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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.

This article presents preliminary evidence for a novel way of promoting use of non-psychopharmacological interventions for mental health problems among nursing home (NH) residents. Mental health assessments addressing cognitive status, mood, behavior problems, typical activities, and quality of life were conducted on newly admitted NH residents, with recommendations supporting non-psychopharmacological alternatives conveyed to the NH staff. The purpose was to determine whether non-psychopharmacological recommendations based on the assessments would have a significant influence on psychoactive prescribing patterns, use of psychological interventions, number of falls, and the number of hospitalizations among NH residents. Chart reviews were conducted 1 month post-NH assessment in a non-randomized design comparing the 23 residents in four for-profit NHs who received a mental health assessment with 25 residents in one of the for-profit NHs who did not receive an assessment. A mental health assessment administ...

* About the Editors * Contributors * Foreword (Robert N. Butler) * Preface * List of Entries * Abuse in nursing homes * Abuse by elders in nursing homes * Advertising * African Americans * Age conflict * Age denial * Age inequality * Age norms * Age segregation * Age stratification * Aged as a minority group * Ageism in the Bible * Ageism survey * Age-specific public programs * Alcoholism * Antiaging medicine * Architecture * Art * Arts * Assisted living * Attribution theory * Benefits of aging * Biological definitions of aging * Blaming the aged * Books * Botox * Cards * Change strategies * Changes in attitudes * Children's attitudes * Children's literature * Churches * Cohorts * Consent to treatment * Cost-benefit analysis * Costs of ageism * Criminal victimization * Cross-cultural ageism * Cultural lag * Cultural sources of ageism * Definitions * Demographic trends * Dentistry * Disability * Discounts * Disengagement theory * Driver's license testing * Education * Employment discrimination * Ethical issues * Euphemisms * Face-lifts * Facts on Aging Quiz * Facts on Aging and Mental Health Quiz * Family * Financial abuse * Functional age * Future of ageism * Generational equity * Geriatrics * Gerontocracy * Gerontology * Health care * Hispanics * History * HIV/AIDS * Hollywood * Housing * Human rights of older persons * Humor * Hypertension * Individual sources of ageism * Intergenerational projects * Isolation * Japan * Journalism * Language * Legal review program * Legal system * Literature * Living wills * Mandatory retirement of judges * Measuring ageism in children * Medical students * Memory and cognitive function * Memory stereotypes * Mental illness * Modernization theory * Nursing * Nursing homes * Organizations opposing ageism * Patronizing * Pension bias * Perpetual youth * Physical therapy * Politics * Positive Aging Newsletter * Public policy * Reducing ageism * Responses to ageism * Retirement communities * Role expectations * Scapegoating * Self-fulfilling prophecy * Semantic differential scale * Senior centers * Sexism * Sexuality * Slogans * Social psychology * Social Security * Societal ageism * Songs * Stage theory * Stereotypes * Subcultures * Successful aging * Suicide * Tax breaks * Television * Terms preferred by older people * Theories of aging * Transportation * Types of ageists * Typologies * Unconscious ageism * Voice quality * Index * Reference Notes Included

Choosing a nursing home for a long-term placement is a daunting and emotionally charged task for families. Nursing homes that directly bill Medicare and Medicaid for residents’ services (approximately 96% of all U.S. facilities) must be certified and inspected annually (Castle, Wagner, Ferguson, & Handler, 2011). Data from the inspections are summarized by the Centers for Medicare and Medicaid Services (CMS) through its Nursing Home Compare website, which provides information to consumers about factors related to the quality of care residents receive (CMS, 2011). CMS grades nursing homes based on, among other things, the average number of nursing hours each resident receives and facility violations of federal regulations. By providing details on nursing homes’ average number of nurse staffing hours per resident a day and the deficiency score found during annual inspections of the home, CMS helps consumers consider the quality of care provided as part of their calculus in selecting a specific facility. Deficiency citations are often used as a measure of nursing home quality (Castle & Myers, 2006; Castle et al., 2011; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Kim, Harrington, & Greene, 2009; Kim, Kovner, Harrington, Greene, & Mezey, 2009; Park & Stearns, 2009). When facilities fail to meet federal requirements, inspectors choose from approximately 180 possible deficiencies and cite the home for violating specific standards. Violations are assessed on two dimensions—scope (how many residents are affected) and severity (likelihood of harming residents). Scope is trichotomized into isolated, a pattern, or a widespread practice. Severity has four categories (no harm, no harm and potential for minimal harm, actual harm, and immediate jeopardy requiring immediate corrective action). The 12 possible combinations of scope and severity constitute the grade from “A” (isolated and no harm = 0 points) to “L” (immediate jeopardy and widespread pattern = 150 points). Deficiencies in categories “F” (potential for widespread harm) and “H” (pattern of actual harm) are considered substandard quality of care. Each deficiency is also placed within categories, such as quality of care, resident rights, or physical environment. If the deficiency is issued in a quality of care, quality of life, or resident rights category and the scope and severity denote substandard care, additional points are added. Thus, a deficiency for inadequate care planning (quality of care violation) would receive 40 points (“H”—pattern of harm) but that same pattern of harm would be only 35 points if it were improper food storage. With the introduction in March 2009 of this comprehensive deficiency score methodology, CMS captures both the scope and severity of all violations cited within the facility and reports deficiencies as a total point score; higher points and more serious violations reflect poorer quality (for further details on the scoring methodology, CMS, 2010). Prior studies have examined the relationship of staffing to deficiencies (Castle et al., 2011; Harrington et al., 2000; Kim, Harrington, et al., 2009; Kim, Kovner, et al., 2009; Park & Stearns, 2009). Harrington and colleagues (2000) measured the number and type of nursing home deficiencies cited during survey inspections and reported that fewer registered nurse (RN) and certified nursing assistant (CNA) staffing hours were associated with higher numbers of citations, especially citations for poor quality of care. A later study by Kim, Kovner, et al. (2009) reported that both total nurse staffing and RN staffing levels were negatively related to total deficiencies, quality of care deficiencies, and serious deficiencies that may cause harm or jeopardy to nursing home residents. Another study by Kim, Harrington, and colleagues (2009) indicates that RN to total nurse staffing ratio was negatively related to serious deficiencies in nursing homes, and as the RN to licensed vocational nurse ratios increased, total deficiencies and serious deficiencies decreased. In a study examining the impact of state staffing standards on quality of care, Park and Stearns (2009) also confirmed that total deficiencies declined significantly as states increased staffing standards. Although these studies do show a relationship between staffing levels and deficiency scores, they were based on staffing data from the Online Survey, Certification, and Reporting (OSCAR) database, which has been criticized for its inconsistent reporting of staffing levels (Kash, Hawes, & Phillips, 2007). Research examining the reliability of OSCAR data indicates that audited cost reports contain a more accurate reflection of day-to-day nurse staffing levels. Furthermore, previous studies have used a “count” of deficiencies, ignoring the scope and severity of these various violations. The current study advances the understanding of the relationship between nursing staff ratios and nursing home quality because we are able to analyze a range of nurse staffing levels as Florida implemented new nurse staffing requirements between 2002 and 2005 and because we use two new indicators of deficiencies—CMS’ new comprehensive total deficiency score and also the quality of care deficiency score. Furthermore, previous studies use only the OSCAR database for staffing levels, but this analysis supplements OSCAR with verified staffing reports submitted to the State. We hypothesize that higher nurse staffing levels—both CNA hours per resident day (HPRD) and licensed nurse (RN and licensed practical nurses [LPN] combined) HPRD—will be significant predictors of lower deficiency scores after controlling for facility characteristics. We examine Florida because in 2001, Florida’s State Legislature mandated a one-time increase from 0.6 HPRD RN/LPN staffing to a minimum of 1.0 HPRD in 2002 and a tiered increase in CNA hours from 1.7 HPRD in 2001 to 2.3 HPRD in 2002, and to 2.6 HPRD in 2003 (S. 1202, 2001). Because Florida also rebased the Medicaid formula to ensure full Medicaid funding of these new staffing levels (Hyer, Temple, & Johnson, 2009) and committed $300 million in state and federal funds to implement and enforce the staffing standards, facilities complied with the mandates. Taking advantage of the variability in staffing that existed in 2002 and 2003 (when new monies were allocated to pay for those direct care staff increases) and extending the analysis through 2004 and 2005, the study was able to examine the relationship among staffing levels and deficiency citations in the fourth largest state, a state with the highest proportion of elders and a state with more than 75,000 nursing home residents (Harrington, Carrillo, & Blank, 2008). Furthermore, previous research has indicated that there is variability in citations across states, and therefore, this study will focus on one state, Florida (Harrington et al., 2000).

Purpose: This study describes Florida’s model of Medicaid nursing home (NH) reimbursement to compensate NHs for disaster-related expenses incurred as a result of 8 hurricanes within a 2-year period. This Florida model can serve as a demonstration for a national model for disaster-related reimbursement. Design and Methods: Florida reimburses NHs for approved disaster-related costs through hurricane interim rate requests (IRRs). The state developed its unique Medicaid per diem rate temporary add-on by adapting its standard rate-setting reimbursement methodology. To understand the payment mechanisms and the costs that facilities incurred as a result of natural disasters, we examined the IRRs and cost reports for facilities requesting and receiving reimbursement. Results: Cost reports and IRR applications indicated that Florida Medicaid spent close to $16 million to pay for hurricane-related costs to NHs. Implications: Without Florida’s Hurricane IRR program, many facilities would have not been reimbursed for their hurricane-related costs. Florida’s model is one that Medicare and other states should consider adopting to ensure that NHs receive adequate reimbursement for disaster-related expenses, including tornadoes, earthquakes, floods, blizzards, and other catastrophic events.

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. Copyright 2009, Oxford University Press.

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.

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 (

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 homedelivered 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/m 2 ) ≥ 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 shortand 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. Am J Clin Nutr 2003;77:847‐56.

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 Administrationsponsored 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.

Background: The prevalence of inadequate nutrient intakes among the homebound elderly and their correlation with individual characteristics and health-related factors remain poorly understood. Objective: We assessed the extent of inadequate dietary intakes of key nutrients among the homebound elderly by using the newly released dietary reference intakes and examined the associations of individual characteristics and health-related factors with low nutrient intakes. Design: This was a cross-sectional examination of data collected during the baseline assessment of a prospective study of nutrition and function among a randomly recruited sample of cognitively eligible recipients of home-delivered meals who completed a home visit and three 24-h dietary recalls (n = 345). Nutrient analysis was performed with the NUTRITION DATA SYSTEM software, and associations were identified through multiple regression models. Results: In multiple regression models, lower intakes of specific nutrients were associated with subjects who were women, who were black, who reported a low income and limited education, and who did not usually eat breakfast. On the basis of the estimated average requirement standard for nutrient inadequacy, the intake of ≥6 nutrients was inadequate in 27% of subjects, of 3-5 nutrients in 40% of subjects, and of 1-2 nutrients in 29% of subjects. On the basis of the adequate intake standard, a less than adequate intake of calcium was reported by 96% of subjects and of vitamin D by 99% of subjects. Conclusions: The findings suggest that home-delivered meals programs should target specific subgroups of participants with interventions, such as a breakfast meal or more-nutrient-dense meals, tailored to increase nutrient intakes and reduce the prevalence of nutrient inadequacy.

Ottenbacher KJ, Branch LG, Ray L, Gonzales VA, Peek MK, Hinman MR. The reliability of upper- and lower-extremity strength testing in a community survey of older adults. Arch Phys Med Rehabil 2002;83:1423-7. Objective: To examine the stability (test-retest reliability) of strength measures in older adults obtained by nontherapist lay examiners by using a hand-held portable muscle testing device (Nicholas Manual Muscle Tester). Design: A prospective relational design was used to collect test-retest data for 1 male subject by using 27 lay raters who completed intensive training in manual muscle. Setting: Data were collected from older Mexican-American adults living in the community. Participants: Twenty-seven lay raters who completed intensive training in manual muscle testing for a field-based assessment and interview of older adults and 63 Mexican-American subjects completing wave 4 of the Hispanic Established Populations for the Epidemiologic Study of the Elderly. Interventions: Training involved reviewing a manual describing each testing position followed by approximately 6 hours of instruction and practice supervised by an experienced physical therapist. Lay raters then collected test-retest information on older Mexican-American subjects. Main Outcome Measure: Stability (test-retest) for a portable manual muscle testing device. Results: Intraclass correlation coefficients (ICCs) were computed for the 27 lay raters examining 1 male subject (2 trials) and 12 lay raters assessing 63 older Mexican-American adults (1 practice and 2 trials recorded). The ICC values for the first 27 lay raters ranged from.74 to.96. The ICC values for the latter 12 lay raters ranged from.87 to.98. No differences were found in ICC values between male or female subjects. Conclusions: Stable and consistent information for upper- and lower-extremity strength was collected from the older adults participating in this study. The results suggest reliable information can be obtained by lay raters using a portable manual muscle testing device if the examiners receive intensive training. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

The Internet (electronic mail and the World Wide Web) may provide new opportunities for communication that can help older adults avoid social isolation. This randomized controlled trial assessed the psychosocial impact of providing Internet access to older adults over a five-month period. One hundred volunteers from four congregate housing sites and two nursing facilities were randomly assigned to receive Internet training or to a wait list control group. The pre & post measures included the UCLA Loneliness scale, modified CES Depression scale, a measure of locus of control, computer attitudes, number of confidants, and overall quality of life. Participants received nine hours of small group training in six sessions over two weeks. Computers were available for continued use over five months and the trainer was available two hours/week for questions. At the end of the trial, 60% of the intervention group continued to use the Internet on a weekly basis. Although there was a trend toward decreased loneliness and depression in intervention subjects compared to controls, there were no statistically significant changes from baseline to the end of trial between groups. Among Internet users (n = 29) in the intervention group there were trends toward less loneliness, less depression, more positive attitudes toward computers, and more confidants than among intervention recipients who were not regular users (n = 19) of this technology. Most elderly participants in this trial learned to use the Internet and the majority continued to use it on a weekly basis. The psychosocial impact of Internet use in this sample suggested trends in a positive direction. Further research is needed to determine more precisely, which older adults, residing in which environmental contexts are more likely than others to benefit from this rapidly expanding information and communication link.

To identify consistent provision of clinical preventive services, we sought to benchmark all acute care Veterans Affairs Medical Centers (VAMCs) against each other nationally on the basis of multiple evidence-based, performance measures to identify facilities performing consistently higher and lower than expected.The 1998 Veterans Health Survey assessed the self-reported delivery of evidence-based clinical preventive services in a stratified national sample of 450 ambulatory care patients seen at each VAMC. Proportions appropriately receiving each service within the recommended time interval were calculated for 138 VAMCs. Percentile ranks for each outcome were assigned. Two approaches were used for benchmarking performance. First, a scaled score for each facility was calculated across the set of 12 measures. Second, facilities were ranked based on the sum of the percentile ranks over a range of specific high cutoffs (eg, 70-80%) and above a range of lower cutoffs (eg, 40-50%). Ranking was validated by comparing with deciles of ranks on chart audit (External Peer Review Program, EPRP) data using Kendall's tau-b and chi2 quality-of-fit test. Differences between consistently high adherence (CHA) and low adherence (CLA) facilities were compared using the Wilcoxon rank sum test on 14 VHS and 11 EPRP outcomes.Data from 39,939 patients (67% response rate) were examined. In combination, cutoffs of greater than 50th percentile and greater than 75th percentile rank yielded 12 of 14 VHS and 6 of 11 EPRP measures different between CHA and CLA facilities. The scaled-score approach resulted in 20 CHA and 14 CLA facilities. The sum of outcomes ranked above 50th percentile and over 75th percentile for CHA facilities (n = 17) was 15 or more. The sum of outcomes ranked above the same cutoffs for CLA facilities (n = 16) was 3 or less. EPRP and 1998 VHS data demonstrated that the survey measures and benchmarking approaches were both reliable and valid. Both approaches resulted in multiple differences between CHA and CLA facilities; differences were greater using the percentile rank approach.The VA has successfully encouraged adoption of evidence-based clinical preventive services throughout its health care system. However, facilities show wide variation in their levels of delivery and can be distinguished on the basis of their consistently high or low levels of adherence. Examining service delivery across multiple performance indicators allows identification of opportunities to improve clinical practice guideline implementation and the delivery of preventive services. This approach identifies model institutions where focused investigation of factors associated with consistent performance may be particularly fruitful.

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 Florida9s 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.

The needs assessment process is indeed complex in the social service context. Whereas most contexts can start with a presumption of "no need," the social service context frequently must start with an assumption of "need met-->change." In addition, underlying values--the individual's, the assessor's, the society's--all play a part in the judgment process. The assumption that the involvement of another in performing the task automatically implies a limitation on the part of the recipient is not warranted, nor is the assumption that the reliance on another by one in need automatically implies the need is met. For purposes of population needs assessments, it is possible to rely on presumptive categorizations as a function of simple response profiles. For individual care planning, however, additional information is essential.

Objective. This study examined differences in the odds of receiving health promotion/disease prevention services recommended by the US Preventive Services Task Force among three subgroups of patients. It tested the hypotheses that those most uninvolved in their own health (as exemplified by the lack of knowledge of blood pressure and cholesterol levels despite having been tested) would receive the least other health promotion services, and those being treated for both high blood pressure and hyperlipidemia would receive the most additional services. Methods. A mail survey was sent to a random sample of 68,422 veterans who had obtained primary care from any of the 153 Veterans Health Administration facilities in 1996. The adjusted response rate was 68%. Subgroup analyses were performed on three subgroups who reported having been tested for both hypertension and hyperlipidemia in the previous year (n = 5,113). Results. Both hypotheses were supported. Uninvolved patients were the least likely subgroup to report obtaining other recommended health promotion services, and the dually treated were most likely. The uninvolved subgroup was significantly more likely to report being female, physically inactive, current smokers, and heavy alcohol drinkers, and to report having a problem with alcohol, and significantly less likely to report being ≥50 years of age and overweight, to almost always wear seat belts, and to obtain at least 90% of their health care at the Veterans Health Administration. Conclusions. Clinicians need to encourage all patients to receive health promotion services, but in particular they should be aware that those who do not know their last hypertension and cholesterol levels despite having been tested are particularly in need of attention.

Background. Models for causation of functional disability differ as to whether different diseases lead to common expres­ sions 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 =.(03), amount of useful movement (p =.(01), overall motor impairment (p =.(03), amount of sensation (p =.000, impairment in memory and thinking (p =.(01), and visual impairment (p =.(01). 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.

This study evaluated the direct and indirect effects of spinal deformity on confidence in mobility among 185 older women with osteoporosis and vertebral fractures. We administered multidimensional tests of physical and psychosocial impairment and function to female residents of continuing care retirement communities, and used path analytic regression methods to delineate relationships between spinal deformity, pain, function and mobility self-confidence. No direct effect of spinal deformity on confidence in mobility was observed. However, important indirect paths mediated by functional limitations were confirmed. A pattern of indirect effects was observed for a broad array of impairment-level constructs. These results support current models of the disablement process that propose functional limitations as the major pathway to disability. However, they also suggest that the impact of impairment-level constructs might be overlooked unless we evaluate indirect, as well as direct effects, on disability.

Purpose: Risk factors, natural history, consequences, therapeutic responses and costs are all likely related to type of urinary incontinence, for example stress or urge. Yet few epidemiologic type specific data are available and only 1 study has been validated urodynamically. We compare the accuracy of a typical questionnaire used in a large epidemiologic study with the criterion standard of multichannel video urodynamic testing.Materials and Methods: The questionnaire was administered before urodynamic testing to 132 subjects 65 years old or older, of whom 80% were women, all were mobile and none was severely demented. Responses to questionnaire items were compared to the criterion standard, singly and in combination, using a total of 4 a priori and post hoc strategies, including a computerized regression tree program.Results: Overall, no analytic strategy correctly classified more than 67% of patients and none accurately classified even a single type of incontinence, including stress incontinenc...

Objective: To develop a self-report instrument that would provide information about the different levels of the disablement process, and that (1) was suitable for persons with spinal cord disease (SCD), (2) could be completed quickly, (3) could be mailed, (4) had acceptable reliability, and (5) would be clinically useful. Study Design: Test-retest using a convenience sample. Methods: Review of the literature and an expert panel were used to develop the instrument. It was mailed to 49,458 individuals in June 1995 and a second mailing was done in August 1995. A subset of 725 individuals who responded to both mailings was used to examine the instrument's test-retest reliability. Results: The instrument has a 4th grade reading level and has questions on causal disease, disease severity, impairment, activities of daily living (including a self-reported version of the Functional Independence Measure, the SRFM), and resource utilization. Individual item test-retest reliability was high for a mailed questionnaire; all kappa coefficients were near or above .60 and most were over .70. Intraclass correlation coefficient for the SRFM was .90 and internal consistency (Chronbach's alpha) was .96. Conclusion: This instrument provides a new, rapid way to obtain information relative to the differing levels of the disablement process.

OBJECTIVE To compare expenditures and healthcare service use between decedents (in their last year of life) and survivors, all of whom were frail older people, under three payor/provider types. DESIGN In-home interviews were conducted by home care nurses at baseline and at 6-month intervals for an 18-month period. Utilization and cost data were collected directly from providers and the Health Care Financing Administration for 12 months immediately before death for decedents and for the first 12 months of follow-up for survivors. SAMPLE Five hundred seventy-seven frail older patients of an integrated healthcare system who were receiving physician prescribed home health services, under Medicare fee-for-service (FFS), Medicare HMO, or Medicare-Medicaid coverage. Frailty was defined as the receipt of physician-prescribed home healthcare services. OUTCOME MEASURES Acute and long-term healthcare service utilization and expenditures; total healthcare expenditures. RESULTS After controlling for baseline differences, significant differences in utilization and expenditures of survivors (n = 450) and decedents (n = 127) were demonstrated. Compared with survivors, frail older decedents were approximately: 7 times as likely to have had any hospital admissions 3 times as likely to have had one or more emergency room visits 8 times as likely to have 30 or more physician visits 4 times as likely to have been admitted to a skilled nursing facility and twice as likely to have used home health services after the baseline episode. On average, total expenditures for decedents were 276% higher than for survivors. Total expenditures for Medicaid-Medicare beneficiaries were 42% higher than expenditures for FFS participants, primarily because of higher hospitalization and emergency room expenditures. There were no differences in utilization and expenditures between HMO enrollees and FFS beneficiaries. Finally, interactions between decedent status and payor/provider were not statistically significant in multivariate analyses. CONCLUSION During the last year of life, frail older people exhibit the same pattern of higher expenditures and service utilization as the general Medicare population. However, differences between decedents' and survivors' healthcare expenditures and resource use did not vary by payor/provider. Thus, cost-containment strategies should focus on new forms of managing healthcare services beyond those currently practiced within Medicare HMOs, traditional FFS, or Medicare-Medicaid in California.

A National sample of persons who died in 1986 was analyzed to obtain a valid estimate of the relationship between functional status and the provision of formal home care during the last year of life. Community-based care has become increasingly important as the size of the elderly population increases and the cost for institutional care rises. When people need help in caring for themselves because of illness, frailty, or disability, community-based care may be more appropriate than acute or institutional care. The year before death is often a time of dependence and a high intensity of health service consumption. Although care at home is provided primarily by families, formal home care is also a critical component in any continuum of care.

As of mid-1994 there were nine replications of the On Lok model operating under dual capitation payments as sites in the Program of All-inclusive Care for the Elderly (PACE). A tenth site had begun operating under capitation, but was unable to remain viable. The present descriptive study documents the growth and development of the first seven of these sites, all that had been operating under capitation during 1992. Comparisons among these sites and with On Lok are presented in the areas of organizational structure, client characteristics, approaches to case management, service delivery options, and financing. There is considerable variability in the implementation of the PACE model. Combined Medicare and Medicaid capitation monthly payments range from $2,147 to $5,973. These seven PACE sites (excluding On Lok) served a total of 888 current clients at the end of 1992, after a cumulative 136 months of experience under capitation. The very slow enrollment rates may imply that the target clients are less enthusiastic about this model than are its architects. The client selection process may suggest niche-marketing or skimming, but not the full representation of the nursing home population in their states. Given both the slow enrollment and the niche-marketing (the benevolent term) or skimming (the pejorative term) that has occurred, caution about the long-term viability of the PACE model may be warranted.

OBJECTIVE: The goal of this study was to estimate the prevalence and correlates of difficulty holding urine among a population of community-dwelling older people. DESIGN: Population-based cross-sectional study. SUBJECTS: A population census identified all residents aged 65 years and older residing in East Boston, Massachusetts, in 1982. MEASURES: Data collected via in-home interviews were used to estimate the prevalence of difficulty holding urine and to provide information regarding potential correlates of urinary difficulty. RESULTS: Of the 3809 study participants (85% response rate), 28% reported having “difficulty holding urine until they can get to a toilet” at least some of the time, and 8% reported difficulty “most” or “all of the time.” Difficulty was associated with age and sex; 44% of women and 34% of men reported some difficulty (P < .001), and 9% of women and 6% of men (P < .001) reported difficulty most or all of the time. For respondents aged 65 to 74 years, 40% reported some difficulty, compared with 47% of those aged 85 and older (Ptrend < .001); difficulty most or all of the time was reported by 6% of those aged 65 to 74 and 12% of those aged 85 and older (Ptrend < .001). Difficulty holding urine was associated with important health and functional measures including depression, stroke, chronic cough, night awakening, fecal incontinence, problems with activities of daily living, decreased frequency and ease in getting out of the house, and poor self-perception of health. CONCLUSIONS: Difficulty holding urine is a prevalent condition among older people living in the community and is associated highly with a number of health conditions and functional problems.

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, Certifi cation, 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 signifi cantly related to lower prevalence of physical restraints (odds ratio [OR] = 0.997, 95% confi dence 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 fi ndings 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.

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE). DESIGN: An intact-group pretest—posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI. PARTICIPANTS: A random sample of community-dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140). MEASUREMENT: A 14-item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participant answers to the quiz were part of a 20-minute telephone interview. RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of “don't know” responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses. CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.

Data from a standardized administrative form, the Patient Review Instrument, were used to evaluate whether the New York Quality Assurance System (NYQAS) had an impact on deterioration in functional status or on the incidence of adverse outcomes among residents in New York's nursing homes. The NYQUAS approach evaluated nursing homes by using "triggers" suggestive of dificient quality of care. A random sample of nursing home facilities was selected from data encompassing 2 years before and 2 years after the implementation of NYQAS in 1988. Growth curve analysis and logistic regression were used to assess the influence of NYQAS on deterioration and on the probability of developing decubitus ulcers or contractures, or of being mechanically restrained. The functional status of most residents did not change significantly over time. After allowing statistically for differences in the resource needs of residents within the facilities, the implementation of NYQAS was associated with decreased deterioration in toileting and/or transferring, depending on the site of care. NYQAS was not associated with changes in incidence rates of decubitus, contractures, or the use of mechanical restraints.

The New York Quality Assurance System (NYQAS) was designed to assure high-quality nursing home care in New York. Among its many incentives, NYQAS may change the likelihood that elderly with heavy-care needs will be admitted to nursing homes. This article addresses that hypothesis. Data for descriptive and multivariate analyses come from the RUGs-Il Patient Review Instrument and the Medicare and Medicaid Automated Certification System files for 1986-1990. The descriptive analyses focus on functional ability in new nursing home residents before and after NYQAS. The multivariate analyses adjust for pre-NYQAS, RUGs-related trends in casemix, resident demographics, and nursing home characteristics that influence casemix. The results suggest a significant but small decrease in functional status at admission during the post-NYQAS era.

Objective: Virtually all estimates of the prevalence and incidence of incontinence in the community rely on self-reported continence status. The goal of this study was to assess the reliability of this measure in older adults. Design: Telephone interviews administered approximately 2 weeks apart. Setting: Community-based congregate living facility. Participants: A convenience sample of approximately 100 residents was contacted by letter; 48 of 51 (94%) who indicated their willingness to participate were interviewed. They included eight men and 40 women >70 years old (79% >80 years old), virtually all of whom were independent in basic ADLs and 83% of whom reported their health as good or excellent. Measurement: Responses to a structured questionnaire. Main Results: The prevalence of urinary incontinence was 40% at baseline and 44% on re-interview; the prevalence of fecal incontinence was 17% on both occasions. All Spearman correlations for items related to urinary incontinence characteristics were between .80 and .86, except for a question related to stress incontinence (r = .62); correlations for fecal incontinence were .67–.69. Conclusion: Prevalence estimates of incontinence are stable over a 2-week period. However, the variability of individual responses, while relatively low, was within the range previously reported for estimates of incidence and remission rates of incontinence in community-dwelling elderly. This, variability should be taken into consideration when interpreting previous studies and designing future ones.

This article focuses on justification of psychoactive medication prescription for NH residents during their first three months post-admission.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.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.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.

Intensive interviews were conducted with 36 older people, using think aloud and cognitive probes, to study response errors in measuring functional status in health surveys. Consistent with the original hypothesis, words or phrases, such as "aids," "help from another person," and "difficulty," were not interpreted by respondents to have the same meaning as intended. Similarly, evidence was obtained indicating that the subjects did not recall all the kinds of help they received, nor report their health as the basis for needing assistance. Moreover, replies to a variety of functional status items were often conditional upon the circumstances. Recommendations for questionnaire design and further research are discussed.

Background and Methods Persons of low socioeconomic status are known to have reduced life expectancy. In a study of the relation of socioeconomic status to disability-free or active life expectancy among older persons, we analyzed prospectively gathered data on 2219 blacks and 1838 whites who were 65 years of age or older in the Piedmont region of North Carolina. We defined disability as the inability to perform independently one or more basic functional activities such as walking, bathing, dressing, eating, and using the toilet. For subgroups defined by sex, race, and education, statistical models were used to estimate, for persons at each year of age, the probability of transition from not being disabled or being disabled at base line to not being disabled, being disabled, or having died one year later. These transition probabilities were then entered into increment-decrement life tables to generate estimates of total, active, and disabled life expectancy (with total life expectancy equal to active life...

State units on aging (SUAs) from 29 states with continuing care retirement community (CCRC) legislation were surveyed to (a) assess staff familiarity with CCRC legislation, (b) examine interdepartmental working relationships surrounding such legislation and ask what role(s) ombudspersons are playing in CCRC oversight, (c) determine what role(s) aging units have had in developing legislation, and (d) gain insights regarding legislative impact. Results indicate that SUAs have been active in legislative development but vary greatly in the intensity of their involvement with the implementation and enforcement of CCRC regulation and in their perception of legislative impact.

Beginning in 1982, the 3-year incidence of nursing home admission was determined for community-dwelling residents aged 65 and over in East Boston, Massachusetts (4%); New Haven, Connecticut (9%); and Iowa and Washington Counties, Iowa (12%). A common methodology was used to collect baseline risk factor and follow-up data on nursing home admissions among persons in each community as part of the National Institute on Aging's Established Populations for Epidemiologic Studies of the Elderly. A multivariate logistic regression model of baseline risk factors that included the participant's age, race, sex, history of prior admission, ADL limitations, cognitive function, living arrangements, and level of income predicted 80% of the users in each community.

The purpose of this study is to group hospital-based home care (HBHC) patients homogeneously by their characteristics with respect to cost of care to develop alternative case mix methods for management and reimbursement (allocation) purposes. Six Veterans Affairs (VA) HBHC programs in Fiscal Year (FY) 1986 that maximized patient, program, and regional variation were selected, all of which agreed to participate. All HBHC patients active in each program on October 1, 1987, in addition to all new admissions through September 30, 1988 (FY88), comprised the sample of 874 unique patients. Statistical methods include the use of classification and regression trees (CART software: Statistical Software; Lafayette, CA), analysis of variance, and multiple linear regression techniques. The resulting algorithm is a three-factor model that explains 20% of the cost variance (R2 = 20%, with a cross validation R2 of 12%). Similar classifications such as the RUG-II, which is utilized for VA nursing home and intermediate care, the VA outpatient resource allocation model, and the RUG-HHC, utilized in some states for reimbursing home health care in the private sector, explained less of the cost variance and, therefore, are less adequate for VA home care resource allocation.

Our purpose was to identify factors predictive of reported dental care use by elders (65+) over a ten-year period in Massachusetts. The Massachusetts Health Care Panel Study began in 1974-75 (wave 1) as a statewide survey of 1625 noninstitutionalized elders. Wave 2 occurred in 1976, wave 3 in 1980, and wave 4 in 1985. The 540 persons who participated in all four waves are the subject of this report. The remainder either died, entered nursing home, or were lost to follow-up. This longitudinal design permits analysis of cohort, aging, and period effects. The outcome variables were self-reported dental care use within two years, or more than two years, as reported at waves 1, 3, and 4. Wave 2 was excluded because less than two years had elapsed since the previous wave. To identify factors predictive of reported use, we used a generalization of the logistic regression model that included a random effect term, which accounts for repeated measures being made on the same subjects. Covariates in the model were dentate status, education, income, cohort, sex, martial status, and time. The variable "time" served as a measure of aging/period effects. Persons were grouped into four birth cohorts. Before adjusting for other covariates, cohort was significantly associated with dental care use, but was not so in the full multivariate model. Dentate status, education, and income were significant predictors of use. The cohort effect was explained by dentate status, education, and income. Time was not significant, indicating no aging/period effects in this ten-year period, or that their net effect was zero.

A 1987 national survey revealed 27 states with continuing care or life care legislation. State oversight staff in 22 states responded to questions concerning characteristics of the regulated continuing care retirement community (CCRC) industry, the regulation of health and human service delivery within CCRCs, and interdepartmental working relationships between oversight agencies and other state units. Discussion focuses on the regulation of long-term care service provision in the CCRC industry.

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.

Hoenig H, Pieper C, Branch LG, Cohen HJ. Effect of motorized scooters on physical performance and mobility: a randomized clinical trial. 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±73.0m [55.5±239.6ft]; usual care, 17.2±72.5m [56.5±238.0ft], 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.

What is already known about this subject • Polypharmacy, to include a subissue of potentially inappropriate prescribing, in community-dwelling elderly is widespread. • The objective of this study was to identify the magnitude of problematic outpatient drug prescribing and its potential association as a risk factor for injuries. What this study adds • This is the first national study of outpatient injuries in elderly veterans. • The results are consistent with previous published literature highlighting the risks associated with prescribing central nervous system drugs in the elderly. 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 ≥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

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.Prospective cohort with 1 year of follow-up (2000-02).In-home assessments of homebound older adults in four North Carolina counties.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.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.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.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.

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.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).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.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.

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.