Recounts of elderly deaths: endorsements for the Patient Self-Determination Act

Circumstances in the last 3 days of life were examined for a sample of 1,227 elderly decedents in Fairfield County, Connecticut, in 1985. Interviews were with a surviving next-of-kin or a nonrelative about 3 months after the event of death. Most decedents were in a hospital or a nursing home the night before death (45% and 24%, respectively). In the days preceding death, about 34% of the decedents knew that death was impending and about 40% had difficulty recognizing family members. These and other findings support the need for elderly people to complete advance directives.

Menopause and African-American women: clinical and research issues

There are currently 3.7 million African-American women aged 35-54 years, and over the next 20 years virtually all of them will experience menopause. Although menopause itself is generally thought of as a naturally occurring biological phenomenon, undergoing the process can increase a woman's risk of disease. This phenomenon is common to women in all racial and ethnic groups. Across these groups, however, the process may be subject to great variability. This article does not include issues related to all minority women, but instead focuses on menopause in African-American women. It is important to note that there may be issues among Asian and Hispanic women that are very different from those of whites and blacks. Unfortunately, there is very little epidemiologic data on menopause or its antecedents in African-American women or in women of other minority groups. To stimulate epidemiologic research into the process of menopause among African-American women, this report will examine data from clinical and government sources. A common problem is that these sources overlook aspects of menopause important for the health of black women in mid and later life, such as menopause-associated symptoms, potentially beneficial hormonal therapies, and potentially debilitating skeletal disease.

Do falls predict institutionalization in older persons? An analysis of data from the Longitudinal Study of Aging

Data from the Longitudinal Study of Aging (LSOA) were analyzed to estimate the subsequent risk of institutionalization associated with a report of one or more falls, and to determine if the association is affected by controlling for demographic traits, chronic conditions, and disabilities present at baseline. Risk was estimated at two time points, 2 years and 4 years after baseline interview. A report of multiple falls at baseline was associated with an increased risk of institutionalization at both 2 years (odds ratio [OR] 3.1; 1.9-5.3) and 4 years (OR 2.6; 1.6-4.4) of follow-up. The risk was decreased but remained significant in a model controlling for age, sex, marital status, and selected chronic conditions associated with both report of falls and institutionalization. However, multiple falls were not significantly associated with institutionalization when measures of disability (number of difficulties with activities of daily living) were added to the model. These analyses suggest that multiple falls should be regarded as an important sentinel event to alert caregivers to the presence of underlying disease and disability that may require intervention.

Musculoskeletal disorders: time trends, comorbid conditions, self-assessed health status, and associated activity limitations

In this report, cases of musculoskeletal disease were identified by a yes response to questions involving joint pain and/or physician-diagnosed arthritis in four national surveys for the following objectives: (a) to assess time trends in case prevalence; (b) to describe respondent health status; (c) to estimate prevalence of joint pain by location; (d) to estimate prevalence of selected comorbid medical conditions; and (e) to estimate among these persons the burden of ADL and IADL disability. These surveys were conducted over a 25-year interval (1960-84). Joint pain is the final common pathway through which a number of these disorders operate and could be expected to identify a subset of persons who have not sought medical consultation. Physician diagnosis of disease is an item that is conceptually a measure of severity. In these samples, there were slightly more persons reporting joint pain than reporting a diagnosis of arthritis in most years. Increases in the prevalence of both joint pain and physician-diagnosed arthritis were noted across survey years and for the cohort aged 65-69 years in NHANES I. Although this analysis is based on national data from persons with arthritis, estimates of disability prevalence from national surveys of the total U.S. population (18,28) are also available for comparison. In this report, persons with arthritis suffer from poorer health status and more disability when compared with U.S. population prevalence. Overall, 14 percent of persons aged 65-74 years reported difficulty walking, and 20 percent of persons with arthritis reported this difficulty. In the U.S. cohort aged 75-84 years, 23 percent reported difficulty walking, compared with 31 percent of those with arthritis. Among persons aged 85 years and over, 40 percent reported difficulty walking, compared with 46 percent of respondents with arthritis. It should be recognized that persons with arthritis are included in the total population estimates and these differences in disability prevalence, therefore, could be much larger. It is important to note, however, that for tasks such as toileting, dressing, and managing money, estimates of disability for the total U.S. and arthritic U.S. populations are similar. These data suggest that arthritis may be a large contributor to certain types of disability.(ABSTRACT TRUNCATED AT 400 WORDS)

Morbidity, disability, and health status of black American elderly: a new look at the oldest-old

There are over 2.5 million black Americans aged 65 and over living in the United States today, including some 258,000 persons aged 85 years and over. The post-World War II baby boom within the US black population should ensure that the numbers of persons aged 65 and over will increase into the 21st Century. If present trends continue, it is projected that the current population of black elders will also age. This means that the numbers of black persons aged 85 and over will also increase. Data from both national surveys and population-based community studies concerning the health and well-being of black elders are now becoming available. This report presents information concerning self-reported health status, chronic disease prevalence, disease-risk-factor prevalence, measures of physical functioning, and nursing home utilization rates for age groups within the black population aged 65 years and over. The availability of such data should lead to the development of targeted interventions designed to lessen impairment and prolong independent living.

Race and sex differences in mortality following fracture of the hip

This paper describes the all-cause mortality experience, following a fracture of the hip, of 712,027 persons covered by the Medicare program from 1984 through 1987. White women experienced the lowest mortality rate (17.2 per 1000 person-months), followed by Black women (22.9 per 1000 person-months), Black men (33.5 per 1000 person-months), and White men (33.7 per 1000 person-months). The observed race-sex differences in survival were found at all ages and regardless of the number of comorbid conditions listed with the discharge diagnosis. While these data demonstrate marked race-sex differences in survival following hip fracture, the cause of these differences is not immediately apparent and demands further investigation.

Prolonged tube feeding in long-term care: nutritional status and clinical outcomes

This study examines nutritional status and clinical outcomes, including pressure ulcers and death in 40 chronically tube-fed long-term care patients. Anthropometric, biochemical, clinical and dietary data were collected over a 3-month period, with follow-up of mortality at 1 year. Subjects' functional and cognitive status was generally poor. Adequate calories and protein were provided, with sample means exceeding standard means for energy, protein and micronutrients. Still, subjects showed weight loss and severe depletion of lean and fat body mass. Mean serum protein and micronutrient status measures were in the low normal range. Hemoglobin, hematocrit, and serum zinc and carotenoid levels were below normal in a sizable proportion of patients. Pressure ulcers were present in 65% of patients. Weight loss was associated with longer time on tube feeding and more pressure ulcers. Negative correlations with ulcer number were observed for cholesterol, albumin, zinc, retinol, alpha-tocopherol and iron. This study shows that despite administration of apparently adequate formula, micronutrient deficiencies and marasmic malnutrition exist in chronically ill patients. Causes may include the combined effects of chronic disease, sepsis, immobility, and severe neurologic deficits. Clinical outcomes may be expressions of an organism-wide diminution of protein synthesis, the cause of which is unknown. For clinical management, serial measures of weight, albumin, cholesterol, hemoglobin and hematocrit are recommended. Future research must address the many subsets of the population of chronically tube-fed patients.

Normal hip and knee active range of motion: the relationship to age

Abnormal joint mobility is an important factor in movement dysfunction and physical disability. Because the decision to treat impaired joint mobility in an older individual may be influenced by assumptions concerning normal range of motion (ROM) at older ages, it is important to establish population-based normative values for hip and knee ROM by age, race, and sex. This study used data from the first National Health and Nutrition Examination Survey (NHANES 1), which involved a national probability sample of persons drawn from the civilian noninstitutionalized population of the United States. Goniometric measurements of hip and knee active range of motion (AROM) were obtained from a subset of the sample consisting of 1,892 subjects. This analysis was limited to the 1,313 white and 370 black subjects. Univariate statistics, weighted by the probability of selection into the sample, were calculated for 12 sex-race-age-group-specific categories. These normal AROM values for the hip and knee calculated from this population based sample were found to differ from estimates found in textbooks by as much as 18 degrees. With one exception, normal values for all motions were lower in the oldest age group than in the youngest age group. The differences in mean AROM were generally small, ranging from 3 to 5 degrees. Only in the case of hip extension did the difference in mean AROM between the youngest and the oldest age groups constitute a decline of more than 20% of the arc of motion. With the possible exception of hip extension, this study supports the conclusion that, at least to age 74 years, any substantial loss of joint mobility should be viewed as abnormal and not attributable to aging and therefore should be treated much as it would be in a younger individual.

Seasonal variation in the incidence of hip fracture among white persons aged 65 years and older in the United States, 1984-1987

This study uses 44 consecutive months of data from the Health Care Financing Administration to assess seasonal trends in hip fracture incidence among the United States white population aged 65 years and older. The authors studied a total of 621,387 cases of hip fracture which occurred from January 1984 to September 1987. During the study period, hip fracture incidence rates display a distinctive pattern of seasonal periodicity; high rates are found in the winter and low rates in the summer among both males and females. This pattern of seasonal periodicity is consistent at ages 65-74 years, 75-84 years, and greater than or equal to 85 years. When the time series of rates are stratified into five geographic levels, each level covering 5 degrees of latitude, the distinctive pattern of seasonal periodicity is the same for all levels.

An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I--Epidemiologic Follow-up Study

The authors studied distributions of body weight for height, change in body weight with age, and the relationship between body mass index and mortality among participants in the Epidemiologic Follow-up Study of the first National Health and Nutrition Examination Survey (NHEFS) (n = 14,407), a cohort study based on an representative sample of the U.S. population. Percentiles of body weight for height according to age and sex are presented. Cross-sectional analyses of body weight suggest that mean body weight increases with age until late middle age, then plateaus and decreases for older aged persons. However, longitudinal analysis of change in weight with age shows that younger persons in the lower quintile at baseline tend to gain more than those in the higher quintile. Older persons in the higher quintile at baseline have the greatest average loss in weight. The relationship of body mass index to mortality is a U-shaped curve, with increased risks in the lowest and highest 15% of the distribution. Increased risk of mortality associated with the highest 15th percentile of the body mass index distribution, as well as the highest 15% of the joint distribution of body mass index and skinfold thickness, is statistically significant for white women. However, the risk diminishes when adjusted for the presence of disease and factors related to disease. More noteworthy is the fact that there is a statistically significant excess risk of mortality for both race and sex groups in the lowest 15% of the body mass index distribution after adjusting for smoking history, and presence of disease. Those in the lowest 15% of the joint body mass index and skinfold thickness distribution, were also at increased risk. Risk of mortality for both men and women who have lost 10% or more of their maximum lifetime weight within the last 10 years is statistically significant, even when controlling for current weight. This study has replicated previously reported relationships, while correcting for several methodological issues.

Mortality postponed and the unmasking of age-dependent non-fatal conditions

Mortality occurs at older ages in our growing and salubrious population. At present, fewer than 20% of all deaths, in Sweden, occur before age 65 with 18% of the Swedish population 65 and over. In the United States, 24% of deaths occur before age 65 with only 12% of the population age 65 and over. All countries in the developed world will have approximately 20% of their populations age 65 and over by about 2020. At that time, the percentage of deaths occurring prior to age 65 should range from 14%-16%. Thus future gains in morbidity and mortality will be influenced, to a lesser extent, by events prior to age 65 and prevention and health promotion strategies post age 65 become increasingly important. Active life expectancy, a developing concept, refers to the years lived in good health with no functional limitations. The period after active life expectancy consists of years of compromised health and well being. At present, each year gained of active life expectancy incurs almost four years of compromised health. A group of age-dependent nonfatal conditions are largely responsible for increased prevalence of social and physical deficits with age. These include dementia, osteoarthritis, diminished hearing and visual acuity, incontinence, depression, widowhood, isolation and institutionalization. Age-specific incidence of most of these conditions is unknown. There is little evidence, however, that adding years to life has postponed their age at onset. For these conditions, postponement is the major mechanism of prevention. We are attempting to construct time trends concerning the age-specific incidence and the ability to postpone age-dependent conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Hip fracture incidence among the old and very old: a population-based study of 745,435 cases

Data were obtained from the Health Care Financing Administration and the Department of Veterans Affairs (formerly called Veterans Administration) on all hospital discharges among the elderly population from 1984 through 1987 and combined with census estimates to calculate incidence rates of hip fracture for the elderly population of the United States. Rates for White women were the highest, reaching 35.4 per 1,000 per year among 95 year-olds. Comparably, White men, Black women, and Black men experienced similar age-related increases in risk, although of less magnitude and relatively less rate of change, respectively.

Weight change, survival time and cause of death in Dutch elderly

Weight change, subsequent survival time and cause of death are reported from the Dutch Longitudinal Study among the Elderly. Data consist of a national sample of persons aged 65-99 years. Six hundred and fifty-eight subjects were examined in the baseline years 1955-1957 and were re-examined 5 years later. Vital status and cause of death were ascertained for 604 of these subjects through 1983. Those subjects who experienced a decline in body mass index (BMI, kg/m(2)) during the period of observation, were likely to be in poorer health and have a shorter survival time than those subjects with stable weight, regardless of initial BMI. Weight gain was associated with shorter survival time only in the age group 65-74 and in those with heart disease. Weight loss, on the other hand, was most likely to result in decreased survival time among those ultimately dying of stroke, pneumonia/influenza or heart disease. As such, weight loss may be an indicator of the severity of disease. The noted associations remained, even when those surviving less than two years were omitted from the analyses. Thus, in longer survivors, weight loss may be associated with decreased vitality and decreased ability to survive once a disease becomes apparent.

Prospective study of pneumonia hospitalizations and mortality of U.S. older people: the role of chronic conditions, health behaviors, and nutritional status

Mortality and hospitalization rates for pneumonia have increased among older Americans during recent years (1979-86), despite a national commitment to the reduction of premature deaths from pneumonia. A prospective study of deaths and hospitalizations attributable to pneumonia was conducted among 5,474 subjects ages 55 and older who participated in the NHANES I Epidemiologic Followup Study. Prevalent chronic conditions, health behaviors, and nutritional status indicators, measured at baseline, were examined in relation to pneumonia hospitalization and death during 12 years of followup. Mortality and hospitalization rates for pneumonia were higher among men than women, and higher among those ages 65 and older than among those 55-64 of both sexes. Risk of pneumonia death was higher among subjects with a history of congestive heart failure, stroke, cancer, or diabetes. Risk of pneumonia hospitalization was higher among subjects with a history of chronic obstructive pulmonary disease and among men who were current smokers. Daily alcohol consumption did not increase risk of pneumonia in this study population. Four measures of nutritional status were examined taking age, prevalent chronic conditions, and cigarette smoking into account: body mass index, arm muscle area, and serum albumin and hemoglobin levels. Risk of pneumonia death was 2.6 times higher in men in the lowest quartile, compared with men in the highest quartile, of body mass index. Similarly, the risk was 4.5 times higher among men in the lowest quartile of arm muscle area. Risk of death from pneumonia was 3.6 times higher among women in the lowest quartile of serum albumin levels compared with women in the highest quartile. Relative risks for these nutritional status indicators remained elevated after adjusting for age and the medical history risk factors. These risk factors should be taken into account when designing and evaluating pneumonia vaccination trials and community prevention programs.

The need for a do-not-resuscitate policy in a public city hospital

Data were collected over a six-month period from in-hospital cardiopulmonary resuscitation (CPR) patients (aged 18 years and older) who were admitted to a public hospital. The sample population was mostly male (55.4 percent), primarily black (90.6 percent), with a mean age of 61 years. Medical expenses for these patients were largely covered by public funds or medical charities, reflecting the predominately low socioeconomic status of the population. The proportion of patients discharged alive after in-hospital CPR was 6.1 percent. The CPR sample contains a large proportion of patients in the terminal phase of diseases such as metastatic cancer, acquired immune deficiency syndrome (AIDS), and end-stage liver disease. Chart reviews revealed that do-not-resuscitate (DNR) orders were not presented as a therapeutic option to either patient or family in the majority of instances. These findings indicate a need to develop standards and strategies for decision making about the use of CPR specific to this population.

Synaptology of retinal terminals in the dorsal lateral geniculate nucleus of the cat

We have made a fine structural investigation of the synaptic patterns made by axon terminals of retinal ganglion cells in the dorsal lateral geniculate nucleus of the cat. We compared the retinal input to dendritic processes that bear clusters of large appendages with the retinal input to relatively smooth dendritic segments that have only a few isolated spines. The study was restricted to the portion of laminae A and A1 that receive central visual field input. We were able to completely reconstruct 33 individual terminal boutons from long series of consecutive thin sections. Retinal terminals that were presynaptic to dendritic appendages tended to occupy the central position in the complex synaptic zones of geniculate fine structure called glomeruli. These terminals were surrounded by significantly more profiles than retinal terminals that were presynaptic to dendritic stems and averaged twice as many synaptic contacts per terminal bouton. The retinal input to dentritic appendages was heavily involved in a specific synaptic pattern called the triadic arrangement while retinal input to dendritic stems was only lightly involved in triads. Dendritic appendages in triads received greater synaptic input from profiles with flattened vesicles than did the dendritic stems that were found in triads.