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Abstract: Objective: The objective of this article was to determine whether, in drug intervention trials, growth mixture modeling (GMM) is able to identify drug-responsive trajectory classes that are not evident in traditional growth modeling approaches. Methods: We reanalyzed acute phase (biweekly data up to 7 occasions) and longitudinal (12 months) data on the 469 patients in the SADHART-CHF study of the safety and efficacy of sertraline for depression in patients with heart failure. GMM was used to identify the trajectory classes present in the treatment and placebo groups, based on Hamilton Depression Rating Scale scores. Results: Two distinct trajectory classes were identified in the treatment group: (1) chronic depressives (12%), who remained depressed through the treatment phase; and (2) responders (88%), who had scores indicating nondepression at the conclusion of the acute phase. At baseline, chronic depressives were distinguished by higher Hamilton Depression Rating Scale scores, the presence of implantable cardioverter defibrillators, and a history of anxiety. During follow-up, they were more likely to have unstable angina. Only responders remitted (70%). Three distinct trajectories were identified in the placebo group: (1) moderating depressives (19%), (2) temporary improvers (13%), and (3) responders (68%). At baseline, the classes differed in mean Hamilton Depression Rating Scale scores, responders'' scores falling between the other 2 classes, and the proportion with renal disease. Only remission differed at follow-up: responders (76%), moderating depressives (21%), and temporary improvers (3%). Where the traditional analytic approach found improvement from moderate to mild depression but no significant treatment effect, GMM found response in 20% more people in the treatment group than in the placebo group. Conclusions: Unlike conventionally used, standard analytic approaches, which focus on intervention impact at study end or change from baseline to study end, GMM enables maximum use of repeated data to identify unique trajectories of latent classes that are responsive to the intervention. ClinicalTrials.gov identifier: NCT00078286. [Copyright &y& Elsevier]

Abstract: Objective: The goals of this study were to (1) determine whether level of social support and living situation predicted emergency department (ED) use among older adults and (2) identify correlates of ED visits according to whether the patient was admitted to the hospital. Methods: Secondary analysis of a longitudinal, prospective study was conducted. Results: In adjusted analyses, subjects who lived alone were 60% more likely to visit the ED than those who lived solely with their spouse. Neither type nor level of social support as measured by the Duke Social Support Index predicted ED use. Indicators of poor physical health (prior hospitalization, poorer self-rated health, and functional disability) were predictors of ED visits that resulted in hospitalization; however, these were not significantly associated with outpatient ED visits. Discussion: Older adults who live alone are more likely to visit the ED. Additional study is needed to understand the determinants of outpatient ED visits. [Copyright &y& Elsevier]

Objective: To investigate the one-month prevalence of depression morbidity and its association with sociodemographic characteristics, health and functional status, and use of health services in community residents aged 60 years and over in Brazil. Methods: This study used a cross-sectional design of face-to-face interviews (N= 7,040) in Rio Grande do Sul State, Brazil. Participants were household residents aged 60 years and older. Measurements included the Short Psychiatric Evaluation Schedule (six-item version) and questionnaire that assessed sociodemographic characteristics, self-reported health status, systemic illnesses, activities of daily living (ADL), use of medical services, and social support. Results: The overall prevalence of depression morbidity was 22% (men: 18%, women: 25.2%). In controlled analyses, younger age, low income, rural origin, never or no longer married, poor self-rated health, presence of systemic illnesses, visual, hearing, or ADL impairments, hospitalization in the past 12 months, and lack of exercise or employment were significantly associated with depression morbidity, whereas living alone was nearly so associated. Gender, education, minority race, or outpatient visits in the previous six months were not associated with depression morbidity. Conclusion: The overall prevalence of depression morbidity was among the highest previously reported for older persons. In controlled analyses, prevalence declined as age increased, and rates were higher for those with lower income and poorer social, health, and functional status, but did not differ significantly by gender, education, or race/ethnicity. Increased attention should be paid to identifying depression morbidity in those with adverse circumstances and to identifying ameliorating interventions. [ABSTRACT FROM AUTHOR]

Background: There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use.Objective: The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged ≥68 years, as determined by the relationship of these criteria to health service use in older community residents.Methods: Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an inhome interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services.Results: A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P < 0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry.Conclusions: Our data suggest that in representative community residents aged >68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria). [Copyright &y& Elsevier]

Background: Constipation, a common and sometimes severe problem in the elderly, is often treated with laxatives.Objective: The purpose of this study was to determine the prevalence of laxative use and identify determinants of such use among representative black and white community-dwelling elderly persons.Methods: This was a cross-sectional survey of 4136 participants at baseline (1986–1987) in the Duke University Established Populations for Epidemiologic Studies of the Elderly. Data on demographic characteristics, health status, health service use, and use of prescription and over-the-counter drugs were collected in participants'' homes. Use of the following types of laxatives was examined: bulking, hyperosmotic, lubricant, stimulant, stool softener, saline, and miscellaneous agents.Results: It was found that 10.2% of participants used ≥1 laxative. Stimulants and bulking agents were the most commonly used classes. Only 11.6% of laxative users reported concurrent consumption of ≥2 laxatives. Multivariate logistic regression analyses indicated that laxative use was more likely in women (adjusted OR, 1.78; 95% CI, 1.34–2.37), those with >4 physicians visits in the previous year (adjusted OR, 1.72; 95% CI, 1.16–2.53), those unable to walk a half mile (adjusted OR, 1.44; 95% CI, 1.11–1.87), and those using ≥4 over-the-counter nonlaxative medications (adjusted OR, 2.09; 95% CI, 1.15–3.81). A nonsignificant association was seen between laxative use and the use of anticholinergic agents (adjusted OR, 1.38; 95% CI, 1.00–1.89).Conclusions: Laxative use is common among community-dwelling elderly persons and is related to specific factors concerning sociodemographics, health status, and access to health care. Studies are needed that examine the impact of laxative use on bowel function and quality of life in the elderly. [Copyright &y& Elsevier]

Background: The role of oxidative stress in the pathogenesis of diseases such as macular degeneration, certain types of cancer, and Alzheimer''s disease has received much attention. Thus, there is considerable interest in the potential contribution of antioxidants to the prevention of these diseases.Objective: The objective of this study was to determine whether use of supplemental antioxidants (vitamins A, C, or E, plus selenium or zinc) was associated with a reduced risk of development of cognitive impairment or cognitive decline in a representative sample of the community-dwelling elderly.Methods: The sample consisted of 2082 nonproxy subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly who were not cognitively impaired at the 1989–1990 interview (baseline for the present analysis). Medication use was determined during in-home interviews. Cognitive function was assessed 3 and 7 years from baseline in terms of incident cognitive impairment, as measured on the Short Portable Mental Status Questionnaire (SPMSQ) using specific cut points (number of errors) based on race and education, and cognitive decline, defined as an increase of ≥ 2 errors on the SPMSQ. Multivariate analyses were performed using weighted data adjusted for sampling design and controlled for sociodemographic characteristics, health-related behaviors, and healt status.Results: At baseline, 224 (10.8%) subjects were currently taking a supplement containing an antioxidant. During the follow-up period, 24.0% of subjects developed cognitive impairment and 34.5% experienced cognitive decline. Current antioxidant users had a 34.0% lower risk of developing cognitive impairment compared with non-antioxidant users (adjusted relative risk [RR], 0.66; 95% CI, 0.44–1.00) and a 29.0% lower risk of experiencing cognitive decline (adjusted RR, 0.71; 95% CI, 0.49–1.01).Conclusion: The results of this analysis suggest a possible beneficial effect of antioxidant use in terms of reducing cognitive decline among the community-dwelling elderly. [Copyright &y& Elsevier]

We linked Medicare claims data to information on 417 patients with a clinical diagnosis of Alzheimer''s disease in the Consortium to Establish a Registry for Alzheimer''s Disease (CERAD) to determine what proportion of them were identified as having Alzheimer''s disease (AD) in Medicare claims records. Seventy-nine percent of these patients were identified as having AD using 5 years of claims data; 87% were identified as demented when a broader set of ICD-9-CM codes was used. An Anderson-Gill counting process approach was used to model the “hazard” of patients being identified as having AD in Medicare claims data. CERAD patients with mild dementia were less likely to be identified in the claims data as having AD. Once identified in Medicare claims as having AD, patients were more likely to be so identified again. When using only the physician supplier and institutional outpatient files, approximately 75% of CERAD patients were identified as having AD; hospital files used alone identified less than one-third (29%) of the CERAD patients as having AD. The data indicate that at least 3 consecutive years of physician supplier and physician outpatient claim files should be used to identify Medicare beneficiaries with AD using Medicare claims. [Copyright &y& Elsevier]

Focus on decline in performance of activities of daily living (ADL) has not been matched by studies of recovery of function. Advised by a broad conceptual model of physical resilience, we ascertain characteristics that identify (1) maintenance, (2) decline, and (3) recovery of personal self-maintenance activities over six years in an older, community representative, African American and white sample. Longitudinal study, analyses included descriptive statistics and repeated measures proportional hazards. Community-representative participants of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), unimpaired at baseline (n = 3187; 46% white, 54% African American; 64% female, 36% male), followed annually for up to 6 years. Data included information on basic activities of daily living (BADL), demographic characteristics, health status, social services provided and received, household size, neighborhood safety, and survival status. Over 6 years, ∼75% remained unimpaired, of whom 30% were unimpaired when they dropped out or died. Of ∼25% who became impaired, just under half recovered. Controlled analyses indicated that those who became impaired were in poorer health, younger, and more likely to be African American. Characteristics of recovery included younger age, not hospitalized in the previous year, and larger household size. Maintenance of health status facilitated continued unimpaired BADL. While decline was associated with poorer health, younger age, and being African American, recovery was also associated with younger age, together with larger household size, and no further deterioration in health as measured here. Maintenance of good health is preferred, but following decline in functioning, increased effort to improve health and avoid further decline, which takes into account not only physical but also personal social conditions, is needed. [ABSTRACT FROM AUTHOR]