Does self-reported functional limitation attributed to symptoms persist 1 year after initial treatment for early breast cancer?

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Background and Significance: Comorbidity, disability and compromised functional status increase with age. It is unclear to what extent the symptoms related to the diagnosis and treatment of cancer play a role in activity limitation in older adults. We examined the prevalence of self-reported functional limitation in a breast cancer population, whether this limitation is attributed to various symptoms, and how this attribution changes over time from early in treatment to 9-months later. Methods: 1,011 patients with breast cancer were surveyed 3 months after diagnosis (baseline) and 933 of those patients were surveyed at 12 months after diagnosis (9 month follow up). In each survey, participants were asked whether or not they had each of 21 symptoms and whether or not each symptom caused significant activity limitation. Results: Of the 933 patients (mean age 62.7 years) who completed baseline and follow up evaluations, 420 were aged 65 years and older. At baseline, 47% of patients 65 years and older reported functional limitation compared with 44% of patients younger than 65 years (p=0.29). Activity limitation at baseline was attributed to nausea in 4% of older patients, (O) and 8% of younger patients (Y) (p=0.016), to pains in the chest area in 11% (O) and 9% (Y) (p=0.21), to joint or muscle aches in 20% (O) and 16% (Y) (p=0.13), to tiring easily in 31% (O and Y), and to depression in 9% (O) and 13% (Y) (p=0.19). At follow up 47% of patients 65 years and older reported functional limitation compared with 40% of patients younger than 65 years (p=0.02). Activity limitation at follow up was attributed to nausea in 3% (O) and 7% (Y) (p=0.003), to pains in the chest area in 11% (O) and 9% (Y) (p=0.21), to joint or muscle aches in 23% (O) and 17% (Y) (p=0.01), to tiring easily in 26% (O) and 24% (Y) (p=0.60), and to depression in 8% (O and Y). Conclusion: Self-reported functional limitation is prevalent 3 months and 1 year after breast cancer diagnosis. Self reported activity limitation in older and younger patients is not significantly different at baseline, and is significantly higher in older patients at follow up, with older patients having significantly less nausea and significantly more joint and muscle aches.

No significant financial relationships to disclose.

Is serum uric acid level associated with all-cause mortality in high-functioning older persons: MacArthur studies of successful aging?

OBJECTIVES

To explore the effect of serum uric acid level on subsequent all-cause mortality in high-functioning community-dwelling older persons. It is controversial whether high serum uric acid level is a true independent risk factor for cardiovascular and total mortality or the association is due to other confounding variables. Furthermore, it remains unclear whether the predictive value of uric acid level on mortality observed in younger cohorts can be extended to older people.

DESIGN

Prospective cohort study.

SETTING

A sample of community-dwelling older people.

PARTICIPANTS

A cohort of 870 participants from the MacArthur Studies of Successful Aging.

MEASUREMENTS

Baseline information was obtained for serum uric acid level, C-reactive protein (CRP), interleukin-6 (IL-6), prevalent medical conditions, and health behaviors. Crude and multivariate logistic regression analyses were used to examine the association between serum uric acid levels and 7-year all-cause mortality, while adjusting for potential confounders.

RESULTS

In men, the multiply adjusted risk ratios for 7-year total mortality were 1.07 (95% CI=0.61-1.88) for the mid tertile of uric acid level and 1.24 (95% CI=0.70-2.20) for the top tertile. In women, the multiply adjusted risk ratios were 0.58 (95% CI=0.29-1.18) and 0.47 (95% CI=0.22-0.99), for the mid and top tertiles respectively. CRP and IL-6 were important confounders in the relationship between serum uric acid and overall mortality.

CONCLUSIONS

High serum uric acid level is not independently associated with increased total mortality in high-functioning older men and women. When evaluating the association between serum uric acid and mortality, the potential confounding effect of underlying inflammation and other risk factors must be considered.

The prognostic value of serum albumin in healthy older persons with low and high serum interleukin-6 (IL-6) levels

OBJECTIVE

We sought to determine the prognostic value of serum albumin for 4-year mortality among high-functioning persons who did or did not have evidence of inflammation as indicated by high interleukin-6 (IL-6) levels.

DESIGN

We used a case-cohort design of healthy, nondisabled older persons who had serum albumin and plasma IL-6 measured at baseline. Crude and multiply adjusted (for sociodemographics and chronic diseases) proportional hazards models were used to identify the effect of baseline levels of serum albumin level on 4-year mortality among those with higher and lower levels of IL-6.

RESULTS

Among subjects without evidence of IL-6-mediated inflammation (IL-6 < 3.20 pg/mL), having a lower (< or = 4.4 g/dL) albumin level was associated with a multiply adjusted relative risk of 2.1 for 4-year mortality compared with those with higher albumin. In the presence of inflammation (IL-6 > or = 3.20 pg/mL), higher and lower serum albumin levels had similar risks (adjusted relative risks 4.0 and 3.8, respectively) compared with the referent group (higher albumin and low IL-6).

CONCLUSIONS

High serum albumin has a protective effect in healthy older persons who do not have evidence of cytokine-mediated inflammation. This protective effect is not conferred in presence of inflammation. The mechanisms by which inflammation eliminates the protective effect of high albumin remain to be determined.

High urinary catecholamine excretion predicts mortality and functional decline in high-functioning, community-dwelling older persons: MacArthur Studies of Successful Aging

PURPOSE

Catecholamine release is a marker of stress, and high plasma norepinephrine levels have been associated with increased mortality. The predictive value of high urinary catecholamine excretion for functional decline and mortality in healthier older persons has not been determined.

SUBJECTS AND METHODS

We used data from the MacArthur Studies of Successful Aging to determine the effects of high urinary catecholamine excretion on 3- and 7-year mortality and functional decline. In 1988, 765 high-functioning older subjects provided complete overnight urine samples for norepinephrine and epinephrine, and 199 of these provided repeat samples in 1991. Subjects who were in the top tertile of urinary norepinephrine or epinephrine excretion in 1988 were considered high excreters; those in the top tertile in both 1988 and 1991 were considered sustained high excreters. We used bivariate and multivariate analysis to examine the relations between high catecholamine excretion and mortality and Rosow-Breslau functional decline in 1991 and 1995.

RESULTS

In multivariate analyses, subjects with high baseline urinary excretion of epinephrine, norepinephrine, or either catecholamine were at higher risk for mortality and functional decline at 3 and 7 years, although the magnitude of risk (adjusted odds-ratios ranged from 1.1 to 3.1) varied depending upon specific catecholamine and outcome measure. Subjects who had sustained high urinary norepinephrine excretion were also at increased risk for 4-year mortality or functional decline.

CONCLUSIONS

High urinary catecholamine excretion in high-functioning, community-dwelling older persons likely reflects subclinical sympathetic stimulation and is a marker of increased risk for functional decline and mortality.

Preventive health behaviors and mammography use among urban older women

A cross-sectional survey of 610 low income women between the ages of 60 and 84 who attended community meal sites in Los Angeles was conducted to determine health behaviors associated with mammography use among urban community dwellers. Preventive practices that require women to take an active role and recurrent participation were positively associated with a current mammography, while services that are clinician-initiated were associated with ever having a mammography.

Dually incontinent nursing home residents: clinical characteristics and treatment differences

OBJECTIVE

Previous studies have described urinary and fecal incontinence in nursing homes and their separate effects on healthcare utilization. However, little is known about those who are incontinent of both.

DESIGN

Retrospective chart review.

SETTINGS

Twenty sites in three states

PARTICIPANTS

A total of 413 nursing home residents were categorized as having neither fecal nor urinary incontinence (C, n = 114), urinary incontinence only (UI, n = 53), fecal incontinence only (FI, n = 9), or were dually incontinent (DI, n = 237).

MEASUREMENTS

Charts were abstracted for sociodemographic information and health status information as well as utilization for the year before the date of abstraction. We then compared these characteristics across groups using ANOVA with pairwise comparisons and multiply adjusted regression.

RESULTS

Almost all patients with DI were cognitively and mobility impaired. However, there were no significant differences between the groups with respect to age and number of diagnoses. A diagnosis of stroke was also more common among those with DI compared with C. When examining healthcare utilization in multiply adjusted regression, dually incontinent residents received significantly fewer days of hospital care than those with UI.

CONCLUSIONS

Dual incontinence in NH residents is likely to have an important functional component. These residents seem to be treated less aggressively with respect to hospitalization compared with those with UI alone. The reasons for these differences need to be explored further.

Hormone replacement therapy use in urban older women attending meal sites: associations with sociodemographic and health characteristics and use of preventive services

OBJECTIVE

To examine sociodemographic, health and preventive health practices associated with hormone replacement therapy (HRT) use in urban community-dwelling older women.

DESIGN

Survey.

SETTING

Community-based meal sites throughout the city of Los Angeles.

PARTICIPANTS

A convenience sample of 705 community-dwelling women older than age 60 who completed questionnaires for the Prevention for Elderly Persons Program.

MEASUREMENTS

Demographic and life style characteristics, functional status, preventive practices, and current and past use of HRT.

RESULTS

Among the 705 women surveyed, 13% reported current use and 17% reported past use of HRT. Current users were more likely to be younger and more likely to report a history of osteoporosis, hysterectomy, and calcium use than never users. White women were more likely to be current users than black women.

CONCLUSIONS

Only a small proportion of the older urban women studied are currently using HRT. In particular, efforts to increase the use of these preventive services need to focus on black women and women who do not have a prior history of osteoporosis.

Using a criterion standard to validate the Alcohol-Related Problems Survey (ARPS): a screening measure to identify harmful and hazardous drinking in older persons

We compared the Alcohol-Related Problems Survey (ARPS), a new screening measure targeted at harmful and hazardous drinking among older individuals, to a criterion standard (CS) among 22 persons aged 65 and older who reported consuming at least one drink of alcohol in the previous 12 months. The CS was conducted by a study physician and research assistant. It assessed risks from alcohol use, and consisted of a structured review of each subject's medical record, clinical interview, physical examination, and an interview with a collateral informant. Analyses included descriptive statistics for demographic and health characteristics, inter-rater reliability, agreement between the ARPS and the CS, reasons for disagreement, and sensitivity and specificity of the ARPS as compared to the CS. Using Landis and Koch criteria, inter-rater reliability between two physicians for 11 subjects was substantial (weighted kappa 0.79), but agreement between the ARPS and the CS was only fair (weighted kappa 0.28). Reasons for disagreement included problems with ARPS' questions and classification rules, and problems with study physicians' assessments of drinking risk. Based on these reasons for disagreement, we made revisions in the ARPS and its classification rules. Agreement between the revised ARPS and the CS improved substantially (weighted kappa 0.62). Sensitivity and specificity of the original ARPS were 80% and 50%, respectively, and both improved to 82% after revisions. The revised ARPS is sensitive and specific for identifying harmful and hazardous drinking in older persons as determined by clinicians.

Predictors of medication prescription in nursing homes

OBJECTIVES

To identify patient characteristics associated with higher numbers of prescribed drugs or risk of receiving one or more inappropriate medications.

DESIGN

A cross-sectional survey using chart reviews.

PARTICIPANTS

A total of 414 long-stay residents of 20 nursing homes in three states

MEASUREMENTS

Current medication orders, sociodemographic information, and diagnoses and health status information as indicated by the MDS. The number of routine, total, and inappropriate medications were tabulated.

RESULTS

Higher numbers of medications were associated with higher total numbers of diseases. In addition, several diseases (congestive heart failure, hypertension, depression, anxiety, and diabetes) were associated with higher numbers of medications even after controlling for total disease burden. Cognitive impairment was associated with fewer medications after controlling for total number of diseases. Advanced age also attenuated the effect of disease burden on the number of total and routine medications. The only independent predictor of more inappropriate medications was higher numbers of routine medications.

CONCLUSION

Several specific disease states predispose patients to prescription of higher numbers of medication, and, these patients must be managed more carefully to prevent adverse drug-drug or drug-disease interactions. Why patients with compromised cognitive status receive fewer medications requires further study.

A prospective study of the effect of fracture on measured physical performance: results from the MacArthur Study--MAC

OBJECTIVE

To examine the impact of fractures on measured physical performance and to assess whether specific fractures have unique sequelae.

SUBJECTS

762 men and women, aged 70 to 79 at baseline, who were part of the MacArthur Study of Successful Aging.

DESIGN

A longitudinal case-cohort: those with prevalent fractures at baseline were excluded; cases were persons with a medically diagnosed hip, arm, spine, or wrist fracture during the follow-up period (1988-1995).

MEASURES

Eight physical performance tests: turning a circle, walking fast, chair stands, timed tap, tandem stand, grip strength, single leg stand, and balance (average of single leg and tandem stands) measured at baseline and follow-up.

ANALYSIS

Two fracture groups were defined: (1) those with incident wrist fractures (n = 7) and (2) those with a fracture of the hip, arm, or spine (combined fractures group, n = 16). Change in physical performance was analyzed using crude, age-adjusted, and multiply-adjusted ANCOVA models.

RESULTS

The combined fracture group demonstrated statistically significant (P < .05) declines seven of eight of the performance tests compared with individuals without fractures. In contrast, individuals with wrist fractures did not experience a statistically significant decline in any performance measure compared with the no fracture group.

CONCLUSIONS

Relative to those without fractures, individuals with a hip, arm, or clinical spinal fracture show similar global declines in physical performance, whereas those with wrist fracture demonstrate no physical performance decrements.

A randomized trial of weighted vest use in ambulatory older adults: strength, performance, and quality of life outcomes

BACKGROUND

Lower extremity weakness is a major risk factor for falls and hip fractures. Aging muscle is capable of responding to strengthening techniques. Strategies for providing accessible, inexpensive, safe, and effective strengthening programs for older adults are needed.

OBJECTIVE

To evaluate whether use of a weighted vest improved strength, physical performance, markers of bone turnover, or health-related quality of life.

DESIGN

A 27-week randomized, controlled, unmasked clinical trial. The primary outcome was peak isokinetic knee extensor strength at follow-up, adjusted for baseline strength.

SETTING

Home-based program.

PARTICIPANTS

A total of 62 women and men, mean age 74 years.

INTERVENTIONS

Subjects were randomized to: no vest (n = 21), 3% body weight (BW) vest (n = 19), or 5% BW vest (n = 22). The vest is a nylon garment with pockets that are loaded with adjustable weights. The vest was prescribed for 2 hours daily, 4 days per week. No specific physical activities were mandated.

MEASUREMENTS

All measures were made at baseline and 27 weeks. These included: knee strength and endurance by isokinetic dynamometer; timed physical performance tests; serum osteocalcin and urinary N-telopeptides; and health-related quality of life scales.

RESULTS

Follow-up values of muscular strength and endurance, physical performance, bone turnover markers, and health-related quality of life did not differ by treatment assignment. The final study visit was attended by 19 (90%), 15 (80%), and 20 (91%) of the control, 3%, and 5% groups, respectively. Three permanent discontinuations of vest use occurred.

CONCLUSIONS

Weighted vest use did not result in improvement in multiple domains of strength and function and did not affect bone turnover markers. We conclude that the training stimulus afforded by the vest (at the dosage tested) was below the required amount to produce strength gains or bone stimulation.

Cost-effectiveness of outpatient geriatric assessment with an intervention to increase adherence

BACKGROUND

Comprehensive geriatric assessment (CGA) can be effective in inpatient units, but such inpatient settings are prohibitively expensive. If similar benefits could be obtained in outpatient settings, CGA might be a more attractive option.

OBJECTIVES

To assess the cost-effectiveness (CE) of an outpatient geriatric assessment with an intervention to increase adherence.

SUBJECTS

Three hundred fifty-one community-dwelling, elderly subjects with at least one of four geriatric conditions.

MEASURES

In addition to the measures of functioning, we collected data on the costs of the intervention itself and on the use of medical services in the 64 weeks after the intervention.

RESULTS

The intervention, which prevented functional decline, cost $273 per participant. The intervention group averaged three more visits than the control group in the first 32 weeks after the intervention, but only 1.2 extra visits in the next 32 weeks. We estimate that the costs of these additional medical services would be $473 for the 5 years after the intervention, leading to a total cost per Quality Adjusted Life Year (QALY) of $10,600.

CONCLUSIONS

The CE of this program compares favorably with many common medical interventions. Whether investments should be made in health care resources on treatments that lead to modest improvements in the functioning of community-dwelling elderly people remains a societal decision.

An in-home nurse-administered geriatric assessment for hypoalbuminemic older persons: development and preliminary experience

BACKGROUND

Although malnutrition in older persons is a common, potentially treatable condition, few data indicate that treatments for this disorder can be effective.

OBJECTIVE

To develop and preliminarily evaluate a two-component intervention that includes a nurse-administered, in-home assessment to identify potentially remediable causes of hypoalbuminemia and protocols to treat these problems.

DESIGN

A pre-test post-test case-series.

SETTING

An academic geriatrics practice.

PARTICIPANTS

Seventeen persons aged 65 and older with serum albumin levels < or = 3.8 g/dL; eight of the participants received pre-and post-test outcome measures.

INTERVENTION

Nurse-administered standardized assessment and intervention protocols.

MEASUREMENTS

Serum albumin, Medical Outcome Study (MOS) SF-36, serum IL-1a and b, TNF alpha, IL-6, and lymphocyte markers of immune function.

RESULTS

The assessment took 87 minutes, on average, and generated a mean 4.2 recommendations. Among the eight subjects with pre- and post-test measures, serum albumin increased by 0.2 g/dL (P = .035). Compared with baseline, two T cell markers of immune function demonstrated changes consistent with better function.

CONCLUSIONS

These preliminary data support the potential benefit of a nurse-administered assessment coupled with protocols to address remediable contributors to hypoalbuminemia.

The prognostic value of sensory impairment in older persons

OBJECTIVES

To determine the relationships between visual and hearing impairment and subsequent functional dependence and mortality among community-dwelling older persons.

DESIGN

A Prospective, cohort study.

SETTING

Community-based.

PARTICIPANTS

A total of 5444 men and women aged 55 to 74 years at baseline.

MEASUREMENTS

Self-reported and measured visual impairment, self-reported and measured hearing impairment, self-reported and measured combined sensory impairment, 10-year mortality, and dependency in activities of daily living (ADL), instrumental ADL (IADL), and Rosow-Breslau (RB) function.

RESULTS

In multiply-adjusted models, adjusting for length of follow-up, socio-demographic characteristics, and chronic conditions, only measured visual impairment was predictive of mortality. Measured visual impairment was also predictive of 10-year ADL and IADL dependence; measured hearing impairment was predictive of RB dependence. Self-reported visual impairment predicted functional impairment on all scales at 10 years, although self-reported hearing impairment predicted only subsequent RB dependence. Measured combined impairment was associated with the highest risk of 10-year functional dependence.

CONCLUSIONS

Sensory impairment is predictive of subsequent functional impairment in older persons.

The predictive value of combined hypoalbuminemia and hypocholesterolemia in high functioning community-dwelling older persons: MacArthur Studies of Successful Aging

OBJECTIVES

To examine the effect of simultaneous hypoalbuminemia and hypocholesterolemia levels on 3- and 7-year rates of mortality and decline in functional status.

METHODS

In this cohort study, 937 community-based persons aged 70 to 79 years in 1988, who had high baseline physical and cognitive functioning, were classified into four groups: Group 1 (low albumin, low cholesterol), Group 2 (low albumin, normal cholesterol), Group 3 (normal albumin, low cholesterol) and Group 4 (normal albumin, normal cholesterol) using baseline blood values. Crude and multiply adjusted rates of (1) mortality (2) decline in Rosow-Breslau (RB) functional status, and (3) mortality or decline in RB functional status in 1991 and 1995 were calculated.

RESULTS

Group 1 subjects had multiply adjusted relative risks (ARR) of 3.62 and 3.53 for 3-and 7-year mortality compared with Group 4. Group 1 subjects had ARRs of 3.82, 3.02, and 2.67 of 3-year mortality or decline in RB activity scale when compared with Groups 4, 2, and 3, respectively.

CONCLUSIONS

Concomitant low serum cholesterol and albumin levels may identify high functioning older persons who are at increased risk of subsequent mortality and functional decline.

Objective and subjective measures of the quality of managed care in nursing homes

BACKGROUND

The number of nursing home (NH) residents enrolled in managed care plans (HMO) will increase, and there is concern that the quality of their medical care may be compromised by cost-containment pressures. In this study, we evaluated the medical care of residents enrolled in 3 health maintenance organizations (HMO) that developed specific long-term care programs.

OBJECTIVES

To compare the medical care received by NH residents enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of care and consumer perception (subjective) measures. To describe the relationship between the objective and subjective measures.

MEASURES

Number of primary care visits per month; process of medical care for 2 geriatric tracer conditions (falls, fevers); family and residents' perceptions of the adequacy of sickness episode management; and the frequency of primary provider visits.

DESIGN

Quasi-experimental.

RESULTS

HMO residents received more timely and appropriate responses to falls and fevers than did FFS residents. HMO residents also received more frequent routine visits by a primary care provider team consisting of a physician and nurse practitioner. Consumer perceptions of quality did not differ between the HMO and FFS groups. Families within both groups were significantly more positive than were residents about the frequency of visits by both physicians and nurse practitioners. Within the HMO group, both families and residents were more positive about the frequency of nurse practitioner visits than were physician visits even when the frequency of visits by the 2 providers were similar.

CONCLUSIONS

Although the medical care received by HMO residents was better on most objective process measures than that received by FFS residents, consumer perceptions of care did not detect those differences. NH residents and families have different perceptions about the adequacy of visits by physicians and nurse practitioners, and both families and residents appear to have different expectations concerning how often they want physicians to visit as compared with nurse practitioners.

Drinking habits among older persons: findings from the NHANES I Epidemiologic Followup Study (1982-84). National Health and Nutrition Examination Survey

OBJECTIVES

To describe alcohol use and its sociodemographic correlates among persons aged 65 years and older in a US probability sample.

DESIGN

Cross-sectional analysis of a national probability sample-based cohort study.

SETTING

Multiple sites throughout the United States.

PARTICIPANTS

A total of 3448 persons aged 65 and older who participated in the first wave of the NHANES I Epidemiologic Followup Study (1982-84).

MEASUREMENTS

We describe the alcohol use behaviors and demographic characteristics of 3448 persons aged 65 and older. Least squares regression models were used to assess associations between older persons' sociodemographic characteristics and alcohol use.

RESULTS

Sixty percent of the sample reported having 12 or more drinks of alcohol in at least 1 year of their lives. Seventy-nine percent of these older drinkers were currently drinking. Twenty-five percent of all drinkers drank daily (31% men, 19% women). Using gender-specific definitions (men >2 drinks/day; women >1 drink/day), 16% of men drinking alcohol and 15% of women drinking alcohol were heavy drinkers. Younger age, male gender, and higher income were associated with greater alcohol use.

CONCLUSIONS

Most older persons who ever drank alcohol in their lifetimes were currently drinking. In addition, a substantial number of older persons were drinking currently at levels that may place them at risk of adverse health consequences.

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations

BACKGROUND

Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain.

OBJECTIVE

To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes.

DESIGN

A randomized controlled trial.

SETTING

Community-based sites.

PATIENTS

363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment)

INTERVENTION

A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations.

MEASUREMENTS

Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Performance Test, NIA lower-extremity battery.

RESULTS

In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated.

CONCLUSIONS

A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

Primary care of long-stay nursing home residents: approaches of three health maintenance organizations

OBJECTIVE

To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs.

DESIGN

Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year.

SETTING

The programs were based in 20 community-based nursing homes in three regions (East, West, Far West).

PARTICIPANTS

Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied.

MAIN OUTCOME MEASURES

Emergency department (ED) and hospital utilization.

RESULTS

All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization.

CONCLUSIONS

HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

Use of primary care teams by HMOS for care of long-stay nursing home residents

OBJECTIVE

To characterize the use of formal primary care programs by health maintenance organizations (HMOs) for their members who are long-stay residents of nursing homes.

DESIGN

Using mail survey techniques, 34 Medicare risk-contracting HMOs with the largest Medicare beneficiary enrollments were asked to complete a written questionnaire. HMOs were asked how they evaluate care in nursing home settings and whether they operate a formal primary care program for members who are long-stay nursing home residents. Those reporting they had programs were asked about the program features, participation in the program, roles performed by clinical practitioners, and clinical caseloads. Surveys were completed by 21 (61.8%) of the HMOs.

PARTICIPANTS

HMO management personnel who know the primary care programs the HMOs operate in affiliated nursing homes.

MEASUREMENTS

Descriptive summaries of the HMOs' responses to the survey questions were generated. For HMOs with primary care programs, caseloads of physicians and nurse practitioners were estimated using survey data reported by the HMOs.

RESULTS

Eight (38.1%) of the responding HMOs operate formal primary care programs in affiliated nursing homes. HMOs with programs consider more factors than non-program HMOs in evaluating care for nursing home residents. Reasons cited most frequently for not having a program are costs and too few nursing home residents. The most common primary care program features are designated physicians and use of physician extenders.

CONCLUSIONS

Survey findings point to the potential importance of formal HMO primary care programs for long-term nursing home residents, which may expand with growth in the older population and Medicare-managed care. Program adoption, however, may depend on sufficient resident participation to be financially feasible.

Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided?

OBJECTIVE

To evaluate whether nursing home residents and their families reported discussions about life-sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician-patient communication about life-sustaining treatment.

DESIGN

Cross-sectional interviews and retrospective chart abstraction.

SETTING

Three regions: West Coast, New England, Western.

SAMPLE

A total of 413 nursing home residents, 363 family/surrogate interviews, and 192 resident interviews.

MAIN OUTCOME MEASURES

Measured were (1) physician-resident communication about life-sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart.

RESULTS

Seventy-four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life-sustaining treatment. Of residents with DNR orders who could have participated in discussions about life-sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician-family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician-resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician-resident discussion about life-sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses.

CONCLUSIONS

Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Development and validation of a geriatrics attitudes scale for primary care residents

OBJECTIVE

To develop and validate an instrument measuring attitudes toward older persons and caring for older patients.

DESIGN

Cross-sectional and longitudinal studies.

SETTING

An academic medical center.

PARTICIPANTS

Initial Study: 121 primary care residents (n = 96), fellows (n = 14), and faculty (n = 11) participated in instrument development in 1995. Longitudinal Study: 95 residents (n = 87) and fellows (n = 8) of the initial cohort participated in the 1996 follow-up study, and 61 of the initial cohort (57 residents and 4 fellows) participated in the 1997 follow-up study. Cross Validation Study: 96 first-year residents (n = 78) and fellows (n = 18) participated in this study.

MEASUREMENTS

A 14-item geriatrics attitudes scale was developed. The items were selected from a pool of 37 items administered to the 121 participants in the initial study.

RESULTS

The instrument demonstrated high reliability (Cronbach's alpha = .76) and known-groups and construct validity. Attitudes were progressively more positive with more medical training (P < .001), and residents with greater career interest in geriatrics scored higher than those less interested (P = .007). Cross validation results supported the reliability and validity of the instrument. Longitudinal data showed significantly different trends of attitude changes among groups of residents and fellows over a 2-year period.

CONCLUSIONS

The 14-item geriatrics attitudes scale developed in this study shows sound reliability, validity, and sensitivity to change among primary care residents. The performance of other groups of medical trainees and the relationship of attitude changes to specific medical training warrant further investigation.

Hearing loss in community-dwelling older persons: national prevalence data and identification using simple questions

OBJECTIVE

To estimate the prevalence of hearing loss among community-dwelling older persons according to clinical criteria and to develop a brief self-report screening instrument to detect hearing loss.

DESIGN

Survey.

SETTING

National probability sample of noninstitutionalized older persons.

PARTICIPANTS

A total of 2506 persons aged 55 to 74 who participated in the National Health and Nutrition Examination Survey.

MAIN OUTCOME MEASURES

Hearing loss as defined by Ventry and Weinstein (VW) criteria and by the High Frequency Pure-Tone Average (HFPTA) scale.

RESULTS

Hearing loss by VW criteria was present in 14.2% and by HFPTA criteria in 35.1% of those surveyed. The prevalence increased with advancing age and was higher among men and those with less education. A logistic regression model identified six independent factors for hearing loss by VW criteria: age > or = 70 years (adjusted odds-ratio (AOR) 2.7, 95% confidence interval (95% CI) 1.6, 4.4), male gender (AOR 3.0, 95% CI 1.9, 4.8), < or = 12th grade education (AOR 3.8, 95% CI 1.8, 7.7), having seen a doctor for deafness or hearing loss (AOR 8.9, 95% CI 5.3, 14.9), unable to hear a whisper across a room (AOR 3.2, 95% CI 2.0, 5.1), and unable to hear a normal voice across a room (AOR 6.2, 95% CI 2.6, 14.9). A clinical scale based on the logistic model had 80% sensitivity and 80% specificity in predicting hearing loss using VW criteria and 59% sensitivity and 88% specificity in predicting hearing loss using HFPTA criteria.

CONCLUSIONS

Hearing loss, as defined by two clinical criteria, is common and can be screened for accurately using simple questions that assess sociodemographic and hearing-related characteristics.

Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons

OBJECTIVE

To develop and validate a brief instrument--the Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI)--to measure older patients' self-efficacy in obtaining medical information and attention to their medical concerns from physicians.

DESIGN

Two consecutive validation surveys.

SETTING

Eleven senior multipurpose centers in Los Angeles County California.

POPULATION

A convenience sample of 163 community-dwelling older persons (Survey 1: n=59, mean age=77.1 years, 76.3% female; Survey 2: n=104, mean age=77.4 years, 57.7% female).

MEASURES

The 10-item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self-reported health and restricted activity days items.

RESULTS

The full 10-item and a 5-item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r=-.27, P=.001) and positively with active coping (r=.17, P=.03) and with patient satisfaction with physician interpersonal manner (r=.49, P < .0001) and communication (r=.51, P < .0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self-reported health (r=.42, P < .0001), education (r = .24, P=.01) and self-mastery (r=.29, P=.01) and negatively with restricted activity days (r=-.25, P=.01). PEPPI-5 demonstrated correlations similar in magnitude, direction, and statistical significance.

CONCLUSION

In either the 5- or 10-item version, PEPPI is a valid and reliable measure of older patients' perceived self-efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.

Acceptability of mobile mammography among community-dwelling older women

OBJECTIVE

To test the acceptability of mobile mammography among community-dwelling older women and to identify factors predictive of mobile mammography acceptance.

DESIGN

Case series.

SETTING

Twelve community meal sites sponsored by the City of Los Angeles Area on Aging.

PARTICIPANTS

Two hundred fifty-five volunteers aged 60 to 84 years who attended community meal sites.

INTERVENTION

On-site mammography offered to women who had not had a mammogram within the last year.

MEASUREMENTS

Mammography acceptance rates, reasons for accepting or declining the mammogram, and breast cancer knowledge, beliefs, and intentions.

MAIN RESULTS

One hundred seven of the 255 (42%) women were ineligible because they had received mammograms within the last year. Of the 148 women eligible, 57% accepted the mammograms and 43% declined; moreover, 20 of the 42 (48%) women who had not had a mammogram within the last 5 years or who never had a mammogram also accepted on-site mammography in the mobile van. Variables identified as predictive of mammogram acceptance included Asian American status, not being an HMO member, being married, a reported willingness to accept a screening mammogram if recommended by a physician, and previous mammogram screening history.

CONCLUSION

Mobile mammography is acceptable to many older community-dwelling women. Although mobile mammography does not eliminate all barriers that inhibit a woman from receiving a mammogram, it may substantially increase screening for some groups.

Geriatric assessment in oncology

With the anticipated growth in the numbers of elderly persons, a higher prevalence of cancers among older persons is expected; as a result, oncologists will treat larger numbers of older persons in their practices. Clinicians caring for older persons with cancer must recognize the heterogeneity of the elderly population and focus their assessments and care plans accordingly. The author reviewed literature and drew conclusions regarding geriatric assessment in several key areas: the medical, cognitive, affective, functional economic, and environmental status of patients; social support for patients; and advance directives. They concluded that for younger and healthier seniors, simple probes for the presence of common geriatric problems may suffice, but traditional means of medical assessment should be supplemented by brief screening for common geriatric conditions and nonmedical issues that are of particular relevance to the health of older persons. Assessment instruments can be used to guide these brief evaluations, but results must be interpreted in the context of the limitations of the instruments used. Patients who are frail or at high risk for functional decline or nursing home placement should receive more extensive evaluation by individual practitioners or by a multidisciplinary team of health care professionals who can provide comprehensive geriatric assessment. By broadening their assessment skills to include domains that are beyond traditional internal medicine and oncology training, oncologists can better serve their older cancer patients.

Development and validation of a geriatrics knowledge test for primary care residents

This study reports the development and preliminary validation of an instrument to measure geriatrics knowledge of primary care residents. A 23-item test was developed using questions selected from the American Geriatrics Society's Geriatrics Review Syllabus. Ninety-six internal medicine and family practice residents, 14 geriatrics fellows, and 11 geriatrics faculty members participated in the study. Findings support the reliability (Cronbach's alpha = 0.66) and validity (content and "known groups") of this short test. Predictive validity and sensitivity of the test to changes in knowledge will have to be further explored as residents progress through their training.

Correlates of hypoalbuminemia in community-dwelling older persons

To identify easily ascertainable sociodemographic and health characteristics that are associated with hypoalbuminemia in community-dwelling older persons, we used data from the first National Health and Nutrition Examination Survey. This population-based stratified probability sample survey included 4728 persons aged 55-74 y. We defined hypoalbuminemia in two ways: < 35 g/L (1.2% of the sample) or < or = 38 g/L (7.9% of the sample) and used multivariate logistic models to identify independent predictors of hypoalbuminemia. Older age; receiving welfare; a condition interfering with eating; vomiting > or = 3 d/mo; previous surgery for gastrointestinal tumor; self-reported heart failure; recurring cough attacks; feeling tired or wornout; edentulous, fair, or poor condition of teeth; little or no exercise; a low-salt diet; trouble chewing meat; self-reported protein albumin, blood, or sugar in urine; and current cigarette smoking were independently associated with albuminemia (< or = 38 g/L) or progressively lower albumin concentrations < 40 g/L. Persons with 3-5 of these factors (51.5% of the sample) had an odds ratio of 2.73 (95% CI: 1.64, 4.54) and those with > or = 6 factors (9.4% of the sample) had an odds ratio of 6.44 (95% CI: 3.49, 11.86) of albuminemia < or = 38 g/L compared with those with 0-2 risk factors (39.1% of the sample). These findings suggest that several easily assessed sociodemographic, lifestyle, and disease-related factors are associated with hypoalbuminemia and might be valuable items to include on general health surveys to identify older persons who have this marker of poor health status.

The performance of simple instruments in detecting geriatric conditions and selecting community-dwelling older people for geriatric assessment

BACKGROUND

comprehensive geriatric assessment (CGA) appears to be less effective when performed in outpatient clinics than in hospital settings. The effectiveness of outpatient CGA might be improved by selectively targeting frailer community-dwelling elderly people. The purpose of this study was to evaluate the clinical performance of rapidly-administered standard screening measures for geriatric syndromes in selecting community-dwelling older people for outpatient CGA.

METHODS

urban-dwelling older people were screened for CGA at community sites using a self-administered questionnaire containing standardized measures for each of four geriatric target conditions: depression, urinary incontinence, falls and functional impairment. The study sample included all 150 consecutive subjects who were screened, failed on one or more of the four target criteria and completed community-based, academically administered CGA. Diagnostic accuracy of the screening instruments was assessed using CGA diagnoses as the 'gold standard'. In addition, patients' potential for benefiting from CGA was determined by whether they received major medical recommendations for further evaluation or treatment.

RESULTS

after completing CGA, 60.2% of those failing on functional impairment, 53.5% of those failing on depression, 30.7% of those failing on falls and 92.7% of those on urinary incontinence, were confirmed as having these or highly related conditions as clinical problems. Overall, 81.3% of the subjects completing CGA received the least one major recommendations for further medical intervention; most of these recommendations (79.5%) were for a target-related condition and the further remainder (20.5%) addressed another significant medical condition.

CONCLUSION

simple screening instruments used in community settings have variable degrees of accuracy, but may be markers for frailty and thus can identify older people likely to benefit from geriatric assessment.

Managing geriatric syndromes: what geriatric assessment teams recommend, what primary care physicians implement, what patients adhere to

OBJECTIVES

To evaluate the responses of primary care physicians and patients to recommendations from a community-based comprehensive geriatric assessment (CGA) program for management of four target conditions: falls, depression, urinary incontinence, and functional impairment.

DESIGN

Case series.

SETTING

Senior centers, meal sites, senior housing, and other community sites as screening locations; and a community-bases academic practice as the location for CGA.

PARTICIPANTS

A total of 150 older patients living in the community who have one or more of the four target conditions and who received CGA.

MEASUREMENTS

Physician implementation and patient adherence rates were ascertained during a face-to-face structured interview with the patient 3 months after CGA.

RESULTS

Two hundred twelve of 528 (40%) CGA recommendations were clearly or possible related to the target or target-related conditions. Of these 212 recommendations, 59% required a physician's order for implementation. The remaining 41% were patient self-care recommendations. Overall physician implementation across conditions was 70%; implementation rates were highest for falls and lowest for functional impairment. Overall patient adherence rate was 85% for physician-implemented recommendations and 46% for self-care recommendations. Patient adherence to recommendations for counseling or support groups and exercise programs was particularly low.

CONCLUSIONS

When examining the process of care of community-based CGA, patient as well as physician adherence must be considered. Although patient adherence to physician-initiated recommendations was high for all conditions, it varied substantially across target conditions and types of recommendations for self-care recommendations.

Predictors of perceived health in hospitalized older persons: a cross-sectional and longitudinal study

OBJECTIVES

To identify the predictors of perceived health and predictors of changes in perceived health in frail hospitalized older persons during the year after hospitalization.

DESIGN

Both cross-sectional and longitudinal multivariate analysis of data from a cohort followed for 1 year.

SETTING

Six hospital in a group practice model health maintenance organization (HMO) in Southern California.

PARTICIPANTS

A total of 1889 persons aged 65 or older who met at least one of 13 inclusionary criteria for a randomized trial of Comprehensive Geriatric Assessment consultation at admission and completed three Functional and Health Status Questionnaires (FHSQ) during a 12-month period.

MEASUREMENTS

Functional and health status measures included basic and intermediate activities of daily living (BADL and IADI) and social activities (SA) scales from the Functional Status Questionnaire as well as the mental health index (MHI) and current health perception (CHP), scales from the Medical Outcomes Study short from. Subject's severity of disease was measured by the Resource Demand Scale (RD Scale).

RESULTS

In the cross-sectional analyses, MHI score, IADL score, RD Scale, history of falls during the 3 months before hospitalization, and female gender were significant predictors of perceived health in all models for each time point, BADL score, age, presence of incontinence, and ethnicity were significant in the model for baseline only, and SA score was significant in models for 3 months and 12 months only. In the longitudinal analyses, the baseline CHP score and the changes in MHI, IADL, and BADL score predicted CHP change from 0 to 3 months and from 3 to 12 months.

CONCLUSIONS

Functional and psychosocial health indicators are the most important and most consistent predictors of perceived health. Our study showed that several predictors of perceived health in cross-sectional analysis did not predict changes in perceived health over a 1-year period. Hence, to fully understand the medical and social contributors to perceived health, a comprehensive approach using both cross-sectional and longitudinal analyses is necessary.

Does estrogen prevent skin aging? Results from the First National Health and Nutrition Examination Survey (NHANES I)

OBJECTIVE

To evaluate the relation between noncontraceptive estrogen use and skin wrinkling, dryness, and atrophy.

DESIGN

Cross-sectional analysis of a national probability sample-based cohort study.

SETTING

Multiple community sites throughout the United States.

PARTICIPANTS

Postmenopausal women (n = 3875) aged 40 years and older at baseline.

MEASUREMENTS

Skin conditions (wrinkling, dryness, and atrophy) were ascertained using a uniform clinical examination by trained dermatology resident physicians. Self-reported use of estrogen before the baseline examination, sunlight exposure, and smoking history were obtained by standardized interview. Body mass index, a measure of weight in kilograms divided by the square of the height in meters, was evaluated in uniform examination clothing.

RESULTS

Mean (+/-SD) age of the participants was 61.6 (+/-9.0) years and mean (+/-SD) number of years since menopause was 15.6 (+/-9.4). Most were white (83.7%), the remainder being African American (15.9%) or another race (0.4%). Atrophy was present in 499 (16.2%), dry skin in 1132 (36.2%), and wrinkled skin in 880 women (28.2%). The prevalence of all 3 skin conditions was lower in African American women compared with white women. Information on hormone use was available for 3403 participants (88%). Among all women, after adjustment for age, body mass index, and sunlight exposure, estrogen use was associated with a statistically significant decrease in the likelihood of senile dry skin (odds ratio, 0.76; 95% confidence interval, 0.60-0.97). The odds of wrinkling were substantially lower in estrogen users, adjusted for age, body mass index, and sun exposure (odds ratio, 0.68; 95% confidence interval, 0.52-0.89) and additionally for smoking (odds ratio, 0.67; 95% confidence interval, 0.44-1.01). In multivariable models, estrogen use was not associated with skin atrophy.

CONCLUSION

These results strongly suggest that estrogen use prevents dry skin and skin wrinkling, thus extending the potential benefits of postmenopausal estrogen therapy to include protection against selected age- and menopause-associated dermatologic conditions.

Determinants of patient adherence to consultative comprehensive geriatric assessment recommendations

BACKGROUND

In consultative models of Comprehensive Geriatric Assessment (CGA), lack of implementation of CGA recommendations is well documented and appears to be a potential explanation for negative findings. The purpose of this study is to identify patient determinants of adherence to recommendations received from a community-based CGA consultative model program.

METHODS

Subjects (N = 139) received self-care and/or physician-initiated CGA recommendations and were interviewed three months later to determine adherence with the most important recommendation, and health belief, communication, and social support factors associated with adherence. Independent variables were organized into the Andersen Behavioral Model for analysis.

RESULTS

At the bivariate level, one predisposing factor (intention) and six enabling factors (low difficulty level, high support, high utility, high self-efficacy, agreement on the importance of the recommendation and good specific communication about the recommendation) were significant determinants of adherence. Two functional health measures and seriousness of the target condition of the recommendation were significant need factors. In the final logistic regression model, one predisposing variable (intention), one enabling variable (utility), and one need factor (high functional status), and two interaction terms significantly predicted adherence.

CONCLUSION

CGA recommendations that are seen as worthwhile, not too much trouble, and able to be accomplished are the most likely to be initiated. Older adults with relatively higher functional levels are also more likely to follow through with CGA recommendations even though their needs may be lower. We found the Andersen Behavioral Model useful in the analysis of factors associated with adherence behavior to consultative CGA recommendations.

The Prevention for Elderly Persons (PEP) Program: a model of municipal and academic partnership to meet the needs of older persons for preventive services

OBJECTIVE

To create a program to identify preventive needs for community-dwelling older persons and incorporate intervention strategies to improve implementation of these services.

DESIGN

Program development and case-series.

SETTING

Community-based meal sites, academically administered program.

PARTICIPANTS

Persons 60 years of age or older attending meal sites and their primary care physicians.

MEASUREMENTS

Demographic characteristics, self reported preventive health behaviors and services, blood pressure measurement.

RESULTS

During the first 2 years of the program, 927 persons 60 years of age or older were screened. The most common physician-initiated preventive recommendations were: tetanus booster (72%), aspirin prophylaxis (68%), pneumonia vaccination (61%), and colorectal cancer screening (51%). The most common self-care recommendations have been: calcium supplementation (54% of women) and breast self examinations (51% of women). As part of the adherence intervention, we were able to complete health educator calls for 600 (65%) subjects. In addition, the physicians of 599 (65%) subjects were contacted either by telephone (n = 496) or by letter only (n = 97).

CONCLUSION

A community based preventive services program can identify large numbers of unmet preventive services needs, and a dual intervention strategy aimed at meeting these needs can be delivered successfully to the majority of participants. Implementation rates of specific recommendations and impacts on health outcomes remain to be determined.

What influences physician practice behavior? An interview study of physicians who received consultative geriatric assessment recommendations

BACKGROUND

Comprehensive geriatric assessment (CGA) in outpatient settings has not been shown to be as effective in reducing mortality and improving health as in hospital settings; this difference has been attributed in part to a lack of direct control over recommendation implementation.

OBJECTIVE

To identify inhibiting and facilitating factors in physicians' compliance with consultative CGA recommendations, so that the effectiveness of outpatient CGA might be improved.

METHODS

A 49-item questionnaire was administered via the telephone to 87 eligible community primary care physicians in Los Angeles, Calif, whose patients had received consultative outpatient CGAs as part of a study of CGA (response rate, 96%). The questionnaire assessed physician compliance with CGA recommendations, reasons for implementing or not implementing the recommendations, and specific physician attitudes, perceptions, and characteristics. The focus of the interview was the CGA recommendation that was determined to be the "most important" by the evaluating geriatrician. Recommendations addressed geriatric syndromes, general medical problems, or psychiatric conditions.

RESULTS

Of the 87 physician respondents, 62 (71%) implemented the most important recommendation. In multivariate analysis, 4 variables were predictive of physician compliance: (1) a patient's request that the recommendation be implemented (odds ratio [OR], 10.8; 95% confidence interval [CI], 1.9-61.3; P = .007); (2) perceived legal liability resulting from nonimplementation of the recommendation (OR, 10.8; 95% CI, 1.1-108.2; P = .04); (3) female physician gender (OR, 9.6; 95% CI, 1.4-67.9; P = .04); and (4) perceived cost-effectiveness of the recommendation (OR, 7.0; 95% CI, 1.6-30.5; P = .01).

CONCLUSIONS

Patient behavior, which may be modifiable, was among the strongest determinants of physician compliance with recommended care. Specifically, when patients requested that a recommendation be implemented, physicians were highly likely to comply. Changing patient behavior within the physician-patient relationship as a way of effecting desired changes in physician health care practices merits further attention.

"Lifestyle" interventions for promoting physical activity: a kilocalorie expenditure-based home feasibility study

The Centers for Disease Control and Prevention and the American College of Sports Medicine in cooperation with the President's Council of Physical Fitness and Sports recommended short periods of daily kilocalorie (calorie) expenditure with moderate-intensity physical activities to complement the currently existing recommendations. In this study the feasibility (adherence and safety) of employing calorie expenditure as the basis for prescribing a home-based walking program to healthy, community-dwelling men and women was examined. This was a 16-week pretest-posttest feasibility study of a home-based calorie-expenditure walking program conducted in an outpatient clinic in an academic medical center. Participants included 20 healthy, elderly, community-dwelling men and women. A 16-week home-based walking program was individually prescribed as a weekly amount of calorie expenditure increasing from an initial 300 calories per week to 1,200 calories per week (approximately 30 minutes of walking daily) during the final 6 weeks of the study. Adherence to the program was recorded individually in a diary (kept daily and reviewed at each visit), body weight, and walking pace. All but one participant were able to complete this 16-week program (95 percent adherence). That a calorie-based approach to promote physical activity among the elderly has a high adherence rate is suggested by these findings. Additional studies are necessary to define the potential role for this approach in promoting physical activity and improving health outcomes among the elderly.

Looking inside the black box of comprehensive geriatric assessment: a classification system for problems, recommendations, and implementation strategies

OBJECTIVE

To develop and test the inter-rater reliability of a coding system for geriatric problems identified through Comprehensive Geriatric Assessment (CGA) of hospitalized older persons, recommendations generated by the assessment, and implementation strategies for these recommendations.

DESIGN

Validation study.

SETTING

A health maintenance organization and a geriatrics academic program.

PARTICIPANTS

A total of 49 hospitalized older persons, who met at least 1 of 13 inclusionary "targeting" criteria, two geriatricians, and one social worker who coded forms.

MEASUREMENTS

Standardized coding of CGA consultation sheets into (1) geriatric problems identified, (2) recommendations, and (3) implementation strategies; inter-rater reliability testing of coding system using two physicians and a social worker.

RESULTS

On average, each assessed patient had 4.8 recommendations. The largest percentages of recommendations were for non-physician referrals (18.2%), advance directives (13.4%), medication adjustments (11.5%), diagnostic evaluation/monitoring (11.5%), and community services (10.9%). The proportions of agreement between raters in coding problems ranged from 0.77 to 0.90, in coding recommendations from 0.69 to 0.86, and in coding implementation strategies from 0.68 to 0.83.

CONCLUSION

A classification system for measuring some components of the process of care of CGA has satisfactory inter-rater reliability, can be adapted for other settings, and may provide valuable insight into determining which components of CGA confer health benefits.

Physician implementation of and patient adherence to recommendations from comprehensive geriatric assessment

PURPOSE

The goals of this study were to develop and determine the feasibility of interventions designed to increase both primary care physician implementation of and patient adherence to recommendations from ambulatory-based consultative comprehensive geriatric assessment (CGA), and to identify sociodemographic and intervention-related predictors of physician and patient adherence.

PATIENTS AND METHODS

One hundred thirty-nine community-dwelling older persons who failed a screen for functional impairment, depressive symptoms, falls, or urinary incontinence received outpatient CGA consultation. These patients and the 115 physicians who provided primary care for them received one of three adherence interventions, each of which had a physician education component and a patient education and empowerment component. Recommendations were classified as physician-initiated or self-care and as "major" or "minor"; one was deemed "most important". Adherence rates were determined on the basis of face-to-face interviews with patients.

RESULTS

Based on 528 recommendations for 139 subjects, physician implementation of "most important" recommendations was 83% and of major recommendations was 78.5%. Patient adherence with physician-initiated "most important" and "major" recommendations were 81.8% and 78.8% respectively. In multivariate models, only the status of the recommendation of "most important" (odds ratio 2.4, 95% CI [confidence interval] 1.3 to 4.5) and health maintenance organization (HMO) status of the patient (odds ratio 2.1, 95% CI 1.3 to 3.6) remained significant in predicting physician implementation. The logistic model predicting patient adherence to physician-initiated recommendations included male patient gender (odds ratio 3.1, 95% CI 1.3 to 7.0), the status of the recommendation of "most important" (odds ratio 1.9, 95% CI 1.0 to 3.8), total number of recommendations (odds ratio 0.7, 95% CI 0.5 to 0.9), and total number of problems identified by CGA (odds ratio 1.8, 95% CI 1.2 to 2.7).

CONCLUSIONS

These findings indicate that relatively modest interventions strategies are feasible and lead to high levels of physician implementation of and patient adherence to physician-initiated CGA recommendations. These interventions appear to be particularly effective in HMO patients and for recommendations that were deemed to be "most important".

Driving and dementia California's approach to a medical and policy dilemma

The cognitive impairment that defines dementia is thought to place affected persons at increased risk for unsafe driving. Nevertheless, many persons with dementia continue to drive after the onset of their illness. Since 1988 California physicians have been required to report older persons with Alzheimer's disease and related disorders to their local health departments, information that is then reported to the Department of Motor Vehicles (DMV). To reevaluate how it acts on this information, the DMV convened an interdisciplinary panel of experts and modified its policies regarding drivers with dementia. As revised, the driver's licenses of persons with moderate or advanced dementia will be revoked without further testing. Persons with early or mild dementia will have the opportunity to demonstrate the capacity to drive through a reexamination process. In this manner, the California DMV hopes to balance the need for public safety and with the preservation of personal independence of persons with dementia.

Postdischarge geriatric assessment of hospitalized frail elderly patients

BACKGROUND

The diffusion of comprehensive geriatric assessment services has been rather limited in North America partly because of reimbursement and organizational constraints.

OBJECTIVE

To evaluate the impact of a comprehensive geriatric assessment intervention for frail older patients that is started before hospital discharge and is continued at home.

METHODS

Patients older than 65 years were selected who had either unstable medical problems, recent functional limitations, or potentially reversible geriatric clinical problems. Patients (n = 354) were randomly assigned to either the intervention group or a control group. Information on survival, readmissions, nursing home placement, medication use, and health status was collected at 30 and 60 days after hospital discharge.

RESULTS

No differences were observed between the two treatment groups in survival, hospital readmission, or nursing home placement by 60 days. After adjustment for baseline characteristics, no significant differences were observed between the two groups on measures of physical functioning, social functioning, role limitations, health perceptions, pain, mental health, energy and/or fatigue, health change, or overall well-being.

CONCLUSIONS

Although efficacy has been demonstrated for some forms of comprehensive geriatric assessment, the types of services that are easier to establish (inpatient consultation services and ambulatory assessment) have not been shown to improve outcomes. Our results indicate that outcomes are unaffected by a limited form of comprehensive geriatric assessment begun in the hospital and completed at home. Further efforts are needed to develop and to evaluate realistic approaches to comprehensive geriatric assessment.

Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group

OBJECTIVE

To examine the attitudes of beginning medical students toward older persons and their medical care.

DESIGN

Cross-sectional survey.

SETTING

Five University of California medical schools.

PARTICIPANTS

Beginning medical school students from the Class of 1994.

MEASUREMENTS

Demographic characteristics, personal contacts with older persons, and previous coursework or research experience with older persons were assessed. Knowledge with regard to aging was measured with a group of 10 questions, which were modified from the Facts on Aging Quiz. The attitudes of students toward older persons were assessed using the Aging Semantic Differential (ASD), the Maxwell-Sullivan Attitude Scale (MSAS), and two case scenarios.

RESULTS

Ninety-two percent of the participants (554 of 603) responded; 93% of these responses were usable. Students were much less likely to admit an acutely ill 85-year-old woman to an intensive care unit, intubate her, and treat her aggressively than they were to treat an acutely ill 10-year-old girl with underlying chronic leukemia. In multivariate models, male gender and younger student age were both independently predictive of less favorable attitudes regarding a 70-year-old person on the ASD Instrumental-Ineffective subscale. Asian-Americans and males had less favorable attitudes on the Autonomous-Dependent and the Personal Acceptability-Unacceptability subscales. More knowledge with regard to aging was predictive of more favorable attitudes on the Autonomous-Dependent and Personal Acceptability-Unacceptability subscales. Male gender and Asian-American ethnicity were significantly associated with less favorable attitudes on the two scales derived from the MSASs. Students who had previously visited a long-term care facility were more likely to disagree that it takes too much time to care for older persons.

CONCLUSION

Beginning medical students have already formed some unfavorable attitudes about older persons. Few independent predictors (either sociodemographic or students' previous experiences) of student attitudes could be identified that would help in the selection of students who had more favorable attitudes toward older persons. Hence, attempts to generate physicians with good attitudes must rely on curricular efforts during medical school and residency training.

Physical therapy to improve functioning of older people in residential care facilities

BACKGROUND AND PURPOSE

The purpose of this study was to determine the effectiveness of an individualized physical therapy mobility training program on the gait, balance, and functional performance of elderly individuals living in residential care facilities.

SUBJECTS

Twenty-seven elderly individuals with impaired balance and difficulty performing at least one functional activity participated in the study. The subjects ranged in age from 71 to 97 years (mean = 87.1, SD = 6.7).

METHODS

Balance and gait speed were assessed at baseline and following physical therapy that consisted of exercises to improve specific functional limitations. Outcomes were reassessed 1 month following completion of the physical therapy.

RESULTS

Gait and balance outcomes were analyzed using a one-way repeated-measures analysis of variance. Improvement was obtained in balance, which was maintained at 1 month follow-up. Gait speed did not improve to a level of statistical significance.

CONCLUSION AND DISCUSSION

After physical therapy, subjects improved in balance and functional performance. An improvement in gait speed may require a longer duration of treatment.