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BackgroundA large proportion of the disease and disability which affects older persons occurs in the years just prior to death. Little prospective evidence is available which quantifies the burden of morbidity and disability during these years.MethodsIn three community-based cohorts of persons age 65 and older, chronic conditions and disability were evaluated for the three years prior to death in 531 persons who had three annual assessments and then died within one year of the third assessment. Number of chronic conditions, prevalence of disability in activities of daily living (ADLs), and prevalence of disability on a modified Rosow-Breslau scale were determined for these decedents and compared to 8821 members of the cohorts known to have survived.ResultsPrevalence rates of disease and disability increased during the follow-up for both decedents and survivors, with decedents generally having higher rates than survivors. Disability rates prior to death, but not the number of diseases, increased with increasing age at death. The odds ratio for disability in ADLs at any of the three assessments for decedents versus survivors ranged from 3.0 to 4.2 in the three communities. In each community the odds ratio for ADL disability was higher in women decedents versus survivors than in men decedents versus survivors.ConclusionsThese results have important implications for disability levels in future older populations in which death is projected to occur at increasingly higher ages.

Background: A myocardial infarction (MI) results typically in abrupt functional deterioration immediately postevent, followed by recovery. The post-MI health disparities experienced by black older adults may be attributable to the social and health correlates of race. We explored patterns of change in functional status in a community-based sample of 243 older white and black persons hospitalized for an incident MI.Methods: The study sample was drawn from the Established Populations for Epidemiologic Studies of the Elderly (EPESE). All older adults hospitalized for an incident MI between the first two waves of data collection were followed up yearly for two additional years. Nonlinear quadratic trajectories of functional status, as measured by disability in activities of daily living (ADL) and functional limitation (FL), were fit using mixed-effects models.Results: Although there were no nonlinear differences in ADL trajectories, there was a faster nonlinear rate of change in FL in older blacks compared to whites, independent of other social and health factors. The baseline white-black gap in FL widened after the MI by the first follow-up, continued to widen at a less accelerated pace until the second follow-up, and narrowed by the third follow-up.Conclusions: Disparities in relevant social and health factors did not account for the more abrupt deterioration in FL postevent or for the more substantial recovery in older blacks compared to older whites. Disparities in therapeutic strategies and the "survival of the fittest" may underlie the pattern of this white-black gap in FL after an incident MI. [ABSTRACT FROM AUTHOR]

Considering that the most vulnerable subgroup of elders for poor nutritional status and functional decline is the increasing number of homebound women, we examined gender differences in physical performance, body composition, and dietary intake in a randomly recruited sample of 345 homebound elders (81% women, 48% black, > 65% income < $750/month). After controlling for demographic and health-related factors, the results from multivariate analyses indicated that women were more likely than men to report the lowest nutrient intake and were 2.9 times more likely to be at the worst level of overall physical performance. These results suggest a heightened vulnerability of homebound older women to poor physical performance, low dietary intake, and increased Body Mass Index (BMI). Prospective research is now needed to examine the interrelationships between physical performance, dietary intake, and body composition among the growing homebound older population. [ABSTRACT FROM AUTHOR]

Background: Models for causation of functional disability differ as to whether different diseases lead to common expressions of disability versus producing unique "disability fingerprints." Multiple sclerosis (MS) and Spinal Cord Injury (SCI) both affect the spinal cord; however, their pathophysiologies differ (progressive vs. nonprogressive; multifocal vs. unifocal).Methods: Patterns of disability were compared among veterans who reported in a national survey that they had MS (n = 1789) or SCI (n = 6361) as the sole cause of their spinal cord dysfunction. The study used self-reported information on disease duration, physical impairments, and self-care skills to compare the two samples for differences in disability overall and after stratification according to (a) disease duration, and (b) specific physical impairments.Results: Patterns of disability differed significantly among persons with MS compared to SCI (p = .001). Differences in level of disability between the two samples remained statistically significant after stratification on disease duration. There were substantial, statistically significant differences between the two samples in the amount and kinds of physical impairment. However, differences in level of disability between the two conditions remained highly significant after stratifying on number of affected limbs (p = .003), amount of useful movement (p = .001), overall motor impairment (p = .003), amount of sensation (p = .001), impairment in memory and thinking (p = .001), and visual impairment (p = .001).Conclusions: This study shows differing diseases indeed have unique disability fingerprints, which remain unique after controlling for disease duration and for population-specific differences in physical impairment. These findings point out the need to explain the disablement process more fully. [ABSTRACT FROM AUTHOR]

This research describes characteristics of community living elders aged 71 and older with long-term care (LTC) needs who pay out-of-pocket for community-based LTC. Community living elders with higher incomes, more friends and non-child relatives outside the home, and greater ADL or IADL needs are more likely to purchase LTC than those without these characteristics. Also the lack of sufficient numbers of children outside the home to provide assistance tended to result in the use of out-of-pocket paid services. Paying for LTC is not associated with the extent of disability experienced. This study clarifies the characteristics of those in need who currently pay out-of-pocket for community LTC as a basis for examining the inadequacies of current LTC financing. [ABSTRACT FROM AUTHOR]

The functional status profile generated from static, cross-sectional data can be misleading. The dynamic perspective generated by longitudinal data emphasize that loss of functional status is not a unidirectional, universal process. The substantial rate of turnover among community-living elders dependent in Activities of Daily Living (ADL) demonstrates that the impairments experienced by a sizable minority (one-eighth to one-third, depending on the time span and the definition of dependency) were only temporary. Alternatively, approximately one-fourth of those ADL-dependent elders living in the community entered the high-cost institutionalized or predeath cohorts within the short term of 15 months compared to the 6 to 8 percent of the ADL-independent community elders. The implications of these population-based, longitudinal data for planning health care systems are emphasized. [ABSTRACT FROM AUTHOR]

The purposes of this article are three. First, to emphasize a basic implication of the common demographic summaries and projections as they apply to long-term care, namely that we need to age-adjust utilization projections. Second, to discuss an example in which the Health Care Financing Administration reminded the rest of us several years ago of the requirement to age-adjust longterm care utilization projections, but presently are ignoring their own counsel in their waivered programs which require a constant absolute level of long-term care utilization over time (and constant absolute levels by definition are not age-adjusted). Third, to pose a question for which home care might be the answer, but the question must be phrased very carefully. [ABSTRACT FROM AUTHOR]

Background: Determining the nature and rate of change in physical function among long-stay nursing home (NH) residents classified by cognitive performance is needed to inform judgments about prognosis and design of clinical trials to minimize functional decline.Methods: The study consisted of a longitudinal analysis using random coefficients models of 71,388 noncomatose residents aged 65 and older admitted in one of five states participating in the Health Care Financing Administration-sponsored National Case Mix and Quality Demonstration Project who stayed in the nursing home 1 year or longer. Linear effects of cognitive impairment on admission and over time on the trajectory of dependence in activities of daily living (ADLs) were estimated, adjusting for demographic status upon admission. Interaction terms were used to determine if subgroups of residents at the same cognitive level were at risk for a steeper than average rate of decline. Measures were derived from the NH Minimum Data Set (MDS+) ratings of each domain. Cognition was measured using the MDS-Cognitive Performance Scale. Physical function was determined by summing ADL dependence ratings of bathing, dressing, grooming, toileting, and eating (range 0 to 20). Demographics included age, gender, race, and marital status.Results: On average, ADL dependence worsened 0.84 points per year among these long-stay residents. Only cognition and marital status had clinically significant effects on ADL dependence. Married residents exhibited more ADL dependence than unmarried residents. Severity of cognitive impairment on admission and over time influenced severity of ADL dependence but not rate of decline. No interaction terms were clinically significant.Conclusions: Clinicians seeking to identify factors that accelerate ADL decline in long-stay NH residents must examine explanatory variables other than cognitive impairment and demographics. [ABSTRACT FROM AUTHOR]

Immunizations have proven to be an important tool for public health and for reducing the impact of vaccine preventable diseases. To realize the maximum benefits of immunizations, a coordinated effort between public policy, health care providers and health systems is required to increase vaccination coverage and to ensure high-quality data are available to inform clinical and public health interventions. Immunization information systems (IIS) are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area. The key output of an IIS is high-quality data for use in targeting and monitoring immunization program activities and providing clinical decision support at the point of care. To be truly effective, IISs need to form a nationwide network and repository of immunization data. Since the early 2000s Centers for Disease Control and Prevention has made strides to help IIS move toward a nationwide network through efforts focused on improving infrastructure and functionality, such as the IIS Minimum Functional Standards, and the IIS Annual Report, a self-reported data collection of IIS progress toward achieving the functional standards. While these efforts have helped immunization programs achieve more functional standards, there is a need to shift focus from infrastructure and functionality improvements to high data quality through objective measurement of IIS performance and evaluating critical outcomes. Additionally, realizing the vision of a nationwide repository of high-quality immunization data requires tackling the many challenges that impact data quality and availability including those related to policy, data sharing, data use, aging IIS technology, sustainability, and participation in the IIS. This paper describes the current state of IIS in the United States, critical challenges impacting the quality of data in IIS, and potential components of a future IIS model to address these challenges., (Copyright © 2020 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Introduction: From 2004 to 2013, there were 9341 lawn mower injuries in children under 20 years old. The incidence of lawn mower injuries in children has not decreased since 1990 despite implementation of various different prevention strategies. In this report, the authors review the results of pediatric lawn mower-related lower-extremity injuries treated at a tertiary care referral center as well as review the overall literature., Methods: A retrospective review was performed at a level 1 trauma center over a 10-year period (2005-2015). Patients younger than 18 years who presented to the emergency room with lower extremity lawn mower injuries were included., Results: Of the 27 patients with lower-extremity lawn mower injuries during this period, the mean age at injury was 5.5 years and Injury Severity Score was 7.2. Most (85%) patients were boys and the predominant type of mower causing injury was a riding lawn mower (96%). Injury occurred in patients who were bystanders in 78%, passengers in 11%, and operators in 11%. Mean length of stay was 12.2 days, and mean time to reconstruction was 7.9 days. Mean number of surgical procedures per patient was 4.1. Amputations occurred in 15 (56%) cases with the most common level of amputation being distal to the metatarsophalangeal joint (67%). Reconstructive procedures ranged from direct closure (41%) to free tissue transfer (7%). Major complications included infection (7%), wound dehiscence (11%), and delayed wound healing (15%). Mean follow up was 23.6 months and 100% of the patients were ambulatory after injury. The subgroup of patients with the most severe injuries, highest number of amputations, and need for overall surgical procedures were patients aged 2 to 5 years. A review of the literature also showed consistent findings., Conclusions: This study demonstrates the danger and morbidity that lawn mowers present to the pediatric population, particularly children aged 2 to 5 years. Every rung of the so-called reconstructive ladder is used in caring for these children. Increased public awareness is insufficient to decrease the incidence of these injuries. These products should have additional warning labels and meet updated changes to the design of lawn mowers to prevent these mutilating injuries successfully.

An acutely painful, erythematous wrist can be due to a variety of pathologic processes, including crystalline arthropathy, infection, trauma, osteoarthritis, and systemic disease. The broad differential diagnosis of the inflamed wrist and nonspecific clinical findings make accurate diagnosis challenging. There is no published clinical or laboratory criterion that reliably differentiates septic wrist arthritis from a sterile inflammatory arthropathy. For septic joint patients, long-term results are notably poorer in patients with a delay in treatment, therefore establishing evidenced-based guidelines deserves attention.After a comprehensive literature review, we present evidenced-based guidelines and an algorithm for the management of the patient with an acutely inflamed wrist concerning for septic arthritis.For determining a diagnosis, systemic blood laboratory results are extremely variable and unreliable. Despite the attention given to the diagnostic potential of synovial fluid tests, the literature consistently demonstrates that diagnostic certainty cannot always be ascertained at the time of presentation based on aspiration fluid samples. Additionally, the investigative work does not necessarily end at the discovery of crystals since concomitant infection is a rare but well reported entity.Relative to larger joints, the wrist is far less likely to be infected and is easier to drain of debris, and therefore the empiric management of an inflamed wrist joint should reflect these differences. For treatment of the suspected or confirmed septic wrist, prompt initiation with appropriate antibiotics and drainage of joint purulence is critical to rapid recovery. However, the best strategy to clear the joint space of infectious material is controversial. Although the traditional standard of care is open drainage of a septic joint, a growing body of literature supports that for a septic wrist joint, a less invasive approach with serial aspiration can be equally efficacious with reduced morbidity and quicker recovery. If the wrist fails to improve with daily aspirations, then arthroscopy or open washout is needed.For patients with suspected wrist joint infection or crystalline arthropathy with probable concomitant infection, a reasonable approach is admission for systemic antibiotics and daily arthrocentesis. If the wrist fails to improve or worsens, then surgical treatment may be pursued. This treatment strategy could potentially avoid the morbidity of surgery while ensuring that no septic wrist goes untreated.

Background: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction., Methods: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation., Results: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix., Conclusions: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.

Microstomia is rarely seen in pediatric patients, but usually results from burns, trauma, or caustic ingestions. There have been multiple studies reporting various techniques for oral commissure reconstruction, but few reports in infants. The authors present another modification of previous techniques of microstomia repair performed in a 10-week-old infant using multiple z-plasties and bilateral mucosal rhomboid flaps.

Atypical fibroxanthoma (AFX) has been characterized variously as a benign noninvasive neoplasm with rare recurrence. We report 2 cases of recurrent AFX. There is ongoing controversy over the diagnosis of AFX versus malignant fibrous histiocytoma (MFH) in the clinical context of recurrent AFX. Histopathologic diagnosis of fibrohistiocytic neoplasms can be quite challenging and small foci of cancer can be easily overlooked. This is particularly problematic when scarring associated with recurrent tumors is present. The utility of en face sections, as utilized in Mohs micrographical surgery, and the employment of immunohistochemical stains may be helpful in diagnosis. Recurrence of AFX can occur but is difficult to distinguish from MFH.

Introduction: A stratification system is useful in deformational plagiocephaly (DP) to help categorize patients and reproduce a consistent treatment strategy. The Argenta classification is a clinical 5-point scale for unilateral DP and 3-point scale for central DP (CDP)., Methods: A retrospective review was completed for patients with DP and classified using the Argenta clinical classification by plastic surgeons at a tertiary medical center over a 12-year period., Results: In the 4483 patients, type III was the most prevalent DP type (42%) followed by II, IV, I, and V. Within CDP, VIB was the most common (6%) followed by VIA and VIC. Right-sided DP (56.8%) was more common than left-sided (28.3%) and bilateral (20.4%) (P < 0.0001). For treatment, 89.8% used molding helmet therapy, 9.3% used positioning only, and 0.4% used sock hat. Helmet use increased with increasing type to 98% with type V. In CDP, there was a significant increase in helmet use between VIA and VIB, but helmet use decreased in VIC. There was a higher rate of positioning only in types I, II, and VIA, which diminished as severity increased. Deformational plagiocephaly corrected to type I or 0 in 83.5% of the patients with the highest correction rate in type I (90.7%). Mean age of correction was 11.4 months and time to correction was 5.7 months. Both significantly increased with severity of type in the patients with DP but not in those with CDP., Conclusions: The Argenta classification scale allows reliable evaluation for cranial deformities and may help predict the optimal type duration of treatment.

Background: Estimations of life expectancies (LE) in health and ill health are important for planning future health care support. This study aimed at quantifying whether an increased LE is accompanied by an increase in the duration of life with dementia (DemLE) in Hong Kong SAR., Methods: Two parameters from a logistic model were used to fit the overall trend of the weighted prevalence of dementia. Abridged age- and sex-specific life tables and Sullivan's method were used to calculate dementia-free LE (DemFLE) for 1998 and 2013., Results: In 2013, among elderly individuals in Hong Kong aged 65 years, men had lived with dementia for 1.8 years and women for 3.6 years. These values are similar to those for subjects aged ≥85 years, while the proportion of DemLE was much greater at advanced ages. Elderly female individuals tend to experience a greater number of years with dementia than males., Conclusion: Our results indicate although LE has increased for all older age groups over time, the increase in DemFLE has not been greater than the gain in LE, suggesting an absolute expansion of the burden of dementia to the community between 1998 and 2013. The results suggest that more caregiving resources and manpower will be needed in the future as the population ages., (© 2015 S. Karger AG, Basel.)

Background: In 1992, the American Academy of Pediatrics discouraged prone sleeping positions because of its association with sudden infant death syndrome. After this was an increased incidence of deformational plagiocephaly (DP)., Methods: A retrospective review was completed for patients with DP and craniosynostosis seen by plastic surgeons at a tertiary medical center during a 19-year period. Two groups of patients were evaluated before (1988-1995) and after (1996-2007) implementation of the "Back to Sleep" campaign., Results: Of the 5169 patients, those with craniosynostosis (n = 279) had a mean age at initial evaluation before and after 1996 of 12.4 versus 5.6 months (P = 0.0008). There was a trend of decreasing age at initial evaluation and first surgery after 1996. For patients with DP (n = 4890), the mean age at initial evaluation before and after 1996 was 11.5 versus 6.0 months (P = 0.10). There was a trend of decreasing age at initial evaluation and DP correction after 1996. The majority of patients had right-sided DP (50.2%), followed by left-sided (24.7%) and bilateral (18.9%). There was no significant difference in DP correction rate (67% versus 87%) or the mean age that DP was corrected (12.8 versus 11.8 mo) before and after 1996. Compared with 1996 to 1999, there was a 214% and 390% increase in DP referrals from 2000 to 2003 and 2004 to 2007. For craniosynostosis, there was a 27% and 129% increase in referrals., Conclusions: The increasing incidence of DP since the Back to Sleep campaign is concerning, but a positive outcome is that patients are being referred and treated at a younger age.

Objectives: We hypothesised that among nursing home decedents, nursing home for-profit status and poor quality-of-care ratings, as well as patient characteristics, would lower the likelihood of transfer to hospital prior to heart disease death., Methods: Using death certificates from a large metropolitan area (Tampa Florida Metropolitan Statistical Area) for 1998-2002, we geocoded residential street addresses of heart disease decedents to identify 2172 persons who resided in nursing homes (n=131) at the time of death. We analysed decedent place of death as an indicator of transfer prior to death. Multilevel logistic regression modelling was used for analysis. Cause of death and decedent characteristics were obtained from death certificates. Nursing home characteristics, including state inspector ratings for multiple time points, were obtained from Florida's Agency for Healthcare Administration., Results: Nursing home for-profit status, level of nursing care and quality-of-care ratings were not associated with the likelihood of transfer to hospital prior to heart disease death. Nursing homes >5 miles from a hospital were more likely to transfer decedents, compared with facilities located close to a hospital. Significant predictors of no transfer for nursing home residents were being white, female, older, less educated and widowed/unmarried., Conclusions: In this study population, contrary to our hypotheses, sociodemographic characteristics of nursing home decedents were more important predictors of no transfer prior to cardiac death than quality rankings or for-profit status of nursing homes.

Objectives: To evaluate an intervention to improve care transitions at the time of skilled nursing facility (SNF) discharge., Design: Natural experiment using a pre-post design., Setting: Veterans Affairs hospital, community SNF, and outpatient clinic., Participants: The pre-intervention group comprised 134 individuals discharged to the community from posthospitalization SNF care, and the intervention group was 217 individuals who received a postdischarge clinic (PDC) intervention at SNF discharge after receiving posthospitalization care at the SNF., Intervention: This study is a natural experiment using a pre-post design. The intervention was a one-time visit to a PDC before SNF discharge, where an advanced nurse practitioner conducted medication reconciliation, ordered medical supplies and equipment and home health services if needed, provided individual and caregiver education, and communicated the information to the individual's primary outpatient care provider through electronic medical records., Measurements: The pre-PDC and PDC intervention groups were compared on various measures of hospital utilization within 30 days of the SNF discharge (number of rehospitalizations, acute care inpatient days, and emergency department (ED) visits)., Results: Although there was a 23% rehospitalization rate in the pre-PDC group, participants in the PDC intervention group had a 14% rehospitalization rate within 30 days of SNF discharge (P = .02). Those who received the PDC intervention had significantly fewer acute care inpatient days during the 30-day follow-up (P < .001). Although the difference in the number of ED visits between the two groups was not statistically significant, the number of ED visits per 1,000 patient follow-up days during the 30-day interval was significantly lower in the PDC intervention group (P = .03)., Conclusion: Comprehensive care coordination at the time of SNF discharge can reduce postdischarge hospital use in settings with shared electronic records., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Purpose of the Study: Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedian's Structure-Process-Outcome (SPO) model, we examined the relationships among top management's ratings of NH PSC, a process of care, and safety outcomes., Design and Methods: Using top management's responses from a nationally representative sample of 3,557 NHs on the 2008 Nursing Home Survey on PSC, the Online Survey, Certification, and Reporting Database, and the Minimum Data Set, we examined the relationships among the three components of Donabedian's SPO model: structure (PSC), a process of care (physical restraints), and patient safety outcomes (residents who fell)., Results: Results from generalized estimating equations indicated that higher ratings of PSC were significantly related to lower prevalence of physical restraints (odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995-0.999) and residents who fell (OR = 0.999, 95% CI = 0.998-0.999). Physical restraint use was related to falls after controlling for structural characteristics and PSC (OR = 1.698, 95% CI = 1.619-1.781)., Implications: These findings can contribute to the development of PSC in NHs and promote improvements in health care that can be measured by process of care and resident outcomes.

Objective: This study examines the relationship between increasing certified nursing assistants (CNAs) and licensed nurse staffing ratios and deficiencies in Florida nursing homes over a 4-year period., Methods: Data from Florida staffing reports and the Online Survey Certification and Reporting database examine the relationship among staffing levels and deficiency citations for 663 Florida nursing homes between 2002 and 2005. Using a generalized estimating equation approach in SAS Proc Genmod, we estimate the relationship between CNA and licensed nursing staff, and facilities' total deficiency score and quality of care deficiency scores-calculated using the Centers for Medicare and Medicaid Services' Nursing Home Compare Five-Star Quality Rating System, which accounts for the complexity of the scope and severity of the cittions., Results: Our results confirmed that higher CNA staffing levels were predictors of lower total deficiency scores and quality of care deficiency scores after controlling for facility characteristics., Conclusion: With a large sample size, repeated measure design, and advanced methods, we have found a relationship between CNA staffing and nursing home quality.

Objectives: This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission., Method: We extracted data from 73 charts drawn from a convenience sample of individuals who were residents of seven nursing homes (NHs) for at least three months during 2009. Six focus groups with NH staff were conducted to explore rationales for psychoactive medication usage., Results: Eighty-nine percent of the residents who received psychoactive medications during the first three months of residence had a psychiatric diagnosis, and all residents who received psychoactive medications had a written physician's order. Mental status was monitored by staff, and psychoactive medications were titrated based on changes in mental status. One concern was that no Level II Preadmission Screening and Annual Resident Review (PASRR) evaluations were completed during the admissions process. Further, while 73% had mental health diagnoses at admission, 85% of the NH residents were on a psychoactive medication three months after admission, and 19% were on four or more psychoactive medications. Although over half of the residents had notes in their charts regarding non-psychopharmacological strategies to address problem behaviors, their number was eclipsed by the number receiving psychopharmacological treatment., Conclusions: While the results suggest that NHs may be providing more mental health care than in the past, psychopharmacological treatment remains the dominant approach, perhaps because of limited mental health training of staff, and lack of diagnostic precision due to few trained geriatric mental health professionals. A critical review of the role of the PASRR process is suggested.

We examined the psychopharmacological services provided within 3 months of nursing home (NH) admission to a whole population of newly admitted Florida NH residents 65 years and older (N = 947) for a 1-year period via secondary analyses of selected variables from Medicaid and the Online Survey and Certification and Reporting System. Within 3 months of admission, 12% received nonpsychopharmacological mental health care. However, 71% of new residents received at least one psychoactive medication, and more than 15% were taking four or more psychoactive medications. Most of those being treated with psychoactive medication had not received psychopharmacological treatment 6 months prior to admission (64%) and had not received a psychiatric diagnosis 6 months preceding admission (71%). Blacks were less likely to receive medications than non-Hispanic Whites. Results expand on past research by identifying an increase in the amount of psychoactive medications prescribed to NH residents, a lack of prior psychiatric treatment and diagnoses for those currently receiving psychoactive medications, only limited provision of nonpsychopharmacological mental health care, and racial or ethnic differences in the use of medications by NHs.

This study examined the prevalence of self-reported 'poor health' among Cuban elders in Havana (n = 1,183) and Miami (n = 288) and explored the roles of chronic conditions and functional disability in their self-reports. A logistic regression model of reported poor health was estimated for each group, testing both independent and interactive effects of chronic conditions and functional disability. Despite differences in sociodemographic characteristics and disease/disability profiles between Cuban elders in the two cities, an equal proportion of each group (13%) reported poor health. Financial strain and functional disability were common predictors of self-reported poor health across the groups. Gender and chronic conditions were significant only in the Havana sample, among whom the likelihood of reporting poor health increased with female gender and the presence of chronic conditions. In the Havana sample, not only did chronic conditions have an independent effect, but also its interaction with functional disability was significant. The overall results suggest a particular role of chronic conditions in determining subjective health among elders in Havana. Findings are discussed in a sociocultural context.

Objective: To investigate the effects of providing a motorized scooter on physical performance and mobility., Design: Randomized clinical trial comparing scooter users with usual care., Setting: One academic and 1 Veterans Affairs medical center., Participants: Ambulatory, community-dwelling outpatients with rheumatoid arthritis or osteoarthritis of the knee., Intervention: Provision of a motorized scooter for 3 months., Main Outcome Measures: Six-minute walk distance (6MWD) and mobility methods in diverse locations at baseline, 1 month, and 3 months, and accidents while using the scooter., Results: The majority of scooter subjects (n=16/22 [72.7%]) used the scooter 4 or more days per week. The difference+/-standard deviation between the 2 groups in change in 6MWD over the study period was not statistically significant (scooter users, 16.9+/-73.0 m [55.5+/-239.6 ft]; usual care, 17.2+/-72.5 m [56.5+/-238.0 ft], P=.55). Four (18.1%) scooter users reported 9 accidents. Over the study period, the proportion of persons reporting use of a scooter (provided by the study or otherwise available) increased in the scooter-users group (eg, food stores, 16.7% to 52.6%; doctor's office, 0% to 35.7%) but not the usual-care group (food stores, 9.1% to 9.5%; doctor's office, 0% to 0%)., Conclusions: Motorized scooters provided to ambulatory persons with arthritis were used intermittently. The greatest short-term risk from scooter usage appeared to be minor collisions.

Aims: The primary objective of this retrospective case-control study in an elderly veteran population was to assess the impact of specific medications with recognized side-effects that increase the risk of a fall and were prescribed prior to fractures treated in the outpatient setting compared with patients treated for nonspecific chest pain., Methods: Two national Veterans Health Administration (VHA) databases were used to identify 17 273 unique patients, aged > or =65 years, treated in outpatient settings with a fracture in fiscal year 2005, and for whom we could link to all of their outpatient prescriptions (809 536). For comparison, we identified other elderly patients with outpatient clinic visits for nonspecific chest pain (N = 62 331) for whom we could link with their 2 987 394 outpatient prescriptions. We categorized the fall-related medications as drugs that primarily affect the cardiovascular (CVS), the central nervous (CNS) or the muscular skeletal system (MSS)., Results: Significant differences in the two patient groups occurred in the CNS category. Approximately 41% of the patients with fracture-coded encounters were prescribed CNS drugs compared with 31% of the patients in the comparison group (P < 0.0003). Finally, the use of muscle relaxants in the MSS category was significantly higher in the fracture group than in the nonspecific chest pain group., Conclusions: Studies using administrative data can foster the development of more proactive pharmacovigilance systems and assist in formulary refinement, particularly in countries with national healthcare systems that have integrated patient data. Particular attention and monitoring of elderly patients taking CNS medications may be important for injury prevention.

Objectives: To determine whether severe obesity in older people is independently associated with diminished lower extremity physical performance (LEP) in a random sample of homebound older adults that were considered ambulatory., Design: Prospective cohort with 1 year of follow-up (2000-02)., Setting: In-home assessments of homebound older adults in four North Carolina counties., Participants: Random sample of 282 home-delivered meal recipients aged 60 and older who completed both in-home assessments (n = 253) or were nursing home residents (n = 29) at the 1-year follow-up assessment of the Nutrition and Function Study., Measurements: Objective measures were selected for baseline and 1-year LEP (timed walking, static and dynamic balance, and chair rise) and baseline body mass index (BMI, based on measured weight and knee height). BMI was categorized as underweight/normal (<25.0 kg/m2), overweight (25.0-29.9 kg/m2), moderately obese (30.0-34.9 kg/m2), and severely obese (> or =35.0 kg/m2). Based on summary scores, overall LEP was categorized as poor, intermediate, or good. Sample characteristics included depressive symptomatology, fear of falling, medical conditions, and medication use., Results: Almost 23% of participants were moderately obese and 15% severely obese. Only severe obesity independently increased the odds (odds ratio 2.9-7.0) for diminished performance at 1 year in individual tests and in overall LEP performance. Severe obesity was independently associated with poor LEP at both assessments or with decline in LEP at 1 year., Conclusion: These results highlight the need to distinguish between moderate and severe obesity in older people in terms of relationships with key functional outcomes. The findings identify severe obesity in older people as an important target for future interventions. In particular, this calls for greater understanding of intervention goals, whether to primarily target weight reduction or improvement in physical performance.

Background: Screening for breast and cervical cancer reduces disease-specific mortality, but high rates of comorbidity and disability among elderly persons may alter the risks and benefits of screening., Methods: We performed a mail survey of primary care physicians to estimate the impact of health status on physicians' intentions to offer cancer screening to older women. Respondents were asked to read a scenario about an older woman. Each scenario patient was one of three ages (70, 80, or 90) and had one of three levels of comorbidity and disability. Respondents were asked to estimate the likelihood of offering screening with mammography and Pap smear to these patients on a 5-point Likert scale. A logistic regression compared those physicians somewhat or very likely to offer screening with those less likely to do so. Further analyses examined the characteristics of physicians likely to "overscreen" the frailest older women (<5 years median life expectancy) or "underscreen" the healthiest (>10 years median life expectancy)., Results: Respondents returned 2003 completed surveys (37.4%). Controlling for age and prior screening, higher levels of comorbidity and disability were associated with a significantly lower likelihood of offering screening for both mammography and Pap smear. Nonetheless, a substantial percentage (30.7%) of physicians indicated a high likelihood of offering a frail 90-year-old woman a mammogram, and 13.4% would offer her a Pap smear. In general, overscreening was more common than underscreening. Female gender was associated with "overscreening" with mammography, whereas male gender and lack of board certification predicted "underscreening." Lack of board certification was associated with "overscreening" with Pap smear., Conclusions: In addition to age, primary care physicians consider health status in deciding to offer cancer screening to older women. Education and guidelines for cancer screening should more explicitly address the risks of overscreening among frail older women.

Objective: The purpose of this study is to evaluate whether the use of medications with urological activity (UA) is associated with self-reported difficulty in control of urination., Methods: This is a cross-sectional study using data from the Duke Established Populations for Epidemiologic Studies of the Elderly., Results: Difficulty holding urine was reported by 49.5% of men and 54.0% of the women. Overall, 50.9% of men and 72.7% of the women took one or more medications with UA. Multivariable logistic regression for men revealed that neither use of any medication with UA (Adjusted [Adj.] Odds Ratio [OR] 1.12, 95% confidence interval [CI] 0.84-1.50) nor the number of medications with UA used was associated with urinary difficulties (Adj. OR 1.08, 95% CI 0.97-1.21). For women, there was a significant association (p < .05) between use of any medication with UA and reported urinary difficulty (Adj. OR = 1.31, 95% CI = 1.05-1.62)., Discussion: Medications with UA may be related to difficulty in controlling urine among community-dwelling elderly women.

Purpose: To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients., Methods: The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse., Results: For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05)., Conclusion: Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.

Purpose: Although it is well-recognized that good nutrition is essential to health, quality of life, and disease management, evidence of the role of nutrition, especially dietary intake, in the development of health-related disability among the more vulnerable older men and women in the community is largely unavailable., Methods: We examined self-reported and performance-based measures at baseline (demographic, psychosocial and health-related factors, BMI, burden of disease, dietary intake from 3 24-hour dietary recalls, lower extremity physical performance, and activities of daily living [ADL]) and 1-year follow-up (ADL) from a randomly recruited sample of homebound elders. Structural equation modeling was used to simultaneously evaluate the direct and indirect relationships among baseline factors and severity of disability in activities of daily living (ADL) at 1-year in 253 homebound elders. results: Almost 32% of the homebound sample reported increased severity of disability over 1 year. The full structural model fit the data very well and revealed that better summary intake of calcium, vitamin D, magnesium, and phosphorus was directly linked to better lower extremity performance (LEP) and indirectly to less severity of disability at one year, after controlling for baseline disability and the interrelationships of other factors. Greater BMI was directly associated with worse LEP and indirectly with greater severity of disability., Conclusions: The findings from this study acknowledge aspects of the complex direct and indirect relationships between nutrient intake, BMI, and disability among homebound elders. These results suggest that nutrient intake and BMI may be reasonable targets for intervention with multiple functional outcomes.

Background: Nutritional intake has been overlooked as a possible contributing factor to lower-extremity physical performance, especially in homebound elderly persons., Objectives: Our objectives were to examine the association of a summary measure of calcium, vitamin D, magnesium, and phosphorus intakes with 1) the inability to perform lower-extremity physical performance tests and 2) declining levels of summary lower-extremity physical performance., Design: Baseline data from the Nutrition and Function Study were used to calculate a summary musculoskeletal nutrient (SMN) score as a measure of nutrient intake (factor analysis) and to examine the association of SMN intake with physical performance (multivariable regression models) among recipients of home-delivered meals who completed an in-home assessment (anthropometric measures and performance-based physical tests) and three 24-h dietary recalls., Results: Among the 321 participants, elderly age, black race, body mass index (in kg/m2) > or = 35, arthritis, frequent fear of falling, and lowest SMN intake were independently associated with being unable to perform functional tests. The lowest SMN intake and the highest BMI were both significantly associated with increasingly worse levels of lower-extremity physical performance, after adjustment for health and demographic characteristics., Conclusions: Considering the importance of identifying short- and long-term outcomes that help elderly persons maintain adequate nutritional status and remain functionally independent at home, the results of this study suggest the need to identify intervention strategies that target the improvement of dietary intake and physical performance. Further investigation is indicated to identify the manner in which nutritional status contributes to the preservation or deterioration of physical performance in homebound elderly persons.

Background: The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates., Methods: Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system., Results: From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke., Conclusions: Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.