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OBJECTIVES To develop a predictive model and risk score for 10-year mortality using health-related quality of life (HRQOL) in a cohort of older women with early-stage breast cancer. DESIGN Prospective cohort. SETTING Community. PARTICIPANTS U.S. women aged 65 and older diagnosed with Stage I to IIIA primary breast cancer (N=660). MEASUREMENTS We used medical variables (age, comorbidity), HRQOL measures (10-item Physical Function Index and 5-item Mental Health Index from the Medical Outcomes Study (MOS) 36-item Short-Form Survey; 8-item Modified MOS Social Support Survey), and breast cancer variables (stage, surgery, chemotherapy, endocrine therapy) to develop a 10-year mortality risk score using penalized logistic regression models. We assessed model discriminative performance using the area under the receiver operating characteristic curve (AUC), calibration performance using the Hosmer-Lemeshow test, and overall model performance using Nagelkerke R(NR). RESULTS Compared to a model including only age, comorbidity, and cancer stage and treatment variables, adding HRQOL variables improved discrimination (AUC 0.742 from 0.715) and overall performance (NR 0.221 from 0.190) with good calibration (p=0.96 from HL test). CONCLUSION In a cohort of older women with early-stage breast cancer, HRQOL measures predict 10-year mortality independently of traditional breast cancer prognostic variables. These findings suggest that interventions aimed at improving physical function, mental health, and social support might improve both HRQOL and survival.

OBJECTIVES To determine life expectancy for older women with breast cancer. DESIGN Prospective longitudinal study with 10 years of follow-up data. SETTING Hospitals or collaborating tumor registries in four geographic regions (Los Angeles, California; Minnesota; North Carolina; Rhode Island). PARTICIPANTS Women aged 65 and older at time of breast cancer diagnosis with Stage I to IIIA disease with measures of self-rated health (SRH) and walking ability at baseline (N = 615; 17% aged ≥80, 52% Stage I, 58% with ≥2 comorbidities). MEASUREMENTS Baseline SRH, baseline self-reported walking ability, all-cause and breast cancer-specific estimated probability of 5- and 10-year survival. RESULTS At the time of breast cancer diagnosis, 39% of women reported poor SRH, and 28% reported limited ability to walk several blocks. The all-cause survival curves appear to separate after approximately 3 years, and the difference in survival probability between those with low SRH and limited walking ability and those with high SRH and no walking ability limitation was significant (0.708 vs 0.855 at 5 years, P ≤ .001; 0.300 vs 0.648 at 10 years, P < .001). There were no differences between the groups in breast cancer-specific survival at 5 and 10 years (P = .66 at 5 years, P = .16 at 10 years). CONCLUSION The combination of low SRH and limited ability to walk several blocks at diagnosis is an important predictor of worse all-cause survival at 5 and 10 years. These self-report measures easily assessed in clinical practice may be an effective strategy to improve treatment decision-making in older adults with cancer.

Background/Objective Current preoperative assessment tools such as the American College of Surgeons Surgical Risk Calculator (ACS Calculator) are suboptimal for evaluating older adults. The objective was to evaluate and compare the performance of the ACS Calculator for predicting risk of serious postoperative complications with the addition of self-reported physical function versus a frailty score. Design Prospective cohort. Setting Two tertiary care academic medical centers in Massachusetts. Participants Individuals aged 65 and older undergoing any surgery with a risk of serious complication of 5% or greater (N = 403). Measurements We measured self-reported physical function using the Late-Life Function and Disability Instrument (LLFDI FUNCTION) and frailty phenotype (FP), which has a score ranging from 0 to 5 based on slow gait speed, weak handgrip, exhaustion, weight loss, or low activity. Using c-statistic and net classification improvement (NRI), we then analyzed capability of LLFDI-FUNCTION versus FP to improve the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery). Increase in c-statistic and net reclassification improvement (NRI) for LLFDI-FUNCTION versus FP in addition to the ACS Calculator for predicting an adverse postoperative course (serious complication, discharge to nursing home, readmission, death within 30 days of surgery) Results Over 30 days, 26% of participants developed an adverse postoperative course. The increase in c-statistic for the ACS Calculator (baseline value 0.645) was slightly greater with LLFDI-FUNCTION (0.076) than with FP (0.058), with a bootstrapped difference in c-statistic of 0.005 (95% confidence interval = 0.002–0.007). NRI was also better with LLFDI-FUNCTION. Conclusion The LLFDI-FUNCTION predicted postoperative complications slightly better than the FP. Further studies are needed to confirm these findings and validate the use of the LLFDI-FUNCTION with the ACS Calculator for preoperative assessments of older adults.

Objectives To determine whether oral health is better in centenarians than in a published birth cohort–matched sample and to compare oral health in centenarian offspring with a case-controlled reference sample. Design Observational cross-sectional study. Setting New England Centenarian Study (NECS). Participants Seventy-three centenarians, 467 offspring, and 251 offspring generation-reference cohort subjects from the NECS. Measurements A self-report questionnaire was administered to measure oral health in all three groups, with edentulous rate as the primary outcome measure. The NECS made information on sociodemographic characteristics and medical history available. Centenarian results were compared with published birth cohort–matched results. Data from offspring and reference cohorts were analyzed to determine differences in oral health and associations between oral health measures and specific medical conditions. Results The edentulous rate of centenarians (36.5%) was lower than that of their birth cohort (46%) when they were aged 65 to 74 in 1971 to 1974 (according to National Center of Health Statistics). Adjusting for confounding factors, the reference cohort was more likely to be edentulous (adjusted odds ratio (AOR) = 2.78, 95% confidence interval CI = 1.17–6.56), less likely to have all or more than half of their own teeth (AOR = 0.48, 95% CI = 0.3–0.76), and less likely to report excellent or very good oral health (AOR = 0.65, 95% CI = 0.45–0.94) than the centenarian offspring. Conclusion Centenarians and their offspring have better oral health than their respective birth cohorts. Oral health may prove to be a helpful marker for systemic health and healthy aging.

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its "Choosing Wisely" campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things-tests, medications, or procedures-that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaign's website (www.choosingwisely.org). The first AGS list was published in February 2013.

Objectives: To compare the efficacy of a computer-based physical activity program (Embodied Conversational Agent�ECA) with that of a pedometer control condition in sedentary older adults. Design: Single-blind block-randomized controlled trial stratified according to clinic site and health literacy status. Setting: Three urban ambulatory care practices at Boston Medical Center between April 2009 and September 2011. Participants: Older adults (N = 263; mean age 71.3; 61% female; 63% African American; 51% high school diploma or less). Intervention: ECA participants were provided with portable tablet computers with touch screens to use for 2 months and were directed to connect their pedometers to the computer using a data cable and interact with a computer-animated virtual exercise coach daily to discuss walking and to set walking goals. Intervention participants were then given the opportunity to interact with the ECA in a kiosk in their clinic waiting room for the following 10 months. Control participants were given a control pedometer intervention that only tracked step counts for an equivalent period of time. Intervention participants were also provided with pedometers. Measurements: The primary outcome was average daily step count for the 30 days before the 12-month interview. Secondary outcomes were average daily step count for the 30 days before the 2-month interview. Outcomes were also stratified according to health literacy level. Results: ECA participants walked significantly more steps than control participants at 2 months (adjusted mean 4,041 vs 3,499 steps/day, P = .01), but this effect waned by 12 months (3,861 vs 3,383, P = .09). For participants with adequate health literacy, those in the ECA group walked significantly more than controls at both 2 months (P = .03) and 12 months (P = .02), while those with inadequate health literacy failed to show significant differences between treatment groups at either time point. Intervention participants were highly satisfied with the program. Conclusion: An automated exercise promotion system deployed from outpatient clinics increased walking among older adults over the short-term. Effective methods for long-term maintenance of behavior change are needed.

Objectives: To examine the effect of breast cancer and its treatment on fracture risk in older breast cancer survivors. Design: A 10-year prospective cohort study beginning 5 years after a diagnosis of breast cancer for survivors and match date for comparison women. Setting: Six integrated healthcare systems. Participants: Women aged 65 and older (1,286 survivors, 1,286 comparison women, mean age 77.7 in both groups, white, non-Hispanic: survivors, 81.6%; comparison women, 85.2%) who were alive and recurrence free 5 years after a diagnosis of early-stage breast cancer and matched on age, study site, and enrollment year to a comparison cohort without breast cancer. Measurements: Cox proportional hazards models were used to estimate the association between fracture risk and survivor-comparison status, adjusting for drugs and risk factors associated with bone health. A subanalysis was used to evaluate the association between tamoxifen exposure and fracture risk. Results: No difference was observed in fracture rates between groups (hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 0.9�1.3). The protective effect of tamoxifen was not statistically significant (HR = 0.9, 95% CI = 0.6�1.2). Conclusion: Long-term survivors of early-stage breast cancer diagnosed at age 65 and older are not at greater risk of osteoporotic fractures than age-matched women without breast cancer. There appears to be no long-term protection from fractures with tamoxifen use.

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.

OBJECTIVES: To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension. DESIGN: Retrospective cohort study with 5 years of follow-up. SETTING: Ten Veterans AFFAIRS (VA) sites. PARTICIPANTS: Four thousand seventy-one ambulatory patients aged 80 and older with hypertension. MEASUREMENTS: The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores. RESULTS: Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74–0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78–0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension. CONCLUSION: In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group.

Objectives: To examine physicians' assessments of tamoxifen effectiveness in breast cancer patients, identify predictors of these assessments, and estimate the relationship between these assessments and receipt of tamoxifen prescription. Design: A cohort of breast cancer patients aged 65 and older at diagnosis and their physicians were surveyed using mailed questionnaires and telephone interviews. Setting: Community and academic hospitals in Rhode Island; North Carolina; Minnesota; and Los Angeles, California between 1996 and 1998. Participants: Physicians completed treatment recommendation forms for 496 of 865 Stage Ic to IIIa breast cancer patients. Measurements: Visual scales measured physicians' assessments of the risk that individual patients would have a breast cancer recurrence or die of breast cancer with, and without, tamoxifen therapy. Results: The mean risk ratio±standard deviation comparing risk of recurrence without tamoxifen with the risk with tamoxifen was 1.8±1.0 and for breast cancer mortality was 1.8±1.2. Only estrogen-receptor status and enrollment site emerged as significant predictors of recurrence and mortality risk ratios in regression models. Patients for whom the physician estimated that the recurrence or mortality risk doubled without tamoxifen were more likely to receive a tamoxifen prescription than patients for whom the physician estimated that tamoxifen would have no effect (odds ratio (OR)=1.4, 95% confidence interval (CI)=0.98–2.1 for recurrence risk, OR=1.8; 95% CI=1.2–2.6 for mortality risk). Conclusion: Estrogen receptor status most strongly influenced physicians' assessments of tamoxifen's effectiveness in individual patients; this effectiveness was not found to be associated with advancing patient age. Estrogen receptor status and enrollment site were related to receipt of tamoxifen prescription, but advancing age was not after accounting for physician's individualized assessment of tamoxifen's effectiveness. These findings suggest that an evidence-based approach for hormonal therapy has been widely adopted for care of older patients with breast cancer.

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.

Objectives: To assess the impact of the patient-physician interaction on breast cancer care in older women. Design: Cross-sectional survey. Setting: Los Angeles County, California. Participants: Two hundred twenty-two consecutively identified breast cancer patients aged 55 and older who were within 6 months of breast cancer diagnosis and/or 1 month posttreatment. Measurements: Dependent variables were patient breast cancer knowledge, treatment delay, and receipt of breast-conserving surgery (BCS). Key independent variables were five dimensions of the patient-physician interaction by patient report, including physician provision of tangible and interactive informational support, physician provision of emotional support, physician participatory decision-making style, and patient perceived self-efficacy in the patient-physician interaction. Age and ethnicity were additional important independent variables. Results: In multiple logistic regression models, only physician interactive informational support had significant relationships with all three dependent variables, controlling for a wide range of patient sociodemographic and case-mix characteristics, visit length, number of physicians seen, social support, and physician sociodemographic and practice characteristics. Specifically, informational support positively predicted patient breast cancer knowledge (adjusted odds ratio (AOR)=1.18, 95% confidence interval (CI)=1.00–1.38), negatively predicted treatment delays (AOR=0.80, 95% CI=0.67–0.94), and positively predicted receipt of BCS (AOR=1.29, 95% CI=1.07–1.56). Age and ethnicity were not significant predictors in these models. Conclusion: One specific domain of the patient-physician interaction, interactive informational support, may provide an avenue to ensure adequate breast cancer knowledge for patient treatment decision-making, decrease treatment delay, and increase rates of BCS for older breast cancer patients, thereby potentially mitigating known healthcare disparities in this vulnerable population of breast cancer patients.

Objectives: To evaluate the effect of nine disabling medical conditions upon recovery from functional limitations by elders. Design: Retrospective analysis of prospective longitudinal cohort. Setting: Community. Participants: Persons aged 65 and older in Framingham Heart Study. Measurements: Change in function in elders from biennial Examinations 18 (1983–85; baseline) through 23 (1994–96). At each examination, subjects reported limitations in heavy household work, walking up and down stairs, walking half a mile, bathing, toileting, and continence. They were also directly observed for performance of transferring in and out of a chair, dressing, walking 50 feet, and carrying a 10-pound object 10 feet. The prevalence of functional limitations and the incidence of recovery from functional limitation by the subsequent examination for each task were calculated. The effects of congestive heart failure, cognitive impairment, diabetes mellitus, stroke, depressive symptoms, hip fracture, knee pain, claudication, and chronic obstructive pulmonary disease were evaluated. The relationship between the total number of comorbid conditions present (0, 1, 2, 3 or more), the presence of each individual condition at the start of each examination cycle, and the incidence of recovery from functional limitations were examined using generalized estimating equations. Results: One thousand eight hundred twenty-five subjects were studied at baseline; 1,026 were available 10 years later. Mean age of subjects at baseline was 73.5 (range 61–95); 60.7% were women. The prevalence of functional limitations ranged from 3.1% to 29.8% at biennial Examination 18 and increased to 15.1% to 32.4% at Examination 23. The incidence of recovery ranged from 3.2% to 78.4% depending upon the task and the examination cycle. Increasing disease burden, as measured by the number of comorbidities, was associated with a decreased likelihood of recovery from functional limitations. Diabetes mellitus, stroke, depressive symptoms, hip fracture, and knee pain had the strongest adverse effect upon recovery from functional limitations. Conclusion: In these community-dwelling elders, recovery from prevalent functional limitations was frequent. Increasing disease burden was associated with a decreased incidence of recovery. Diabetes mellitus, stroke, depressive symptoms, hip fracture, and knee pain had the strongest adverse effect on recovery from functional limitations.

Age is the most important risk factor for breast cancer; age is also a risk factor for undermanagement of breast cancer. One thousand eight hundred fifty-nine women aged 65 and older with early-stage breast cancer were studied, and it was found that undermanagement is a risk factor for recurrence and for dying of breast cancer. Although conservative treatment is probably warranted in patients with tumors having excellent prognostic characteristics and in women with limited life expectancies, standard treatment is needed for the majority of older women if the disproportionate burden of breast cancer in this age group is to be reduced. Better strategies are needed for identifying those most likely to benefit from standard treatment and from systematic surveillance for recurrence. In this regard, collaboration between oncologists and primary care physicians is essential for achieving high-quality care and outcomes in this vulnerable group of patients.

Objectives: To identify older adults with comorbidities or poor functional status at high risk of postoperative venous thromboembolism (VTE). Design: Retrospective cohort study. Setting: Veterans Affairs Medical Center (VAMC). Participants: Older adults who underwent total hip and knee replacement (THR and TKR) from 2002 to 2009. Measurements: Using multivariate logistic regression, the independent effect of cardiopulmonary comorbidities and diabetes on VTE was analyzed. Functional status expressed in a summary physical component score (PCS) was also analyzed in a subset of individuals in whom information on it was available. Results: There were 23,326 THR and TKR surgeries performed at the VAMC during the study period. Individuals with chronic obstructive pulmonary disease (COPD) had a 25% greater risk of VTE (odds ratio (OR) = 1.25, 95% confidence interval (CI) = 1.06�1.48), whereas those with coronary artery disease, congestive heart failure, and cerebrovascular disease did not have a greater risk of VTE. Individuals with diabetes mellitus had a lower risk of VTE (OR = 0.77, 95% CI = 0.64�0.92). Individuals with low PCS, which were available for 3,169 patients, had a 62% greater risk, although the effect did not reach statistical significance (lowest vs highest quartile OR = 1.62, 95% CI = 0.93�2.80). Conclusion: Individuals with COPD had slightly greater risk of VTE, whereas low functional status had a larger effect that did not reach statistical significance. The constraints of administrative data analysis and sample size available for PCS limit conclusions about the role of these comorbidities and functional status.

OBJECTIVES: To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation. DESIGN: A longitudinal observational study, with baseline data being reported herein. SETTING: Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana. PARTICIPANTS: Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics. MAIN OUTCOME MEASUREMENTS: The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters. RESULTS: The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05). CONCLUSION: The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases. J Am Geriatr Soc 44:1314–1321, 1996.

Breast cancer is common in women aged 80 and older and is increasing because of longer life expectancies and greater use of mammography screening. Although mortality from breast cancer has declined in women younger than 70, it has increased in women aged 80 and older, and this may be partly due to less aggressive treatment of these women.[1–3] Women aged 80 and older are less likely to receive axillary lymph node dissection, radiation after breast conserving surgery, chemotherapy, or steroid receptor assessment than younger women.[2–10] Limited clinical trial data on the efficacy of many breast cancer treatments for women aged 80 and older may explain some of the variation in treatment of these women,[11] but few studies have examined breast cancer treatment decision-making in women aged 80 and older.[12] Better understanding breast cancer treatment decisions of older women is important because less-aggressive treatment has been associated with greater breast cancer mortality.[2] Although few studies have examined the breast cancer treatment decisions of women aged 80 and older, studies that have examined breast cancer decision-making in younger postmenopausal women have found that patient age,[7, 9, 13, 14] treatment preferences, [13,14] culture and faith [15,16], health, [9,13,14, 17,18], socioecodemographic characteristics, [13, 18–20], tumor characteristics [7,17,21], family influence [13,14,17], and physician communication [13,14,17,18] affect treatment decisions. This study aimed to identify factors that affect that treatment decisions of women aged 80 and older to better understand their decision-making and ideally to lead to better counseling regarding breast cancer care for older women. When data on efficacy and outcomes are limited, as is the case for most breast cancer treatments in women aged 80 and older, that is when the most complicated decision-making occurs and when patients and families need the most assistance from clinicians.[21]

Objective: To identify characteristics present at the time of elders' (≥75 years of age) hospitalization that predicted caregivers' self-reported physical and psychological health 1 year later. Design: A prospective observational cohort study of 104 family caregivers followed for 1 year from the time of their elders' hospitalization. Setting: Urban community hospital with academic affiliation. Subjects: Caregivers of patients enrolled in an evaluation of inpatient interdisciplinary geriatric assessment who provided care for the entire year of follow-up and who participated in all interviews. Main Outcomes: Self-reported physical and psychological health. Results: Caregivers' baseline self-reported physical health (AOR = 21.8; 95% CI = 4.65–102), the impact of caregiving on their social and leisure time activities (AOR = 9.93; 95% CI = 1.71–57.8), and their relationship to their elders (AOR = 6.50; 95% CI = 1.20–35.2) were all significantly associated with self-reported physical health at follow-up. Caregivers' baseline self-reported health (AOR = 3.70; 95% CI = 1.11–12.5), whether or not they had additional current caregiving responsibilities (AOR = 6.67; 95% CI = 1.89–25.0), and the interaction of perceptions of caregiving and the adequacy of family help were significant predictors of psychological health at follow-up, adjusted for baseline psychological health. Conclusion: Information available at the time of elderly patients' admission to the hospital can help to differentiate those caregivers at risk for future physical and psychological distress from those who are likely to continue doing well.

Age is the most important risk factor for breast cancer; age is also a risk factor for undermanagement of breast cancer. One thousand eight hundred fifty-nine women aged 65 and older with early-stage breast cancer were studied, and it was found that undermanagement is a risk factor for recurrence and for dying of breast cancer. Although conservative treatment is probably warranted in patients with tumors having excellent prognostic characteristics and in women with limited life expectancies, standard treatment is needed for the majority of older women if the disproportionate burden of breast cancer in this age group is to be reduced. Better strategies are needed for identifying those most likely to benefit from standard treatment and from systematic surveillance for recurrence. In this regard, collaboration between oncologists and primary care physicians is essential for achieving high-quality care and outcomes in this vulnerable group of patients.

Comprehensive geriatric assessment has emerged as an effective strategy for improving outcomes for frail older patients in the hospital setting. Attention, however, has not been given to determining whether this process has any effect on their family caregivers. As part of a randomized controlled clinical trial designed to test the efficacy of early interdisciplinary geriatric assessment for acutely ill hospitalized patients 75 years of age or older, their family caregivers were studied to determine if the process had a positive effect on caregivers' self-reported health and emotional well-being. One hundred forty-two caregivers were approximately evenly distributed between experimentals (n = 69) and controls (n = 73). By three months after the patients' hospitalization, experimental caregivers were more likely to report good general health (81% vs 63%, P = .049) than were controls. The positive effect persisted after statistical adjustment for confounding variables. Experimental caregivers were not significantly more likely to have good emotional health at follow-up than were controls (65% vs 58%, P = .43), even after statistical adjustment. Although the findings are modest, they suggest that the acute hospital setting may be an ideal place to develop interventions designed to enhance family caregivers' well-being during the early months following hospitalization. This may be particularly true when the interventions with caregivers are coupled with a geriatric assessment and care plan process.

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.

To determine the relationship between blood pressure (BP) and all-cause mortality in subjects aged 80 and older with hypertension.Retrospective cohort study with 5 years of follow-up.Ten Veterans AFFAIRS (VA) sites.Four thousand seventy-one ambulatory patients aged 80 and older with hypertension.The outcome measure was likelihood of survival during the follow-up period. Vital status was obtained from VA and Social Security files. Variables collected for adjustment in Cox regression models were baseline BP, medications, demographics, diagnoses, and health-related quality of life (HRQoL); HRQoL information was available on 1,289 subjects based on Veterans Health Study Short From-36 (SF-36) questionnaire scores.Subjects with higher BP (up to a systolic BP (SBP) of 139 mmHg and a diastolic BP (DBP) of 89 mmHg) were less likely to die during follow-up than subjects with lower BP. After baseline adjustments, the hazard ratio for a 10-point increase in SBP was 0.82 (95% confidence interval (CI)=0.74-0.91), up to a SBP of 139 mmHg, and for DBP was 0.85 (95% CI=0.78-0.92), up to a DBP of 89 mmHg. There was no significant association between survival and BP levels in subjects with uncontrolled hypertension.In a cohort of very old, hypertensive veterans, in subjects with controlled BPs, subjects with lower BP levels had a lower 5-year survival than those with higher BPs. This suggests that clinicians should use caution in their approach to BP lowering in this age group.

To examine physicians' assessments of tamoxifen effectiveness in breast cancer patients, identify predictors of these assessments, and estimate the relationship between these assessments and receipt of tamoxifen prescription.A cohort of breast cancer patients aged 65 and older at diagnosis and their physicians were surveyed using mailed questionnaires and telephone interviews.Community and academic hospitals in Rhode Island; North Carolina; Minnesota; and Los Angeles, California between 1996 and 1998.Physicians completed treatment recommendation forms for 496 of 865 Stage Ic to IIIa breast cancer patients.Visual scales measured physicians' assessments of the risk that individual patients would have a breast cancer recurrence or die of breast cancer with, and without, tamoxifen therapy.The mean risk ratio+/-standard deviation comparing risk of recurrence without tamoxifen with the risk with tamoxifen was 1.8+/-1.0 and for breast cancer mortality was 1.8+/-1.2. Only estrogen-receptor status and enrollment site emerged as significant predictors of recurrence and mortality risk ratios in regression models. Patients for whom the physician estimated that the recurrence or mortality risk doubled without tamoxifen were more likely to receive a tamoxifen prescription than patients for whom the physician estimated that tamoxifen would have no effect (odds ratio (OR)=1.4, 95% confidence interval (CI)=0.98-2.1 for recurrence risk, OR=1.8; 95% CI=1.2-2.6 for mortality risk).Estrogen receptor status most strongly influenced physicians' assessments of tamoxifen's effectiveness in individual patients; this effectiveness was not found to be associated with advancing patient age. Estrogen receptor status and enrollment site were related to receipt of tamoxifen prescription, but advancing age was not after accounting for physician's individualized assessment of tamoxifen's effectiveness. These findings suggest that an evidence-based approach for hormonal therapy has been widely adopted for care of older patients with breast cancer.

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.

To assess the impact of the patient-physician interaction on breast cancer care in older women.Cross-sectional survey.Los Angeles County, California.Two hundred twenty-two consecutively identified breast cancer patients aged 55 and older who were within 6 months of breast cancer diagnosis and/or 1 month posttreatment.Dependent variables were patient breast cancer knowledge, treatment delay, and receipt of breast-conserving surgery (BCS). Key independent variables were five dimensions of the patient-physician interaction by patient report, including physician provision of tangible and interactive informational support, physician provision of emotional support, physician participatory decision-making style, and patient perceived self-efficacy in the patient-physician interaction. Age and ethnicity were additional important independent variables.In multiple logistic regression models, only physician interactive informational support had significant relationships with all three dependent variables, controlling for a wide range of patient sociodemographic and case-mix characteristics, visit length, number of physicians seen, social support, and physician sociodemographic and practice characteristics. Specifically, informational support positively predicted patient breast cancer knowledge (adjusted odds ratio (AOR)=1.18, 95% confidence interval (CI)=1.00-1.38), negatively predicted treatment delays (AOR=0.80, 95% CI=0.67-0.94), and positively predicted receipt of BCS (AOR=1.29, 95% CI=1.07-1.56). Age and ethnicity were not significant predictors in these models.One specific domain of the patient-physician interaction, interactive informational support, may provide an avenue to ensure adequate breast cancer knowledge for patient treatment decision-making, decrease treatment delay, and increase rates of BCS for older breast cancer patients, thereby potentially mitigating known healthcare disparities in this vulnerable population of breast cancer patients.

To evaluate the effect of nine disabling medical conditions upon recovery from functional limitations by elders.Retrospective analysis of prospective longitudinal cohort.Community.Persons aged 65 and older in Framingham Heart Study.Change in function in elders from biennial Examinations 18 (1983-85; baseline) through 23 (1994-96). At each examination, subjects reported limitations in heavy household work, walking up and down stairs, walking half a mile, bathing, toileting, and continence. They were also directly observed for performance of transferring in and out of a chair, dressing, walking 50 feet, and carrying a 10-pound object 10 feet. The prevalence of functional limitations and the incidence of recovery from functional limitation by the subsequent examination for each task were calculated. The effects of congestive heart failure, cognitive impairment, diabetes mellitus, stroke, depressive symptoms, hip fracture, knee pain, claudication, and chronic obstructive pulmonary disease were evaluated. The relationship between the total number of comorbid conditions present (0, 1, 2, 3 or more), the presence of each individual condition at the start of each examination cycle, and the incidence of recovery from functional limitations were examined using generalized estimating equations.One thousand eight hundred twenty-five subjects were studied at baseline; 1,026 were available 10 years later. Mean age of subjects at baseline was 73.5 (range 61-95); 60.7% were women. The prevalence of functional limitations ranged from 3.1% to 29.8% at biennial Examination 18 and increased to 15.1% to 32.4% at Examination 23. The incidence of recovery ranged from 3.2% to 78.4% depending upon the task and the examination cycle. Increasing disease burden, as measured by the number of comorbidities, was associated with a decreased likelihood of recovery from functional limitations. Diabetes mellitus, stroke, depressive symptoms, hip fracture, and knee pain had the strongest adverse effect upon recovery from functional limitations.In these community-dwelling elders, recovery from prevalent functional limitations was frequent. Increasing disease burden was associated with a decreased incidence of recovery. Diabetes mellitus, stroke, depressive symptoms, hip fracture, and knee pain had the strongest adverse effect on recovery from functional limitations.

UNLABELLED Geriatric assessment units have improved pharmacotherapy for their patients by decreasing the number of medications prescribed. The Senior Care Study, a randomized controlled trial, compared a multidisciplinary-team approach to patient care to the standard medical practice of the institution. As a part of the trial, the effectiveness of an interdisciplinary team intervention in improving the use of medications was studied. Study goals were to decrease medications used, decrease unnecessary medications, and improve medication choices in our acutely ill inpatient population. A pharmacist interviewed all experimental patients and patient records, and presented medication concerns and recommendations at a team conference. MEDICATIONs were counted on admission and on the third day, sixth week, and third month after randomization. MEDICATIONs were paired with patient problems. MEDICATION problem pairs were judged as inappropriate choices if there were potential side effects that would affect patient function, and if better alternatives were available. The 215 control and 221 experimental patients in the study were similar in age, sex, place of origin, and number of medications on admission. Experimental patients took fewer medications than controls on the third day (5.3 versus 5.9, P less than .05). Experimental patients received fewer multiple unpaired medications (11% versus 19%, P less than .025) and fewer inappropriate medication choices (20% versus 37%, P less than .005). The results suggest that the team intervention was effective in improving pharmacotherapy in the acute-care setting.

Successful models of inpatient geriatric assessment have often involved long hospital stays, specialized interdisciplinary care, and prolonged follow-up, which are difficult to achieve within a prospective payment system. A randomized clinical trial was undertaken to evaluate the efficacy (maintenance or improvement in mental, emotional, and physical function) of using a geriatric assessment process in acute hospital care without increasing hospital charges or lengths of stay. Four hundred thirty-six patients greater than or equal to 75 years of age were randomly allocated to treatment (n = 221) or control (n = 215) conditions. Patients in the treatment group were admitted to a special unit and evaluated on admission by an interdisciplinary team, which developed a care plan. Although primary care was provided by the patient's own physician, the team followed the patients as consultants on the unit in the hospital, and by telephone for 2 months after discharge. The control group was placed on other units and received usual hospital care. The treatment and control groups were similar at study entry. At follow-up, there were no significant differences between the groups with respect to lengths of stay, hospital charges, mortality, change in physical function, or change in mental function. The treatment group changed more often in measured emotional function (chi 2 = 6.213, P = .045). This study indicates that it is feasible to implement consultative interdisciplinary team care in the acute-care hospital, but that its efficacy may be limited when applied to an unselected group of older patients.

We examined the relationship between age and extent of disease at initial diagnosis as part of a population-based, prospective study documenting the patterns of care received by over 1500 newly diagnosed lung, breast, and colorectal cancer patients identified in nine Rhode Island hospitals. For each cancer site examined, no age by extent of disease relationship was observed; however, analysis by sex among lung cancer patients indicated an inverse age relationship for men. The absence of an age effect for breast cancer patients is in contrast to earlier research findings that identify a positive association between extent of disease and age at diagnosis. Past results may reflect age-related differences in patient and physician screening behavior characteristic of earlier time periods.

To evaluate the current outcome of patients hospitalized with diabetic hyperosmolar state (DHS), we retrospectively studied 135 patients admitted to two general hospitals over an 11-year period. Mortality was 17%. Patients who died had a mean age of 77 years, compared to 68 years for the survivors (P = 0.008). They were also more likely to be nursing home residents (48 versus 23%, P = 0.01). Additionally, mean serum osmolality was significantly higher among those who died (383 versus 358 mosm/L, P less than 0.0001) as was blood urea nitrogen (81.3 versus 62.3 mg/dl, P = 0.006) and sodium (148 versus 137.4 mEq/L, P less than 0.001). However, mean glucose level and anion gap were similar among patients who died and patients who survived (1068 versus 1092 mg%; 23 versus 24 mEq/L, respectively). The presence of a chronic disease or an acute comorbid illness was not associated with mortality. Diminished physiologic reserve, attendant comorbidity, or functional disability may explain the effect of age and nursing home residence. High osmolality may indicate a greater water deficit and a more advanced stage of DHS at the time of diagnosis.

Elderly stroke patients and their families were studied to determine 1) the health effects of providing home care on family caregivers, 2) whether or not caregivers actually providing care in the home experience different effects than caregivers whose family members live in nursing homes, and 3) factors associated with any observed deleterious effects of caregiving. One hundred forty-seven stroke patients were eligible for study. Of these, 101 were available for follow-up; 89 family caregivers were interviewed (88%). Caregivers reported both positive and negative effects of providing home care. When actual home caregivers were compared with potential caregivers (those with family members in institutions), no differences in effects were seen. The relationship between each of three health effects (general, social, and emotional) and patient and caregiver attributes was explored. No factors were found to be related to poorer perceived general health. Dependent patient functional status and additional life stress were both associated with diminished social activity and emotional ill-health. In the latter instance, insufficient social activity and help from family were additional risk factors. If policy is going to advocate home care, its consequences for family caregivers must be known.

With the graying of America, more older persons will be driving. Physiological changes associated with normal aging and diseases that commonly affect the elderly may compromise their ability to drive safely. Although all states have regulations governing driving licensure, few offer specific guidelines regarding older persons. Accordingly, much of the responsibility for determining medical competence to drive and counseling patients in this regard is left to physicians. Normal physiologic changes may limit sensory information, particularly visual, available to the driver. In addition, chronic diseases in older persons including coronary artery disease, dementia and other neurologic disorders, diabetes mellitus, and drug use may increase the risk of crashes while driving. Once the question of competence to operate an automobile has been raised, ethical dilemmas must be addressed regarding the benefit of continued driving for the individual versus the risk to that person and society as a whole. In this article, we review the medical grounds for determining competence to drive, discuss ethical implications, and report current legal regulations for physicians and aging drivers. Future directions and possible areas for further research are outlined.