Rural-Urban Differences in Chronic Disease and Drug Utilization in Older Oregonians.

PURPOSE: To characterize disease burden and medication usage in rural and urban adults aged ≥85 years. METHODS: This is a secondary analysis of 5 years of longitudinal data starting in the year 2000 from 3 brain-aging studies. Cohorts consisted of community-dwelling adults: 1 rural cohort, the Klamath Exceptional Aging Project (KEAP), was compared to 2 urban cohorts, the Oregon Brain Aging Study (OBAS) and the Dementia Prevention study (DPS). In this analysis, 121 participants were included from OBAS/DPS and 175 participants were included from KEAP. Eligibility was determined based on age ≥85 years and having at least 2 follow-up visits after the year 2000. Disease burden was measured by the Modified Cumulative Illness Rating Scale (MCIRS), with higher values representing more disease. Medication usage was measured by the estimated mean number of medications used by each cohort. FINDINGS: Rural participants had significantly higher disease burden as measured by MCIRS, 23.0 (95% CI: 22.3-23.6), than urban participants, 21.0 (95% CI: 20.2-21.7), at baseline. The rate of disease accumulation was a 0.2 increase in MCIRS per year (95% CI: 0.05-0.34) in the rural population. Rural participants used a higher mean number of medications, 5.5 (95% CI: 4.8-6.1), than urban participants, 3.7 (95% CI: 3.1-4.2), at baseline (P < .0001). CONCLUSIONS: These data suggest that rural and urban Oregonians aged ≥85 years may differ by disease burden and medication usage. Future research should identify opportunities to improve health care for older adults.

A randomized trial of acupuncture for vasomotor symptoms in post-menopausal women.

OBJECTIVE: The goal of this study was to determine whether acupuncture would relieve the vasomotor symptoms of post-menopausal women. DESIGN: A randomized, single-blind trial. SETTING: A small city in a rural area of Eastern Oregon. INTERVENTIONS: Women were recruited into the study from the community by advertising or physician referral. All study subjects were in non-surgical menopause and medically stable. Study subjects were randomly assigned to receive 12 weeks of treatment with either Chinese Traditional Medicine (TCM) acupuncture (n=27) or shallow needle (sham) acupuncture (n=24). OUTCOME MEASURES: Study participants kept a diary recording their hot flashes each day. At baseline, study participants filled out Greene Climacteric Scales and the Beck Depression and Anxiety Inventories. These same outcomes were also measured at week 4 of treatment and at 1 week and 12 weeks after treatment. The number of hot flashes and the numeric scores on the Climacteric Scales and the Beck inventories were compared between the verum and shallow needling groups using two-way repeated measures. RESULTS: Both groups of women showed statistically significant improvement on all study parameters. However, there was no difference between the improvement in the shallow needle and verum acupuncture groups. Study subjects were not able to guess which group they had been assigned to. CONCLUSIONS: This study showed that both shallow needling and verum acupuncture were effective treatments of post-menopausal vasomotor symptoms. Study subjects were not able to distinguish shallow needling from real TCM acupuncture. Shallow needling may have therapeutic effects in itself reducing its utility as a "placebo" control for verum acupuncture. This result is consistent with other published studies.

Chronic opioid therapy and preventive services in rural primary care: an Oregon rural practice-based research network study.

PURPOSE: For clinicians, using opioid therapy for chronic noncancer pain (CNCP) often gives rise to a conflict between treating their patients' pain and fears of addiction, diversion of medication, or legal action. Consequent stresses on clinical encounters might adversely affect some elements of clinical care. We evaluated a possible association between chronic opioid therapy (COT) for CNCP and receipt of various preventive services. METHODS: We conducted a retrospective cohort study in 7 primary care clinics within the Oregon Rural Practice-based Research Network (ORPRN). Using medical records of 704 patients, aged 35 to 85 years, seen during a 3-year period, we compared the receipt of 4 preventive services between patients on COT for CNCP and patients not on chronic opioid therapy (non-COT). We used multivariate log-binomial regression analyses to estimate the relative risk of receipt of each preventive service. RESULTS: After adjustment for plausible confounders, we found that patients using COT had a statistically significantly lower relative risk (RR) of receipt of cervical cancer screening (RR = 0.60; 95% confidence interval [CI], 0.47-0.76) and colorectal cancer screening (RR = 0.42; 95% CI, 0.22-0.80) when compared with non-COT patients. The RR was reduced, without statistical significance, for lipid screening (RR = 0.77; 95% CI, 0.54-1.10), and not notably reduced for smoking cessation counseling (RR = 0.95; 95% CI, 0.78-1.15). CONCLUSIONS: Patients using COT for CNCP were less likely to receive some preventive services. Research is needed to better understand barriers to and improved methods for providing preventive services for these patients.

Technology use by rural and urban oldest old.

OBJECTIVES: Technologies designed to optimally maintain older people as they age in their desired places of residence are proliferating. An important step in designing and deploying such technologies is to determine the current use and familiarity with technology in general among older people. The goal of this study was to determine the extent that community-dwelling elderly at highest risk of losing independence, the oldest old, use common electronic devices found in residential urban or rural settings. METHODS: We surveyed 306 nondemented elderly age 85 or over; 144 were part of a rural aging study, the Klamath Exceptional Aging Project, and 181 were from an urban aging cohort in Portland. RESULTS: The most frequently used devices were televisions, microwave ovens, and answering machines. Persons with mild cognitive impairment were less likely to use all devices than those with no impairment. Higher socioeconomic status and education were associated with use of more complicated devices. Urban respondents were more likely than rural ones to use most devices. CONCLUSION: Technology use by very old community-dwelling elderly is common. There are significant differences in use between rural and urban elderly.

Dementia-free survival among centenarians: an evidence-based review.

BACKGROUND: The 2000 U.S. census identified 50,454 Americans older than 100 years (18 per 100,000). Increased longevity is only of benefit if accompanied by the maintenance of physical, social, and cognitive function into advanced age. The goal of this review was to identify research describing centenarians to find the prevalence of dementia-free survival. METHODS: We reviewed 650 publications to find studies that described the prevalence of dementia in centenarians, were community-based, had data that were specific to persons older than 100 years, and were published in peer-reviewed journals. For each study, we identified the prevalence of dementia, the completeness of the sample, the number of study participants, the method used to diagnose dementia, and the duration of the study. RESULTS: We identified 20 research groups from 14 countries with publications meeting our search criteria. The studies showed substantial variation in methods of assessing cognitive status, assuring a complete cohort, and sample size. Few studies reported longitudinal data or attempted diagnosis of the cause of dementia. The prevalence of dementia-free survival past 100 years of age varied between 0 and 50 percent. CONCLUSIONS: The methodology used in studies regarding dementia prevalence among centenarians is sufficiently varied that combination of existing studies into a meta-analysis is not possible. Suggestions for assuring quality in future centenarian research are presented.

Hyperkalemia.

Hyperkalemia is a potentially life-threatening metabolic problem caused by inability of the kidneys to excrete potassium, impairment of the mechanisms that move potassium from the circulation into the cells, or a combination of these factors. Acute episodes of hyperkalemia commonly are triggered by the introduction of a medication affecting potassium homeostasis; illness or dehydration also can be triggers. In patients with diabetic nephropathy, hyperkalemia may be caused by the syndrome of hyporeninemic hypoaldosteronism. The presence of typical electrocardiographic changes or a rapid rise in serum potassium indicates that hyperkalemia is potentially life threatening. Urine potassium, creatinine, and osmolarity should be obtained as a first step in determining the cause of hyperkalemia, which directs long-term treatment. Intravenous calcium is effective in reversing electrocardiographic changes and reducing the risk of arrhythmias but does not lower serum potassium. Serum potassium levels can be lowered acutely by using intravenous insulin and glucose, nebulized beta2 agonists, or both. Sodium polystyrene therapy, sometimes with intravenous furosemide and saline, is then initiated to lower total body potassium levels.

Patterns of dietary supplement usage in demographically diverse older people.

OBJECTIVE: To analyze dietary supplement usage data from 494 older adults, aged 65 to 101 years. SETTING: Community dwellers living independently of institutionalized care. DESIGN: All dietary supplements, including botanicals, were recorded to aid in assessing the health status of older adults. PARTICIPANTS: 1) 224 individuals enrolled in a study that follows the health of persons 85 years and older (oldest-old) in Klamath County, a non-metropolitan area in southern Oregon; 2) 134 participants of oldest-old age living in the metropolitan Portland area, enrolled in a randomized clinical trial of GBE biloba extract (GBE) for dementia prevention; and 3) 136 participants, ages 65-85 years (young-old), also of the Portland area, enrolled in a study of the effects of yoga and exercise on cognition. MEASUREMENTS: Data verified from labels, not from self-report. RESULTS: Of the participants, 70.6% used dietary supplements. Women took supplements more often than men, and usage decreased with age. A greater percentage, 67.4%, of the non-metropolitan oldest-old took supplements, compared to 56.7% of the metropolitan oldest-old. The greatest usage, 89.7%, was in the metropolitan young-olds. All of these percentages exceed those for comparable age groups in national representative surveys. CONCLUSIONS: Dietary supplement usage by older adults in these studies in Oregon exceeded that in other reports and may reflect high interest in complementary and alternative medicine. This report confirms the results of other studies showing that elderly adults, particularly women, use dietary supplements more than other segments of the US population. Researchers and clinicians should be aware of this pattern and potential conflicts with research design or treatment regimen intended for older people.

Benefits and challenges of research with the oldest old for participants and nurses.

The Klamath Exceptional Aging Project is a longitudinal aging study of people 85 and over, the "oldest old," in rural Oregon. Although conducting research with those 85 and over can be challenging, it is increasingly more important that this group be included in research studies given their importance in society. Benefits for the oldest old participating in research include an opportunity for altruism, productivity, and generativity and the expression of power and control. Benefits for nurses conducting research with this group include gaining a unique understanding of the world of the elderly, the honor of being a confidante for them, and the opportunity to provide truly caring nursing to a vulnerable age group. There is also a great sense of satisfaction in adding to the knowledge base needed to attain successful aging.

Chronic hepatitis C infection in a rural Medicaid HMO.

CONTEXT: Chronic hepatitis C infection (CHCI) is an increasingly common problem, affecting about 2% of the US population. The cost and complexity of treatment and difficulties in communicating with the infected population are of concern to insurers and health planners. PURPOSE: To describe the clinical features of patients with CHCI in a rural Medicaid-covered population and to describe a method developed for treating CHCI in an underserved rural community. METHODS: We developed a disease management approach to patients with CHCI receiving insurance coverage through a Medicaid HMO in rural Oregon. A locally based multidisciplinary hepatitis committee was formed to develop a management protocol and a process for selecting patients for treatment. The committee met monthly to develop the treatment plan for individual patients. Day-to-day treatment was provided by a nurse under the supervision of the committee. FINDINGS: One hundred forty-three adults with CHCI were identified by their primary care physicians. About half the patients had a type 1 genotype. Treatment with pegylated interferon and ribavirin was completed on 21 persons, 11 (52%) of whom had a virologic cure. Problems with treatment toxicity were common. Patient satisfaction with the treatment by the nurse was high. CONCLUSIONS: CHCI is common in this rural, nonminority Medicaid-insured population. A locally based disease management model was developed that was well received by patients and was successful in delivering a high quality of care for people with CHCI in a rural area.