Showing papers in "Journal of the American Geriatrics Society in 2007"

Geriatric Syndromes: Clinical, Research, and Policy Implications of a Core Geriatric Concept

Abstract: Geriatricians have embraced the term "geriatric syndrome," using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors-older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility-were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.

Geriatric syndromes : Clinical, research, and policy implications of a core geriatric concept. Commentary

Abstract: Geriatricians have embraced the term "geriatric syndrome," using it extensively to highlight the unique features of common health conditions in older people. Geriatric syndromes, such as delirium, falls, incontinence, and frailty, are highly prevalent, multifactorial, and associated with substantial morbidity and poor outcomes. Nevertheless, this central geriatric concept has remained poorly defined. This article reviews criteria for defining geriatric syndromes and proposes a balanced approach of developing preliminary criteria based on peer-reviewed evidence. Based on a review of the literature, four shared risk factors-older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility-were identified across five common geriatric syndromes (pressure ulcers, incontinence, falls, functional decline, and delirium). Understanding basic mechanisms involved in geriatric syndromes will be critical to advancing research and developing targeted therapeutic options, although given the complexity of these multifactorial conditions, attempts to define relevant mechanisms will need to incorporate more-complex models, including a focus on synergistic interactions between different risk factors. Finally, major barriers have been identified in translating research advances, such as preventive strategies of proven effectiveness for delirium and falls, into clinical practice and policy initiatives. National strategic initiatives are required to overcome barriers and to achieve clinical, research, and policy advances that will improve quality of life for older persons.

Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care.

Abstract: OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home. DESIGN: A randomized, controlled trial. SETTING: Two health maintenance organizations in two states. PARTICIPANTS: Homebound, terminally ill patients (N 5298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months. INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services. MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care. RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (Po.05) and were more likely to die at home than those receiving usual care (Po.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P 5.01) or be admitted to the hospital than those receiving usual care (Po.001), resulting in significantly lower costs of care for intervention patients (P 5.03). CONCLUSION: In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care. J Am Geriatr Soc 55: 993–1000, 2007.

Alternative definitions of sarcopenia, lower extremity performance, and functional impairment with aging in older men and women

Abstract: OBJECTIVES: To compare two methods for classifying an individual as sarcopenic for predicting decline in physical function in the Health, Aging and Body Composition Study. DESIGN: Observational cohort study with 5 years of follow-up. SETTING: Communities in Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Men and women aged 70 to 79 (N=2,976, 52% women, 41% black). MEASUREMENTS: Appendicular lean mass (aLM) was measured using dual energy x-ray absorptiometry, and participants were classified as sarcopenic first using aLM divided by height squared and then using aLM adjusted for height and body fat mass (residuals). Incidence of persistent lower extremity limitation (PLL) was measured according to self-report, and change in objective lower extremity performance (LEP) measures were observed using the Short Physical Performance Battery. RESULTS: There was a greater risk of incident PLL in women who were sarcopenic using the residuals sarcopenia method than in women who were not sarcopenic (hazard ratio (HR)=1.34, 95% confidence interval (CI)=1.11–1.61) but not in men. Those defined as sarcopenic using the aLM/ht2 method had lower incident PLL than nonsarcopenic men (HR=0.76, 95% CI=0.60–0.96) and women (HR=0.75, 95% CI=0.60–0.93), but these were no longer significant with adjustment for body fat mass. Using the residuals method, there were significantly poorer LEP scores in sarcopenic men and women at baseline and Year 6 and greater 5-year decline, whereas sarcopenic men defined using the aLM/ht2 method had lower 5-year decline. Additional adjustment for fat mass attenuated this protective effect. CONCLUSION: These findings suggest that sarcopenia defined using the residuals method, a method that considers height and fat mass together, is better for predicting disability in an individual than the aLM/ht2 method, because it considers fat as part of the definition.

Exercise Program for Nursing Home Residents with Alzheimer's Disease: A 1-Year Randomized, Controlled Trial

Abstract: OBJECTIVES: To investigate the effectiveness of an exercise program in improving ability to perform activities of daily living (ADLs), physical performance, and nutritional status and decreasing behavioral disturbance and depression in patients with Alzheimer's disease (AD). DESIGN: Randomized, controlled trial. SETTING: Five nursing homes. PARTICIPANTS: One hundred thirty-four ambulatory patients with mild to severe AD. INTERVENTION: Collective exercise program (1 hour, twice weekly of walk, strength, balance, and flexibility training) or routine medical care for 12 months. MEASUREMENTS: ADLs were assessed using the Katz Index of ADLs. Physical performance was evaluated using 6-meter walking speed, the get-up-and-go test, and the one-leg-balance test. Behavioral disturbance, depression, and nutritional status were evaluated using the Neuropsychiatric Inventory, the Montgomery and Asberg Depression Rating Scale, and the Mini-Nutritional Assessment. For each outcome measure, the mean change from baseline to 12 months was calculated using intention-to-treat analysis. RESULTS: ADL mean change from baseline score for exercise program patients showed a slower decline than in patients receiving routine medical care (12-month mean treatment differences: ADL=0.39, P=.02). A significant difference between the groups in favor of the exercise program was observed for 6-meter walking speed at 12 months. No effect was observed for behavioral disturbance, depression, or nutritional assessment scores. In the intervention group, adherence to the program sessions in exploratory analysis predicted change in ability to perform ADLs. No adverse effects of exercise occurred. CONCLUSION: A simple exercise program, 1 hour twice a week, led to significantly slower decline in ADL score in patients with AD living in a nursing home than routine medical care.

Improvement in usual gait speed predicts better survival in older adults.

Abstract: OBJECTIVES: To estimate the relationship between 1-year improvement in measures of health and physical function and 8-year survival. DESIGN: Prospective cohort study. SETTING: Medicare health maintenance organization and Veterans Affairs primary care programs. PARTICIPANTS: Persons aged 65 and older (N=439). MEASUREMENTS: Six measures of health and function assessed at baseline and quarterly over 1 year. Participants were classified as improved at 1 year, transiently improved, or never improved for each measure using a priori definitions of meaningful change: gait speed (usual walking pace over 4 m), 0.1 m/s; Short Physical Performance Battery, 1 point; Medical Outcomes Study 36-item Short Form Health Survey physical function, 10 points; EuroQol, 0.1 point; National Health Interview activity of daily living scale, 2 points; and global health change, two levels or reaching the ceiling. Mortality was ascertained from the National Death Index. Covariates included demographics, comorbidity, cognitive function, and hospitalization. RESULTS: Of the six measures, only improved gait speed was associated with survival. Mortality after 8 years was 31.6%, 41.2%, and 49.3% for those with improved, transiently improved, and never improved gait speed, respectively. The survival benefit for improvement at 1 year persisted after adjustment for covariates (hazard ratio=0.42, 95% confidence interval=0.29–0.61, P<.001) and was consistent across subgroups based on age, sex, ethnicity, initial gait speed, healthcare system, and hospitalization. CONCLUSION: Improvement in usual gait speed predicts a substantial reduction in mortality. Because gait speed is easily measured, clinically interpretable, and potentially modifiable, it may be a useful “vital sign” for older adults. Further research is needed to determine whether interventions to improve gait speed affect survival.

Association between advance directives and quality of end-of-life care: a national study.

Abstract: OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act. DESIGN: Mortality follow-back survey. SETTING: People who died in a nursing home, hospital, or at home. PARTICIPANTS: Bereaved family member or other knowledgeable informant. MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support. RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1–1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0–1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support. CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.

Frailty in Older Men: Prevalence, Progression, and Relationship with Mortality

Abstract: OBJECTIVES: To describe the association between frailty and health status, the progression of frailty, and the relationship between frailty and mortality in older men. DESIGN: Cross-sectional and prospective cohort study. SETTING: Six U.S. clinical centers. PARTICIPANTS: Five thousand nine hundred ninety-three community-dwelling men aged 65 and older. MEASUREMENTS: Frailty was defined as three or more of the following: sarcopenia (low appendicular skeletal mass adjusted for height and body fat), weakness (grip strength), self-reported exhaustion, low activity level, and slow walking speed. Prefrail men met one or two criteria; robust men had none. Follow-up averaged 4.7 years. RESULTS: At baseline, 240 subjects (4.0%) were frail, 2,395 (40.0%) were prefrail, and 3,358 were robust (56.0%). Frail men were less healthy in most measures of self-reported health than prefrail or robust men. Frailty was somewhat more common in African Americans (6.6%) and Asians (5.8%) than Caucasians (3.8%). At the second visit, men who were frail at baseline tended to remain frail (24.2%) or die (37.1%) or were unable to complete the follow-up visit (26.2%); robust men tended to remain robust (54.4%). Frail men were approximately twice as likely to die as robust men (multivariate hazard ratio (MHR)=2.05, 95% confidence interval (CI)=1.55–2.72). Mortality risk for frail men was greater in all weight categories than for nonfrail men but was highest for normal-weight frail men (MHR=2.39, 95% CI=1.51–3.79, P for interaction=.01). The relationship between frailty and mortality was somewhat stronger in younger men than older men (P for interaction=.01). CONCLUSION: Frailty in older men is associated with poorer health and a greater risk of mortality.

A Higher Dose of Vitamin D Reduces the Risk of Falls in Nursing Home Residents: A Randomized, Multiple‐Dose Study

Abstract: OBJECTIVES: To determine the effect of four vitamin D supplement doses on falls risk in elderly nursing home residents. DESIGN: Secondary data analysis of a previously conducted randomized clinical trial. SETTING: Seven hundred twenty-five-bed long-term care facility. PARTICIPANTS: One hundred twenty-four nursing home residents (average age 89). INTERVENTION: Participants were randomly assigned to receive one of four vitamin D supplement doses (200IU, 400IU, 600IU, or 800IU) or placebo daily for 5 months. MEASUREMENTS: Number of fallersand number offalls assessed using facility incident tracking database. RESULTS: Over the 5-month study period, the proportion of participants with falls was 44% in the placebo group (11/ 25), 58% (15/26) in the 200IU group, 60% (15/25) in the 400IU group, 60% (15/25) in the 600IU group, and 20% (5/23) in the 800IU group. Participants in the 800IU group had a 72% lower adjusted-incidence rate ratio of falls than those taking placebo over the 5 months (rate ratio 50.28; 95% confidence interval 50.11‐0.75). No significant differences were observed for the adjusted fall rates compared to placebo in any of the other supplement groups. CONCLUSION: Nursing home residents in the highest vitamin D group (800IU) had a lower number of fallers and a lower incidence rate of falls over 5 months than those taking lower doses. Adequate vitamin D supplementation in elderly nursing home residents could reduce the number of falls experienced by this high falls risk group. JA m Geriatr Soc 55:234–239, 2007.

Inflammation and Frailty in Older Women

Abstract: OBJECTIVES: To evaluate relationships between white blood cell (WBC) count and interleukin-6 (IL-6) and prevalent frailty. DESIGN: Cross-sectional study. SETTING: Two population-based studies, the Women's Health and Aging Studies (WHAS) I and II, Baltimore, Maryland. PARTICIPANTS: Five hundred fifty-eight women aged 65 to 101 from WHAS I and 548 women aged 70 to 79 from the merged WHAS I and II cohorts. MEASUREMENTS: Frailty was determined using validated screening criteria. WBC counts and IL-6 levels were measured using standard laboratory methods. Odds ratios (ORs) for frailty were evaluated across tertiles of baseline WBC counts and IL-6 levels, adjusting for age, race, education, body mass index, and smoking status. RESULTS: In WHAS I, those in the top tertile of WBC count and IL-6 had ORs of 4.25 (95% confidence interval (CI)=1.89–9.58) and 3.98 (95% CI=1.76–9.00), respectively, for frailty (both P<.001). In the combined models, participants in the top tertile of WBC count had an OR of 3.15 (95% CI=1.34–7.41), adjusting for IL-6 (P<.01), and those in the top tertile of IL-6 had an OR of 2.81 (95% CI=1.19–6.64), adjusting for WBC count (P<.05). Furthermore, participants in the top tertiles of WBC count and IL-6 had an OR of 9.85 (95% CI=3.04–31.99), and those in the middle/top tertiles had an OR of 5.40 (95% CI=1.83–15.92) (P<.001, trend test) for frailty. These results were validated in the merged WHAS I and II. CONCLUSION: Higher WBC counts and IL-6 levels were independently associated with prevalent frailty in community-dwelling older women.

Trends in Hypertension Prevalence, Awareness, Treatment, and Control in Older U.S. Adults: Data from the National Health and Nutrition Examination Survey 1988 to 2004

Abstract: OBJECTIVES: To describe hypertension trends in U.S. adults aged 60 and older using National Health and Nutrition Examination Survey (NHANES) data. SETTING: NHANES III (1988-1994) and NHANES 1999 to 2004. DESIGN: Cross-sectional nationally representative health examination survey. PARTICIPANTS: Participants in NHANES III (n = 5,093) and NHANES 1999 to 2004 (n = 4,710). MEASUREMENTS: Blood pressure (BP). RESULTS: In 1999 to 2004, 67% of U.S. adults aged 60 and older years were hypertensive, an increase of 10% from NHANES III. Between 1988 to 1994 and 1999 to 2004, hypertension control increased for men from 39% to 51% (P .05). Non-Hispanic black men and women had higher prevalences of hypertension than non-Hispanic whites (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.90-3.40 and OR = 2.07, 95% CI = 1.31-3.26, respectively), but men were less likely to have controlled BP (OR = 0.60, 95% CI = 0.41-0.86). Mexican-American men and women were less likely than non-Hispanic whites to have controlled BP (OR = 0.55, 95% CI = 0.33-0.91 and OR = 0.63, 95% CI= 0.40-0.98, respectively). Women and men aged 70 and older were significantly less likely to control their hypertension than those aged 60 to 69. In addition, women aged 70 and older were significantly less aware and treated. Having BP measured within 6 months was significantly associated with greater awareness, greater treatment in men and women, and greater control in women. A history of diabetes mellitus or chronic kidney disease (CKD) was significantly associated with less hypertension control. CONCLUSION: There was a significant increase in hypertension prevalence from 1988 to 2004. Hypertension control continues to be problematic for women, persons aged 70 and older, non-Hispanic blacks and Mexican Americans, and individuals with diabetes mellitus and CKD.

Interventions to Reduce Fear of Falling in Community-Living Older People: A Systematic Review

Abstract: The objective was to assess which interventions effectively reduce fear of falling in community-living older people. An extensive search for relevant literature comprised a database search of PubMed, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials; expert consultation; and manually searching reference lists from potentially relevant papers. Randomized, controlled trials that assessed fear of falling in community-living older people were included. Two independent reviewers extracted data from full papers on study characteristics, methodological quality, outcomes, and process characteristics of the intervention. The search identified 599 abstracts, and 19 papers met the inclusion criteria. Seven of those papers were identified using expert consultation. Fifty-five percent of all validity items and 39% of process characteristic items were fulfilled across the 19 trials. Twelve of the 19 papers were of higher methodological quality. In 11 of these trials, fear of falling was lower in the intervention group than in the control group. Interventions that showed effectiveness were fall-related multifactorial programs (n=5), tai chi interventions (n=3), exercise interventions (n=2), and a hip protector intervention (n=1). Three of these interventions explicitly aimed to reduce fear of falling. Several interventions, including interventions not explicitly aimed at fear of falling, resulted in a reduction of fear of falling in community-living older people. Limited but fairly consistent findings in trials of higher methodological quality showed that home-based exercise and fall-related multifactorial programs and community-based tai chi delivered in group format have been effective in reducing fear of falling in community-living older people.

Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program.

Abstract: OBJECTIVES: To determine the effects of a small-house nursing home model, THE GREEN HOUSE® (GH), on residents' reported outcomes and quality of care. DESIGN: Two-year longitudinal quasi-experimental study comparing GH residents with residents at two comparison sites using data collected at baseline and three follow-up intervals. SETTING: Four 10-person GHs, the sponsoring nursing home for those GHs, and a traditional nursing home with the same owner. PARTICIPANTS: All residents in the GHs (40 at any time) at baseline and three 6-month follow-up intervals, and 40 randomly selected residents in each of the two comparison groups. INTERVENTION: The GH alters the physical scale environment (small-scale, private rooms and bathrooms, residential kitchen, dining room, and hearth), the staffing model for professional and certified nursing assistants, and the philosophy of care. MEASUREMENTS: Scales for 11 domains of resident quality of life, emotional well-being, satisfaction, self-reported health, and functional status were derived from interviews at four points in time. Quality of care was measured using indicators derived from Minimum Data Set assessments. RESULTS: Controlling for baseline characteristics (age, sex, activities of daily living, date of admission, and proxy interview status), statistically significant differences in self-reported dimensions of quality of life favored the GHs over one or both comparison groups. The quality of care in the GHs at least equaled, and for change in functional status exceeded, the comparison nursing homes. CONCLUSION: The GH is a promising model to improve quality of life for nursing home residents, with implications for staff development and medical director roles.

Effect of a Collaborative Approach on the Quality of Prescribing for Geriatric Inpatients: A Randomized, Controlled Trial

Abstract: OBJECTIVES: To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing. DESIGN: Randomized, controlled trial, with the patient as unit of randomization. SETTING: Acute GEM unit. PARTICIPANTS: Two hundred three patients aged 70 and older. INTERVENTION: Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients. MEASUREMENTS: Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge. RESULTS: Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR) 59.1, 95% confidence interval (CI) 54.2‐21.6 and OR 56.1, 95% CI 52.2‐17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria. CONCLUSION: Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes. JA m Geriatr Soc 55:658–665, 2007.

Validity of the Patient Health Questionnaire 2 (PHQ‐2) in Identifying Major Depression in Older People

Abstract: OBJECTIVES: To determine the performance of the Patient Health Questionnaire 2 (PHQ-2) against the criterion standard for diagnosing major depression, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and to examine its performance across age, sex, and racial/ethnic groups. DESIGN: Cross-sectional observational study. SETTING: The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (2001/02), a nationally representative survey of the noninstitutionalized U.S. household population. PARTICIPANTS: The 8,205 adults aged 65 and older who participated in NESARC. MEASUREMENTS: The PHQ-2's criterion validity (sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) against the DSM-IV) and construct validity (Spearman correlations between the PHQ-2 and the six scales of the Medical Outcomes Study 12-item Short Form Questionnaire (SF-12)) were calculated. RESULTS: The PHQ-2's criterion validity for major depression was good (sensitivity=100%, specificity=77%, AUC=0.88). Its sensitivity was 100% for each subgroup. Specificity increased with age, was higher for men than for women, and differed across racial and ethnic groups. For the total sample and each sex, all six SF-12 scales were significantly lower in people who tested positive using the PHQ-2. For each age and racial or ethnic group, most of the six scales differed significantly between those who tested positive and tested negative. CONCLUSION: The PHQ-2 is a valid screening tool for major depression in older people but should be followed by a more-comprehensive diagnostic process. Although its specificity differs by age, sex, and racial and ethnic groups, these differences appear to be of little clinical significance.

Systemic markers of inflammation and cognitive decline in old age

Abstract: OBJECTIVES: To investigate whether higher circulating levels of C-reactive protein (CRP), interleukin-6 (IL-6), and a1-antichymotrypsin (ACT) are associated with worse cognitive function and decline in old age. DESIGN: Two independent population-based cohort studies. SETTING: The Rotterdam Study (mean follow-up 4.6 years) and the Leiden 85-plus Study (maximal follow-up 5 years). PARTICIPANTS: Three thousand eight hundred seventyfour individuals, mean age 72, from the Rotterdam Study, and 491 individuals, all aged 85, from the Leiden 85-plus Study. MEASUREMENTS: Both studies assessed global cognition, executive function, and memory. Linear regression analyses were used in the current study to investigate the associations between inflammatory markers and cognitive function and decline. RESULTS: In the Rotterdam Study, higher levels of CRP and IL-6 were cross-sectionally associated with worse global cognition and executive function (Po.05). ACT was not associated with cognitive function. In the Leiden 85-plus Study, estimates were similar for CRP, although not statistically significant. Higher IL-6 levels were related to a steeper annual decline in memory function in the longitudinal analysis in the Leiden 85-plus Study (Po.05). The effect of higher IL-6 levels on global and memory function decline was stronger in apolipoprotein E (APOE) e4 carriers (P-interaction 5.01) than in those who were not (P-interaction 5.05). In the Rotterdam Study, higher IL-6 levels were related to a steeper annual decline in global cognition in APOE e4 carriers only. CONCLUSION: Systemic markers of inflammation are only moderately associated with cognitive function and decline and tend to be stronger in carriers of the APOE e4 allele. Systemic markers of inflammation are not suitable for risk stratification. J Am Geriatr Soc 55:708‐716, 2007.

The geriatric emergency department.

Abstract: With the aging of the population and the demographic shift of older adults in the healthcare system, the emergency department (ED) will be increasingly challenged with complexities of providing care to geriatric patients. The special care needs of older adults unfortunately may not be aligned with the priorities for how ED physical design and care is rendered. Rapid triage and diagnosis may be impossible in the older patient with multiple comorbidities, polypharmacy, and functional and cognitive impairments who often presents with subtle clinical signs and symptoms of acute illness. The use of Geriatric Emergency Department Interventions, structural and process of care modifications addressing the special care needs of older patients, may help to address these challenges.

A randomized, controlled trial of tai chi for the prevention of falls: The central sydney tai chi trial

Abstract: OBJECTIVES: To determine the effectiveness of a 16-week community-based tai chi program in reducing falls and improving balance in people aged 60 and older. DESIGN: Randomized, controlled trial with waiting list control group. SETTING: Community in Sydney, Australia. PARTICIPANTS: Seven hundred two relatively healthy community-dwelling people aged 60 and older (mean age 69). INTERVENTION: Sixteen-week program of communitybased tai chi classes of 1 hour duration per week. MEASUREMENTS: Falls during 16 and 24 weeks of follow-up were assessed using a calendar method. Balance was measured at baseline and 16-week follow-up using six balance tests. RESULTS: Falls were less frequent in the tai chi group than in the control group. Using Cox regression and time to first fall, the hazard ratio after 16 weeks was 0.72 (95% confidence interval (CI) 50.51‐1.01, P 5.06), and after 24 weeks it was 0.67 (95% CI 50.49‐0.93, P 5.02). There was no difference in the percentage of participants who had one or more falls. There were statistically significant differences in changes in balance favoring the tai chi group on five of six balance tests. CONCLUSION: Participation in once per week tai chi classes for 16 weeks can prevent falls in relatively healthy community-dwelling older people. J Am Geriatr Soc 55:1185–1191, 2007.

Completing an Advance Directive in the Primary Care Setting: What Do We Need for Success?

Abstract: OBJECTIVES: To systematically review studies designed to increase advance directive completion in the primary care setting and employ meta-analytic techniques to quantify their effects. DESIGN: Extensive bibliographic searches of English-language literature published from January 1991 through July 2005 were conducted. Investigators abstracted prespecified information (e.g., design, study duration, types of interventions employed) and advance directive completion rates for intervention and control arms in each investigation and calculated absolute rate differences (i.e., difference in completion rates between the two groups) for each study. Individual study and pooled-effect sizes were also calculated, along with 95% confidence intervals (CIs). SETTING: Literature review. RESULTS: Eighteen studies were retained in the final sample. Most studies employed multimodal interventions. The most common approach consisted of educational materials directed at patients (through mailing or at visit) coupled with a patient–healthcare provider interaction in a group or individual setting (n=7). Absolute differences in completion rates varied from a high of 44% (favors intervention) to a low of –2% (favors control). Effect sizes could be calculated for 15 of the 18 studies. The pooled effect size was 0.50 (95% CI=0.17–0.83), indicating a moderate overall effect in favor of the intervention. CONCLUSION: The majority of studies demonstrated statistically significant effects associated with the advance directive intervention. The most successful interventions incorporated direct patient–healthcare professional interactions over multiple visits. Passive education of patients using written materials (without direct counseling) was a relatively ineffective method for increasing advance directive completion rates in the primary care setting.

Effects of community occupational therapy on quality of life, mood and health status of dementia patients and their caregivers: a randomized controlled trial.

Abstract: BACKGROUND Cure of dementia is not possible, but quality of life of patients and caregivers can be improved. Our aim is to investigate effects of community occupational therapy on dementia patients' and caregivers' quality of life, mood, and health status and caregivers' sense of control over life. METHODS Community-dwelling patients aged 65 years or older, with mild-to-moderate dementia, and their informal caregivers (n = 135 couples of patients with their caregivers) were randomly assigned to 10 sessions of occupational therapy over 5 weeks or no intervention. Cognitive and behavioral interventions were used to train patients in the use of aids to compensate for cognitive decline and caregivers in coping behaviors and supervision. Outcomes, measured at baseline, 6 weeks, and 12 weeks, were patients' and caregivers' quality of life (Dementia Quality of Life Instrument, Dqol), patients' mood (Cornell Scale for Depression, CSD), caregivers' mood (Center for Epidemiologic Studies Depression Scale, CES-D), patients' and caregivers' health status (General Health Questionnaire, GHQ-12), and caregivers' sense of control over life (Mastery Scale). RESULTS Improvement on patients' Dqol overall (0.8; 95% confidence interval [CI], 0.6-.1, effect size 1.3) and caregivers' Dqol overall (0.7; 95% CI, 0.5-.9, effect size 1.2) was significantly better in the intervention group as compared to controls. Scores on other outcome measures also improved significantly. This improvement was still significant at 12 weeks. CONCLUSION Community occupational therapy should be advocated both for dementia patients and their caregivers, because it improves their mood, quality of life, and health status and caregivers' sense of control over life. Effects were still present at follow-up.

Japan's universal long-term care system reform of 2005: containing costs and realizing a vision.

Abstract: Japan implemented a mandatory social long-term care insurance (LTCI) system in 2000, making long-term care services a universal entitlement for every senior. Although this system has grown rapidly, reflecting its popularity among seniors and their families, it faces several challenges, including skyrocketing costs. This article describes the recent reform initiated by the Japanese government to simultaneously contain costs and realize a long-term vision of creating a community-based, prevention-oriented long-term care system. The reform involves introduction of two major elements: "hotel" and meal charges for nursing home residents and new preventive benefits. They were intended to reduce economic incentives for institutionalization, dampen provider-induced demand, and prevent seniors from being dependent by intervening while their need levels are still low. The ongoing LTCI reform should be critically evaluated against the government's policy intentions as well as its effect on seniors, their families, and society. The story of this reform is instructive for other countries striving to develop coherent, politically acceptable long-term care policies.

Prevalence of Peripheral Arterial Disease and Risk Factors in Persons Aged 60 and Older: Data from the National Health and Nutrition Examination Survey 1999-2004

Abstract: OBJECTIVES: Peripheral arterial disease (PAD) is associated with significant cardiovascular morbidity and mortality. The study objectives were to examine the prevalence of PAD and associated risk factors. DESIGN: A cross-sectional nationally representative health examination survey. SETTING: The National Health and Nutrition Examination Survey 1999–2004. PARTICIPANTS: Data from 3,947 men and women aged 60 and older who received a lower extremity examination. MEASUREMENTS: The main outcome was PAD, defined as an ankle-brachial blood pressure index of less than 0.9 in either leg. RESULTS: In older U.S. adults, PAD prevalence was 12.2% (95% confidence interval (CI) = 10.9–13.5%). PAD prevalence increased with age. PAD prevalence was 7.0% (95% CI = 5.6–8.4%) for those aged 60 to 69, 12.5% (95% CI = 10.4–14.6%), and 23.2% (95% CI = 19.8–26.7%) for those aged 70 to 79 and 80 and older. Age-adjusted estimates show that non-Hispanic black men and women and Mexican-American women had a higher prevalence of PAD than non-Hispanic white men and women (19.2%, 95% CI = 13.7–24.6%; 19.3%, 95% CI = 13.3–25.2%; and 15.6%, 95% CI = 12.7–18.6%, respectively). The results of the fully adjusted model show that current smoking (OR = 5.48, 95% CI = 3.60–8.35), previous smoking (OR = 1.94, 95% CI = 1.39–2.69), diabetes mellitus (OR = 1.81, 95% CI = 1.12–2.91), low kidney function (OR = 2.69, 95% CI = 1.58–4.56), mildly decreased kidney function (OR = 1.71, 95% CI = 1.22–2.38), high-sensitivity C-reactive protein greater than 3.0 mg/L (OR = 2.69, 95% CI = 1.24–5.85), treated but not controlled hypertension (OR = 1.95, 95% CI = 1.40–2.72), and untreated hypertension (OR = 1.68, 95% CI = 1.13–2.50) were all significantly associated with prevalent PAD. CONCLUSION: PAD prevalence increases with age and is associated with treatable risk factors for cardiovascular disease.

Protective Association Between Neighborhood Walkability and Depression in Older Men

Abstract: OBJECTIVES: To evaluate the association between neighborhood walkability and depression in older adults. DESIGN: Cross-sectional analysis using data from Adult Changes in Thought (ACT), a prospective, longitudinal cohort study. SETTING: King County, Washington. PARTICIPANTS: Seven hundred forty randomly selected men and women aged 65 and older, cognitively intact, living in the same home for at least 2 years. MEASUREMENTS: Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale. The Walkable and Bikable Communities Project provided objective data predicting the probability of walking at least 150 minutes per week in a particular neighborhood. ACT data were linked at the individual level via a geographic information system to this walkability score using buffer radii of 100, 500, and 1,000 meters around the subject's home. Multiple regression analysis tests were conducted for associations between the buffer-specific neighborhood walkability score and depressive symptoms. RESULTS: There was a significant association between neighborhood walkability and depressive symptoms in men when adjusted for individual-level factors of income, physical activity, education, smoking status, living alone, age, ethnicity, and chronic disease. The odds ratio for the interquartile range (25th to 75th percentile) of walkability score was 0.31 to 0.33 for the buffer radii (P=.02), indicating a protective association with neighborhood walkability. This association was not significant in women. CONCLUSION: This study demonstrates a significant association between neighborhood walkability and depressive symptoms in older men. Further research on the effects of neighborhood walkability may inform community-level mental health treatment and focus depression screening in less-walkable areas.

Knee extension strength cutpoints for maintaining mobility.

Abstract: OBJECTIVES: To identify levels of knee extensor strength that are associated with high and low risk of incident severe mobility limitation (SML) in initially well-functioning older adults. DESIGN: Prospective cohort study. SETTING: University clinic center. PARTICIPANTS: One thousand three hundred fifty-five men and 1,429 women (aged 73.6±2.85) who reported no mobility limitation. MEASUREMENTS: Unilateral knee extensor isokinetic strength of participants was obtained. Participants were followed over a median of 5.90 years for the onset of SML, defined as two consecutive reports of a lot of difficulty or inability to walk one-quarter of a mile or climb 10 steps. Deciles of knee extension strength relative to body weight were evaluated to identify cutpoints most predictive of incident SML. Cutpoints were then compared with prevalence of having slow gait speed (<1.22 m/s) and mortality. RESULTS: Two sex-specific knee extension strength cutpoints were found. High and low risk of SML corresponded to less than 1.13 newton-meters (Nm)/kg (1st decile) and more than 1.71 Nm/kg (6th decile) in men and less than 1.01 Nm/kg (3rd decile) and more than 1.34 Nm/kg (7th decile) in women, respectively. Moderate risk was defined as being between the low- and high-risk cutpoints. Individuals with knee extension strength in the high- and moderate-risk categories were more likely to have a gait speed less than 1.22 m/s (hazard ratio (HR)=7.00, 95% confidence interval (CI)=5.47-8.96 and HR=2.14 7.00, 95% CI=1.73-2.64, respectively) and had a higher risk of death (HR=1.77, 95% CI=1.41-2.23 and HR=1.51, 95% CI=1.24-1.84, respectively) than individuals in the low-risk category. Adjustment for demographic factors, health behaviors, and medical conditions did not alter these associations. CONCLUSION: Knee extensor strength cutpoints provide objective markers to identify initially well-functioning older adults at high and low risk of future mobility limitation. © 2007, The American Geriatrics Society.

Fear of falling in older women: a longitudinal study of incidence, persistence, and predictors

Abstract: OBJECTIVES: To determine longitudinal predictors of incident and persistent fear of falling (FOF) in older women. DESIGN: Longitudinal study. SETTING: Clinical research center based at a university hospital. PARTICIPANTS: One thousand two hundred eighty-two community-dwelling women aged 70 to 85. MEASUREMENTS: FOF at baseline and after 3 years of follow-up; a range of baseline demographic and clinical variables, including mobility, balance, and depression. RESULTS: FOF was present in 418 subjects (33%) at baseline, developed in 30% of women who had been free of the symptom at baseline, and was reported by a total of 46% of the sample after 3 years of follow-up. In cross-sectional multivariable analysis, baseline FOF was independently associated with a range of variables, including living alone, obesity, cognitive impairment, depression, and impairments in balance and mobility. Baseline predictors of FOF that persisted after 3 years were similar, whereas obesity and slower timed up and go test scores predicted new-onset FOF. CONCLUSION: FOF in older women is a common and persistent complaint that is caused mainly by impairments of balance and mobility. A range of social, psychological, and physical risk factors for disability are associated with persistence of FOF. These results imply that early intervention may be important for the prevention of persistent FOF.

Metabolic Syndrome and Cognitive Decline in Elderly Latinos: Findings from the Sacramento Area Latino Study of Aging Study

Abstract: OBJECTIVES: To investigate the effect of metabolic syndrome on cognitive function in an elderly Latino population and to determine whether inflammation modifies this association. DESIGN: A longitudinal cohort study. SETTING: Sacramento area and the surrounding California counties from 1998 to 1999. PARTICIPANTS: One thousand six hundred twenty-four Latinos aged 60 and older who participated in the Sacramento Area Latino Study of Aging. MEASUREMENTS: Baseline metabolic syndrome was calculated using the Third Adult Treatment Panel of the National Cholesterol Education Program. Cognitive function was measured using the Modified Mini-Mental State Examination (3MS) and the Delayed Word-List Recall (DelRec), a verbal memory test. The effect of metabolic syndrome on cognitive change scores was examined using random effects models; in addition, the effect of the individual components of the syndrome on cognitive change was examined. RESULTS: Of the 1,624 participants, 718 (44%) had metabolic syndrome at baseline. Those with metabolic syndrome had worse 3-year change scores on 3MS (P 5.04) and DelRec (P 5.03). Multivariate adjustment attenuated the results for DelRec but not for 3MS. This association was especially pronounced in participants with a high serum level of inflammation, resulting in an average 3MS score 0.64 points lower per year (P 5.03) for those with metabolic syndrome. Individual components of metabolic syndrome were not associated with cognitive decline except for elevated glucose on the DelRec (P 5.02) and high blood pressure on 3MS (P 5.05). CONCLUSION: Metabolic syndrome and inflammation may both contribute to cognitive decline in older people of diverse backgrounds. The results also suggest that, in elderly Latinos, the composite measure of metabolic syndrome is a greater risk for cognitive decline than its individual components. J Am Geriatr Soc 55:758–762, 2007.

Prescribing in Palliative Care as Death Approaches

Abstract: OBJECTIVES: To determine how prescribing for comorbid illnesses and symptom control changes during the palliative phase of a terminal illness. DESIGN: This prospective cohort study explores the relative contribution to prescribing of symptom-specific medications (SSMs) and long-term medications for comorbid medical conditions. SETTING: Regional consultative palliative care program, Adelaide, South Australia. PARTICIPANTS: Two hundred sixty consecutive patients, 96% of whom had cancer, who enrolled and subsequently died in a larger randomized trial exploring palliative service delivery. MEASUREMENTS: Medication and performance data were collected monthly from referral until death (mean 107 days, median 93 days, standard deviation (SD) 103 days, range 11–752 days). Prespecified subgroup analyses of age, performance status, and the baseline use of medications for comorbid medical conditions were performed. RESULTS: At baseline, the mean total number of medications±SD was 4.9±2.8 (range 0–16), SSMs was 2.3±1.5 (range 0–7), and medications for comorbid medical conditions was 2.6±2.4 (range 0–13). As death approached, the total number of medications increased because of SSM prescribing (2.5 more medications, 95% confidence interval (CI)=2.2–2.9; P<.001) with a decrease in medications for comorbid medical conditions (1.1 fewer medications, 95% CI=0.8–1.3; P<.001). There was an increase in the number of medications meeting Beers' criteria for high-risk inappropriate medication use for SSMs (29% to 48%). More SSMs were prescribed in people with better performance status, and older participants took more medications for comorbid medical conditions. CONCLUSION: Prescribing changes as life-limiting illnesses progress, with older people taking more medications. Medications for comorbid medical conditions should be reviewed in the context of their original therapeutic goals.

Sleep complaints in community-living older persons: a multifactorial geriatric syndrome.

Abstract: In older persons, sleep complaints in the form of insomnia and daytime drowsiness are highly prevalent and are associated with adverse outcomes. The underlying mechanisms are linked to age-related declines in physiology (normal aging) and age-related increases in disease prevalence (usual aging). This article describes how normal aging leads to less-restorative sleep, characterized by reductions in homeostatic and circadian sleep, and to phase advancement of the sleep-wake cycle, characterized by older persons being more alert in the early morning but drowsier in the early evening. It also describes how usual aging leads to sleep complaints through reductions in health status, loss of physical function, and primary sleep disorders. Psychosocial influences are likewise described, and their relevance to sleep complaints is discussed. These aging-related changes are subsequently incorporated into a conceptual model that describes sleep complaints as a consequence of multiple and interdependent predisposing, precipitating, and perpetuating factors, akin to a geriatric syndrome. The discussion concludes by applying the conceptual model to the sleep-related care of an older person with insomnia and daytime drowsiness and suggesting that the diagnostic assessment consider, in addition to primary sleep disorders, multiple domains, including medical, physical, cognitive, psychological, and social matters, with the intent of developing an overall therapeutic plan and establishing long-term follow-up.

Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set.

Abstract: Objectives: To update and increase the comprehensiveness of the Assessing Care of Vulnerable Elders (ACOVE) set of process-of-care quality indicators (QIs) for the medical care provided to vulnerable elders and to keep up with the constantly changing medical literature, the QIs were revised and expanded. Design: The ACOVE Clinical Committee expanded the number of measured conditions to 26 in the revised (ACOVE-3) set. For each condition, a content expert created potential QIs and, based on systematic reviews, developed a peer-reviewed monograph detailing each QI and its supporting evidence. Using these literature reviews, multidisciplinary panels of clinical experts participated in two rounds of anonymous ratings and a face-to-face group discussion to evaluate whether the QIs were valid measures of quality of care using a process that is an explicit combination of scientific evidence and professional consensus. The Clinical Committee evaluated the coherence of the complete set of QIs that the expert panels rated as valid. Results: ACOVE-3 contains 392 QIs covering 14 different types of care processes (e.g., taking a medical history, performing a physical examination) and all four domains of care: screening and prevention (31% of QIs), diagnosis (20%), treatment (35%), and follow-up and continuity (14%). All QIs also apply to community-dwelling patients aged 75 and older. Conclusion: ACOVE-3 contains a set of QIs to comprehensively measure the care provided to vulnerable older persons at the level of the health system, health plan, or medical group. These QIs can be applied to identify areas of care in need of improvement and can form the basis of interventions to improve care.

China: The Aging Giant

Abstract: This article examines the changing demographics of China, with particular attention paid to the effect of the one-child policy in relation to long-term care of older people. It also examines the current state of health care for older people. Long-term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries. Geriatric departments in university-based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower- and middle-class Chinese and have increased more quickly than has the standard of living in the past 20 years. Family and community support for older people is strong in China. Some older people have one-to-one care from a baomu (literally "protection" (bao) "mother" (mu)), a type of live-in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.