of death independent of functional impairment and comorbidities. To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals. [ABSTRACT FROM AUTHOR]

Objectives To examine racial differences in readmissions of older adults undergoing elective total hip and knee replacement, to determine the relationship between nurse staffing and readmission, and to study whether the relationship between staffing and readmission differs for older black and white adults. Design Cross-sectional analysis of multiple linked secondary data sources. Setting Nonfederal acute care hospitals in California, Florida, New Jersey, and Pennsylvania (n = 483). Participants Patients aged 65 and older undergoing elective total hip or total knee replacement (N = 106,848; n = 102,762 white, n = 4,086 black). Measurements Unplanned readmission within 30 days of discharge. Results Older black patients were more likely to have an unplanned readmission (7.5%) than their white counterparts (5.6%). Even after adjusting for patient- and hospital-level factors, older black patients had 40% greater likelihood of readmission (odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.21-1.61). Each additional patient per nurse was associated with 8% greater odds of readmission for older white patients (OR = 1.08, 95% CI = 1.01-1.15) and 15% greater odds for older black patients (OR = 1.15, 95% CI = 1.08-1.22) after adjusting for patient- and hospital-level factors. Conclusion Older minorities are more likely than their white counterparts to experience an unplanned readmission after elective orthopedic surgery. More-favorable nurse staffing was associated with lower odds of readmission of older black and white patients, but better-staffed hospitals had a greater protective effect for older black patients. [ABSTRACT FROM AUTHOR]

Objectives To identify factors associated with end-of-life (EoL) transition from usual place of care to the hospital as place of death for people aged 75 and older. Design Population-based mortality follow-back survey. Setting Deaths over 6 months in 2012 in two unitary authorities in England covering 800 square miles with more than 1 million residents. Participants A random sample of people aged 75 and older who died in a care home or hospital and all those who died at home or in a hospice unit (N = 882). Cases were identified from death registrations. The person who registered the death (a relative for 98.9%) completed the survey. Measurements The main outcome was EoL transition to the hospital as place of death versus no EoL transition to the hospital. Multivariable modified Poisson regression was used to examine factors (illness, demographic, environmental) related to EoL transition to the hospital. Results Four hundred forty-three (50.2%) individuals responded, describing the care of the people who died. Most died from nonmalignant conditions (76.3%) at a mean age of 87.4 ± 6.4. One hundred forty-six (32.3%) transitioned to the hospital and died there. Transition was more likely for individuals with respiratory disease than for those with cancer (prevalence ratio ( PR) = 2.07, 95% confidence interval ( CI) = 1.42-3.01) and for people with severe breathlessness ( PR = 1.96, 95% CI = 1.12-3.43). Transition was less likely if EoL preferences had been discussed with a healthcare professional ( PR = 0.60, 95% CI = 0.42-0.88) and when there was a key healthcare professional ( PR = 0.74, 95% CI = 0.58-0.95). Conclusion To reduce EoL transition to the hospital for older people, there needs to be improved management of breathlessness in the community and better access to a key healthcare professional skilled in coordinating care, communication, facilitating complex discussions, and in planning for future care. [ABSTRACT FROM AUTHOR]

Objectives To investigate factors associated with place of death of individuals in the Mount Sinai Visiting Doctors Program ( MSVD). Design A retrospective chart review was performed of all MSVD participants who died in 2012 to assess predictors of place of death in the last month of life. Setting MSVD, a home-based primary and palliative care program in New York. Participants MSVD participants who were discharged from the program because of death between January 2012 and December 2012 and died at home, in inpatient hospice, or in the hospital (N = 183). Measurements Electronic medical records were reviewed to collect information on demographic characteristics, physician visits, and end-of-life conversations. Results Of 183 participants, 103 (56%) died at home, approximately twice the national average; 28 (15%) died in inpatient hospice; and 52 (28%) died in the hospital. Bivariate analyses showed that participants who were white, aged 90 and older, non-Medicaid, or had a recorded preference for place of death were more likely to die outside the hospital. Diagnoses and living situation were not significantly associated with place of death. Multivariate logistic regression analysis showed no statistical association between place of death and home visits in the last month of life (odds ratio = 1.21, 95% confidence interval = 0.52-2.77). Conclusion Home-based primary and palliative care results in a high likelihood of nonhospital death, although certain demographic characteristics are strong predictors of death in the hospital. For MSVD participants, home visits in the last month of life were not associated with death outside the hospital. [ABSTRACT FROM AUTHOR]

Objectives To assess the content validity and psychometric characteristics of the Knowledge about Older Patients Quiz ( KOP-Q), which measures nurses' knowledge regarding older hospitalized adults and their certainty regarding this knowledge. Design Cross-sectional. Setting Content validity: general hospitals. Psychometric characteristics: nursing school and general hospitals in the Netherlands. Participants Content validity: 12 nurse specialists in geriatrics. Psychometric characteristics: 107 first-year and 78 final-year bachelor of nursing students, 148 registered nurses, and 20 nurse specialists in geriatrics. Measurements Content validity: The nurse specialists rated each item of the initial KOP-Q (52 items) on relevance. Ratings were used to calculate Item-Content Validity Index and average Scale-Content Validity Index (S- CVI/ave) scores. Items with insufficient content validity were removed. Psychometric characteristics: Ratings of students, nurses, and nurse specialists were used to test for different item functioning ( DIF) and unidimensionality before item characteristics (discrimination and difficulty) were examined using Item Response Theory. Finally, norm references were calculated and nomological validity was assessed. Results Content validity: Forty-three items remained after assessing content validity (S- CVI/ave = 0.90). Psychometric characteristics: Of the 43 items, two demonstrating ceiling effects and 11 distorting ability estimates ( DIF) were subsequently excluded. Item characteristics were assessed for the remaining 30 items, all of which demonstrated good discrimination and difficulty parameters. Knowledge was positively correlated with certainty about this knowledge. Conclusion The final 30-item KOP-Q is a valid, psychometrically sound, comprehensive instrument that can be used to assess the knowledge of nursing students, hospital nurses, and nurse specialists in geriatrics regarding older hospitalized adults. It can identify knowledge and certainty deficits for research purposes or serve as a tool in educational or quality improvement programs. [ABSTRACT FROM AUTHOR]

Older adults have a greater risk of experiencing functional decline and iatrogenic complications during hospitalization than younger individuals. Geriatric day hospitals ( GDHs) have been implemented mainly for rehabilitation. The goal of the current study was to expand the GDH spectrum of care to prevent hospital admissions in this population. This study details an innovative model of GDH care that offers short-term, nonrehabilitative treatment to older adults who have experienced an acute event, those with a decompensated chronic disease, or those in need of a minor procedure that would be unattainable in a regular outpatient setting. During the 6-hour visits made weekly for up to 2 months, participants receive integrated evaluations of their various health domains, education, and rapid access to examinations and procedures based on a multidisciplinary approach. In the first 6 years, 2,322 individuals attended the GDH. The analysis of a representative sample (n = 645) revealed that 81% were treated in the GDH without the need for another type of hospital care. This percentage was high for the different reasons for referral (infection, 71%; delirium, 73%; decompensated chronic disease, 81%). Between baseline and discharge, participants maintained their functional status, and their self-reported health improved. This study represents the first step in describing the role of the GDH as a possible alternative to emergency department use or hospitalization for older adults. Future studies are needed to determine the optimal individual for this model of care and to ensure its cost-effectiveness. [ABSTRACT FROM AUTHOR]

Objectives This study examined potential barriers to mental healthcare use of older adults from diverse ethnic and racial backgrounds. Design Data were obtained from the 2007, 2009, 2011-12, and 2013-14 California Health Interview Survey ( CHIS), a population-based survey representative of California's noninstitutionalized population. Participants The total sample consisted of 75,324 non-Hispanic white ( NHW), 6,600 black, 7,695 Asian and Pacific Islander ( API), and 4,319 Hispanic adults aged 55 and older. Results Results from logistic regression analyses that controlled for multiple demographic and health status characteristics revealed ethnic and racial differences in reasons for not seeking treatment and for terminating treatment. Specifically, API and Hispanic adults had greater odds than NHWs of endorsing feeling uncomfortable talking to a professional as a reason for not seeking treatment. Hispanic respondents had lower odds of endorsing concerns about someone finding out than APIs, and APIs and blacks had significantly greater odds of endorsing this concern as a reason for not seeking treatment than NHWs. When asked about reasons for no longer receiving treatment, all respondents, irrespective of race or ethnicity, endorsed that they no longer needed treatment as the most frequent reason for terminating treatment, although specific ethnic and racial differences emerged with respect to perceptions of not getting better, lack of time or transportation, and lack of insurance coverage as reasons for no longer seeking treatment. Conclusion Understanding how barriers to mental health treatment differ for older adults from diverse ethnic and racial backgrounds is an important step toward designing interventions to overcome these obstacles and improve mental health outcomes. [ABSTRACT FROM AUTHOR]

Objectives To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life ( EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life. Design Retrospective cohort study. Setting Health and Retirement Study ( HRS). Participants Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105). Measurements Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected. Results The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models. Conclusion Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences. [ABSTRACT FROM AUTHOR]

Objectives To use place-of-service ( POS) codes in the Medicare hospice claims files to document where elderly hospice users with cancer die. Design Retrospective cohort study. Setting Surveillance, Epidemiology, and End Results ( SEER) cancer registry areas. Participants Elderly Medicare beneficiaries who died of lung, breast, colorectal, or pancreatic cancer in 2007 and 2008 (N = 46,037). Measurement Use of hospice, place of service at death (home, nursing home, hospital, inpatient hospice, other), length of stay in hospice. Results Two-thirds of the beneficiaries used hospice. Younger, male, black, Asian, and unmarried beneficiaries and those enrolled in fee-for-service Medicare or from areas with lower income were less likely to use hospice. Hospice enrollment also varied significantly according to SEER registry. Thirty percent of the hospice users were not receiving home-based care at the time of death, and 17% were enrolled for less than 3 days. Factors associated with hospice death in the home mirrored those associated with hospice use. Individuals dying in hospitals (odds ratio ( OR) = 5.13, 95% confidence interval ( CI) = 4.63-5.69), inpatient hospice ( OR = 1.86, 95% CI = 1.70-2.02), and nursing homes ( OR = 1.19, 95% CI = 1.10-1.28) had greater odds of a short hospice stay (≤7 days) than those dying at home, after controlling for all other measured factors, whereas those dying in nursing homes had greater odds of long stays (>180 days) ( OR = 1.46, 95% CI = 1.28-1.67). Conclusion New hospice POS codes are useful for understanding place of death for hospice users. Hospice deaths cannot be assumed to happen at home. [ABSTRACT FROM AUTHOR]

Objectives To determine whether obese older adults who qualify for nursing home ( NH) placement are as likely as nonobese adults to be admitted to NHs that provide adequate quality of care. Design Retrospective study. Setting NHs in New York State. Participants Individuals aged 65 and older newly admitted to a NH in New York State in 2006-07. Measurements Total and healthcare-related deficiency citations for each facility were obtained from the Online Survey, Certification, and Reporting file. Bivariate and multivariate regression analyses were used to assess the association between obesity (body mass index ( BMI) 30.0-39.9 kg/m2) and morbid obesity ( BMI ≥ 40.0 kg/m2) separately and admission to facilities with more deficiencies. Results NHs that admitted a higher proportion of morbidly obese residents were more likely to have more deficiencies, whether total or healthcare related. These NHs also had greater odds of having severe deficiencies, or falling in the top quartile ranking of total deficiencies. After sequentially controlling for the choice of facilities within the inspection region, resident characteristics, and facility covariates, the association between morbid obesity and admission to higher-deficiency NHs persisted. Conclusion Residents with morbid obesity were more likely to be admitted to NHs of poorer quality based on deficiency citations. The factors driving these disparities and their impact on the care of obese NH residents require further elucidation. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effects of postoperative rehabilitation on the outcomes of older adults with dementia who experienced hip fracture. Design Retrospective cohort study. Setting Ontario, Canada. Participants Community-dwelling adults with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized as no rehabilitation, complex continuing care ( CCC), home-care based rehabilitation ( HCR), and inpatient rehabilitation ( IPR). Measurements Time to long-term care ( LTC) placement, mortality, and risk of repeat hip fracture and falls. Results Of 11,200 individuals with dementia who experienced a hip fracture during the study period, 4,494 (40.1%) received no rehabilitation, 2,474 (22.1%) were admitted to CCC, 1,157 (10.3%) received HCR, and 3,075 (27.4%) received IPR. HCR and IPR were associated with less risk of LTC admission after discharge from hospital than no rehabilitation. All three forms of rehabilitation were associated with lower risk of mortality than no rehabilitation, with the greatest effect observed with IPR. HCR was associated with a higher risk of falls than no rehabilitation ( P = .03); there were no other significant between-group differences in risk of falls or repeat fractures ( P > .05). Conclusion Postfracture rehabilitation for older adults with dementia is associated with lower risk of LTC placement and mortality. Improving access to rehabilitation services for this vulnerable population may improve postfracture outcomes. [ABSTRACT FROM AUTHOR]

Background Elderly adults (65 years of age and older) are of particular concern for traumatic amputations due to age-related changes in vision and coordination, making them more susceptible to injury. Objectives The objective of this study is to describe the epidemiology of traumatic amputations in the elderly adults treated in United States emergency departments (ED). Design A retrospective analysis using data from the National Electronic Injury Surveillance System from 2010 to 2013. Participants People aged 65 years and older treated in U.S. hospital EDs for traumatic amputations from 2010 to 2013. Results There were 15,611 elderly patients treated for amputations from 2010 to 2013, averaging 3,902 amputations per year in the United States. The frequency of amputations declined with increasing age. The mean age was 74 years old. Males represented 84% of the cohort. The majority of the injuries that were recorded took place at home (71%). The most common associated consumer products were saws, lawnmowers, and doors. Saws accounted for approximately 45% of amputations. In females, doors were the most common consumer product associated with amputations. Approximately 45% of amputations were complete amputations. The most common digit to be amputated was the thumb (24%). Approximately 72% of the cases in the cohort were treated and released from the ED. Conclusion Traumatic amputations in elderly adults were frequently due to saws and lawnmowers. An increase in injury prevention efforts in this patient population is warranted. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the cost-effectiveness of the Geriatric Care Model ( GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care. Design Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial. Setting Primary care (35 practices) in two regions in the Netherlands. Participants Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147). Intervention The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs. Measurements Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey ( SF-12) physical ( PCS) and mental component summary ( MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D. Results Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = −$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low. Conclusion Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended. [ABSTRACT FROM AUTHOR]

Objectives To describe the characteristics of home-based primary care practices: staffing, administrative, population served, care practices, and quality of care challenges. Design Survey of home-based primary care practices. Setting Home-based primary care practices in the United States. Participants Members of the American Academy of Home Care Medicine and nonmember providers identified by surveyed members. Measurements A 58-item questionnaire that assessed practice characteristics, care provided by the practice, and how the quality of care that the practice provided was assessed. Results Survey response rate was 47.9%, representing 272 medical house calls practices. Mean average daily census was 457 patients (median 100 patients, range 1-30,972 patients). Eighty-eight percent of practices offered around-the-clock coverage for urgent concerns, 60% held regularly scheduled team meetings, 89% used an electronic medical record, and one-third used a defined quality improvement process. The following factors were associated with practices that used a defined quality improvement process: practice holds regularly scheduled team meetings to discuss specific patients (odds ratio ( OR) = 2.07, 95% confidence interval ( CI) = 1.02-4.21), practice conducts surveys of patients ( OR = 8.53, 95% CI = 4.07-17.88), and practice is involved in National Committee for Quality Assurance patient-centered medical home ( OR = 3.27, 95% CI = 1.18-9.07). Ninety percent of practices would or might participate in quality improvement activities that would provide them timely feedback on patient and setting-appropriate quality indicators. Conclusions There is a substantial heterogeneity of home-based primary care practice types. Most practices perform activities that lend themselves to robust quality improvement efforts, and nearly all indicated interest in a national registry to inform quality improvement. [ABSTRACT FROM AUTHOR]

Objectives To explore differences in sociodemographic and psychological correlates of institutional trust in health care in an aging population of African Americans and non-Hispanic whites. Design Cross-sectional survey data from the longitudinal Chicago Health and Aging Project. Setting Population-based study of three communities in the Chicago area. Participants African Americans (n = 2,284) and non-Hispanic whites (1,354) with a mean age of 79.3. Measurements Demographic factors, socioeconomic status ( SES), healthcare access, cynical hostility, perceived discrimination, depression, and institutional trust in health care. Results African Americans reported substantially lower healthcare trust than non-Hispanic whites ( P < .001). After adjustment for demographic variables and SES, only race ( P < .001) and age ( P = .008) were significantly associated with healthcare trust scores. The association between race and healthcare trust was slightly attenuated after adjusting for cynical hostility, depressive symptoms, and perceived discrimination ( P < .001). Each of these variables was negatively associated with healthcare trust, and together these accounted for approximately 15% of racial differences in healthcare trust. Conclusion Psychological factors, not demographic characteristics, SES, or healthcare factors, appear to contribute the most to disparities in healthcare trust between older African Americans and non-Hispanic whites. [ABSTRACT FROM AUTHOR]

Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound. As part of a quality improvement project to address individual, program, and system needs, a portion of a large, physician-led academic home-based primary care practice was restructured into a team-based model. With support from an office-based nurse practitioner, a dedicated social worker, and a dedicated administrative assistant, physicians were able to care for a larger number of patients. Hospitalizations, readmissions, and patient satisfaction remained the same while physician panel size increased and physician satisfaction improved. The Team Approach is an innovative way to improve interdisciplinary, team-based care through practice restructuring and serves as an example of how other practices can approach the complex task of caring for the homebound. [ABSTRACT FROM AUTHOR]

Objectives To assess the relationship between the number of primary care providers ( PCPs) in an area and emergency department ( ED) visits by older adults. Design Population-based cross-sectional observational study. Setting Nonfederal EDs in North Carolina in 2010. Participants All older adults (n = 640,086) presenting to a nonfederal ED in North Carolina in 2010. Measurements The primary outcome was the number of ED visits by older adults in each ZIP code per 100 adults aged 65 and older living in that ZIP code. A secondary outcome was the number of ED visits not resulting in hospital admission per 100 older adults. The primary predictor variable was the number of PCPs per 100 older residents for each ZIP code. Covariates included those representing healthcare need (Medicare hospitalizations, nursing home beds), predisposing factors for healthcare use (race, education, population density of older adults), and enabling factors (distance to the nearest ED). Results In a multivariable regression model corrected for spatial clustering, ZIP code characteristics associated with ED visits included more hospitalizations by Medicare beneficiaries, more nursing home beds, and closer proximity to an ED. Number of PCPs per 100 older adult residents in each ZIP code was not associated with ED use, and the 95% confidence limit indicates at most a small effect of PCP availability on ED use. Conclusion These findings suggest that primary care availability has at most a limited effect on ED use by older adults in North Carolina. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which addresses a population-based study on what the authors refer to as the factors that are associated with potentially inappropriate medication (PIM) use in elderly Koreans in an outpatient medical care setting, and it mentions drug prescription data.

Cultural attitudes about medical decision-making and filial expectations may lead some surrogates to experience stress and family conflict. Thirteen focus groups with racially and ethnically diverse English and Spanish speakers from county and Veterans Affairs hospitals, senior centers, and cancer support groups were conducted to describe participants' experiences making serious or end-of-life decisions for others. Filial expectations and family dynamics related to birth order and surrogate decision-making were explored using qualitative, thematic content analysis, and overarching themes from focus group transcripts were identified. The mean age of the 69 participants was 69 ± 14, and 29% were African American, 26% were white, 26% were Asian or Pacific Islander, and 19% were Latino. Seventy percent of participants engaged in unprompted discussions about birth order and family dynamics. Six subthemes were identified within three overarching categories: communication (unspoken expectations and discussion of death as taboo), emotion (emotional stress and feelings of loneliness), and conflict (family conflict and potential solutions to prevent conflict). These findings suggest that birth order and family dynamics can have profound effects on surrogate stress and coping. Clinicians should be aware of potential unspoken filial expectations for firstborns and help facilitate communication between the patient, surrogate, and extended family to reduce stress and conflict. [ABSTRACT FROM AUTHOR]

The interdisciplinary team ( IDT) approach is critical in the care of elderly adults. Performance-based tools to assess IDT skills have not been well validated. A novel assessment tool, the standardized patient ( SP) and standardized interdisciplinary team meeting ( SIDTM), consisting of two stations, was developed. First, trainees evaluate a SP hospitalized after a fall. Second, trainees play the role of the physician in a standardized IDT meeting with a standardized registered nurse ( SRN) and standardized medical social worker ( SMSW) for discharge planning. The SP- SIDTM was administered to 52 fourth-year medical students ( MS4s) and six geriatric medicine fellows ( GMFs) in 2011/12. The SP, SRN, and SMSW scored trainee performance on dichotomous checklists of clinical tasks and Likert scales of communication skills, which were compared according to level of training using t-tests. Trainees rated the SP- SIDTM experience as moderately difficult, length of time about right, and believability moderate to high. Reliability was high for both cases (Cronbach α = 0.73-0.87). Interobserver correlation between SRN and SMSW checklist scores (correlation coefficient ( r) = 0.82, P < .001) and total scores ( r = 0.69, P < .001) were high. The overall score on the SP- SIDTM case was significantly higher for GMF (75) than for MS4 (65, P = .002). These observations support the validity of this novel assessment tool. [ABSTRACT FROM AUTHOR]

The goal of this mixed-methods study was to characterize the perceptions of multicultural long-term care nurses about patient dignity at the end-of-life ( EOL). The study was conducted in a large, urban, long-term care ( LTC) facility. Participants were 45 long-term care nurses and 26 terminally ill nursing home residents. Nurses completed an open-ended interview about their perceptions of the concept of dying with dignity, and the data were analyzed using grounded theory methods. Main themes identified as promoting resident dignity at the EOL included treating them with respect, helping them prepare for the EOL, promoting shared decision-making, and providing high-quality care. The nurses' cultural and religious backgrounds influenced their perceptions of what constitutes dignity-conserving care. Foreign-born nurses stressed the need for EOL rituals, but this was strikingly absent in the statements of U. S.-born nurses. Foreign-born Catholic nurses stated that the dying experience should not be altered using analgesics to relieve suffering or by attempts to hasten death by forgoing curative therapy or by other means. Nurses and terminally ill individuals completed the Dignity Card-sort Tool ( DCT). A comparison of the DCT responses of the LTC nurses cohort with those of the terminally ill participants revealed that the nurses felt patient dignity was eroded when patient wishes were not followed and when they were treated without respect. In contrast, dying LTC residents felt that poor medical care and loss of ability to choose care options were the most important factors leading to erosion of dignity. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to a study on the overlap of frailty, comorbidity, disability, and poor self-rated health in community-dwelling near-centenarians.