Framing Effects on End-of-Life Preferences Among Latino Elders.

This study compared how the presentation of end-of-life (EOL) choices influences responses by Latino and White older adults relative to resuscitation preferences. The authors apply prospect theory, which deals with decision making based on how choices are framed. Participants were presented with differently ordered questions framing a resuscitation scenario and asked to rate their preferences. Results show that Latino participants were significantly influenced by the framing order of treatment options with regard to resuscitation while Whites were not. Health professionals need to be aware that the ways they present EOL options are likely to affect the choices of Latino older adults. Further research is needed with Latino subgroups.

Correlates associated with the desire for PEG tube placement at the end of life among community-dwelling older Mexican Americans: a pilot study.

BACKGROUND AND AIMS: Use of percutaneous endoscopic gastrostomy (PEG) tubes in older adults remains controversial. This cross-sectional study examines community-dwelling Mexican American older adults' attitudes toward PEG tube placement in the hypothetical event of a terminal illness. METHODS: Interviews were conducted with 100 community-dwelling Mexican American (MA's) adults, age 60 and over, in San Antonio, Texas. Subjects were screened for cognitive competence using Folstein's mini-mental examination. This was followed by an evaluation of socioeconomic status, depressive symptoms, religiosity, health status and attitudes toward end-of-life care, including PEG tube feeding. RESULTS: Higher income MA's, professionals, those without a living will, those who saw religious belief as not important and those who attended church less than once a month were more likely to agree with PEG placement (all P < 0.05). Logistic regression analysis revealed that higher income (OR = 3.16, CI = 1.13-8.83), lack of a living will (OR = 3.34, CI = 1.03-20.87) and low importance of religious beliefs (OR = 7.14, CI = 1.25-41.67) were all independently associated with the desire for insertion of a PEG tube at the end of life. CONCLUSIONS: This is the first community-based study to describe older Mexican American's attitudes toward PEG tube placement at the end of life. Older community-dwelling Mexican Americans with higher incomes, lack of a living will or low religious involvement might be more likely to choose PEG tube placement even in the context of a terminal condition.

The role of physical activity and diabetes status as a moderator: functional disability among older Mexican Americans.

PURPOSE: we investigate the temporal association between the rate of change in physical function and the rate of change in disability across four comparison groups: Those with and without diabetes who report >30 min of physical activity per day, and those who report <30 min of physical activity per day. METHODS: six waves of longitudinal data from the Hispanic Established Population for Epidemiologic Studies of the Elderly were utilised. At baseline, there were a total of 3,050 elder participants aged 65 years old or greater. The longitudinal rates of change in disability and physical function were compared by the diabetes status (ever versus none) and the physical activity status (less than or greater than or equal to 30 min per day). RESULTS: disability and physical function data were analysed using a latent growth curve modelling approach adjusted for relevant demographic/health-related covariates. There were statistically significant longitudinal declines in physical function and disability (P < 0.001) in all groups. Most notable, the physical activity status was an important moderator. Those with >30 min of activity demonstrated better baseline function and less disability as well as better temporal trajectories than those reporting <30 min of physical activity per day. Comparisons between diabetes statuses within the same physical activity groups showed worse disability trajectories among those with diabetes. CONCLUSIONS: a longitudinal decline in physical function and disability is moderated most notably by physical activity. The diabetes status further moderates decline in function and disability over time. Increased physical activity appears to be protective of disability in general and may lessen the influence of diabetes-related disability in older Mexican Americans, particularly at the end of life.

Attitudes regarding the use of ventilator support given a supposed terminal condition among community-dwelling Mexican American and non-Hispanic white older adults: a pilot study.

PURPOSE: To determine the factors that are associated with Mexican Americans' preference for ventilator support, given a supposed terminal diagnosis. METHODS: 100 Mexican Americans, aged 60-89, were recruited and screened for MMSE scores above 18. Eligible subjects answered a questionnaire in their preferred language (English/Spanish) concerning ventilator use during terminal illness. Mediator variables examined included demographics, generation, religiosity, occupation, self-reported depression, self-reported health, and activities of daily living. RESULTS: Being first or second generation American (OR = 0.18, CI = 0.05-0.66) with no IADL disability (OR = 0.11, CI = 0.02-0.59) and having depressive symptoms (OR = 1.43, CI = 1.08-1.89) were associated with preference for ventilator support. IMPLICATIONS: First and second generation older Mexican Americans and those functionally independent are more likely to prefer end-of-life ventilation support. Although depressive symptoms were inversely associated with ventilator use at the end of life, scores may more accurately reflect psychological stress associated with enduring the scenario. Further studies are needed to determine these factors' generalizability to the larger Mexican American community.

Mini-mental state exam domains predict falls in an elderly population: follow-up from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (H-EPESE) study.

OBJECTIVES: Assessment of the predictive ability of the Mini-Mental Status Exam (MMSE) domains (orientation to time, orientation to place, registration, attention and calculation, recall, language, and visual construction) for falls in Mexican American elders tested the hypothesis that low MMSE domain scores are related to an increased number of falls. DESIGN: Data were obtained from the 1998-99 re-survey (Wave 3) Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE), a population-based study of older Mexican Americans residing in the southwestern United States. METHODOLOGY: We used a retrospective case control study design; 926 subjects who were aged > or = 77 years at Wave 3 were examined. MMSE scores were utilized to predict falls two years later. Measurements included sociodemographic characteristics, MMSE scores, activities of daily living (ADL), instrumental activities of daily living (IADL), and fall rates. MAIN OUTCOME MEASURES: Relationships between MMSE domain scores and falls. RESULTS: Of the 681 subjects examined two years later, 35.7% experienced at least one fall. Subjects with errors on orientation to place (OR = 2.01) and visual construction (OR = 1.9) were most likely to fall. CONCLUSIONS: MMSE domains with poor scores and most predictive of falls in Mexican Americans elders were orientation to place and visual construction. Further evaluation for confusion level and visual ability in elders presenting with dysfunction on these domains may lead to a reduction of falls in this ethnic group.

Association of suboptimal prescribing and change in lower extremity physical function over time.

BACKGROUND: Previous studies have found inconsistent links between suboptimal prescribing and negative patient outcomes. While suboptimal prescribing consists of multiple components, e.g. drugs to avoid in the elderly (DAE), potential drug interactions (PDI) and polypharmacy, most research has focused on the impact of drugs to avoid. This study explores the relationship between suboptimal prescribing, comorbid disease, and change in lower extremity functional limitation (LEFL). METHODS: This prospective cohort study used data from the Hispanic Established Population for the Epidemiologic Study of the Elderly. Baseline data collection occurred between 1993 and 1994 with three additional waves of data collected approximately every 2 years. Based on the disablement process model, the dependent variable was change in LEFL over the 7-year study period. Independent variables included suboptimal prescribing: DAE, PDI and polypharmacy. Measures of pathology included comorbid diseases (stroke, cancer, hypertension, cardiovascular disease, arthritis, and diabetes). Age, gender, education, smoking, cognitive status, depression, body mass index, marital status, and self-reported health were controlled in analyses. RESULTS: Diabetes, stroke, and arthritis were associated with a decline in LEFL. Polypharmacy mediated the relationship between diabetes and LEFL, and polypharmacy was also significantly associated with decrements in LEFL. CONCLUSION: The effect of suboptimal prescribing on change in LEFL was limited to both direct and mediational effects of polypharmacy. Additional research exploring the association between suboptimal prescribing and a variety of quality measures using a diverse set of outcomes would improve our understanding of the impact of suboptimal prescribing more broadly defined.

Total anticholinergic burden and survival within a cohort of elderly Mexican Americans.

AIM: Studies examining the association between mortality and anticholinergic burden in the geriatric population are conflicting and are absent in the Mexican American population. The present study aimed to determine whether higher anticholinergic burden increases mortality in a cohort representative of community-based older Mexican Americans in the USA. METHODS: This retrospective cohort database study used the Hispanic Established Populations for the Epidemiologic Study of the Elderly cohort. The primary outcome, mortality, was assessed beginning at the second interview in 1995 until the fifth interview in 2005. Medications were classified for anticholinergic burden according to the modified-Anticholinergic Drug Scale and were summed across all reported medications creating a measure of total anticholinergic burden. Anticholinergic burden was tested for association with mortality using survival analysis. RESULTS: The 1497 older adults reporting medication usage were included. Survival analysis showed a statistically significant (P < 0.05) relationship between anticholinergic burden and increased mortality. CONCLUSIONS: Anticholinergic burden is associated with increased mortality in Southwestern Mexican American older adults who report taking prescription or non prescription medications. These findings suggest that anticholinergic burden might be a risk factor for mortality in this selected population, with additional studies required to further define the risk. Geriatr Gerontol Int 2017; 17: 1515-1521.

Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study.

BACKGROUND: Numerous methods have been used to evaluate medication management quality in older adults; however, their predictive validities are unknown. Major medication quality indicators include polypharmacy, drug-drug interactions, and inappropriate medication use. To date, no study has attempted to evaluate the three approaches systematically or the effect of each approach on mortality in a Hispanic population. Our objective was to evaluate the relationship between polypharmacy, drug-drug interactions, and inappropriate medication use on the mortality of a community-based population of Mexican American older adults. METHODS: We used a life table survival analysis of a longitudinal survey of a representative sample of 3,050 older Mexican Americans of whom 1,823 were taking prescription and over-the-counter medications. RESULTS: After adjustment for relevant covariates, use of more than four different medications (polypharmacy) was independently associated with mortality. The presence of major drug interactions and the use of inappropriate medications were not significantly associated with mortality in our study sample. CONCLUSION: Polypharmacy (>4 medications) is significantly associated with mortality in Mexican American older adults. This community-based study is the first to demonstrate a direct association between polypharmacy and mortality in this population.

Geriatrics in Brazil: a big country with big opportunities.

Brazil has approximately 180 million inhabitants, of whom 15.2 million are aged 60 and older and 1.9 million are aged 80 and older. By 2025, the Brazilian elderly population is expected to grow to more than 32 million. Brazil has many problems related to its geographic and population size. Great distances between major cities, marked cultural and racial heterogeneity between the various geographic regions, high poverty levels, and decreasing family size all combine to put pressure on the medical and social services that can be made available to the elder population. Less than 500 Brazilian physicians are certified as geriatricians, translating into one geriatrician for every 37,000 elderly Brazilians. Beside 15 geriatric medicine residencies a larger number of fellowship programs exist, and these programs are in high demand, with more than 20 candidates per position, indicating new opportunities for growth in elder care. In addition, geriatric initiatives such as the annual elder vaccination program and the elder statute, recently approved by the Brazilian Congress, indicate that geriatric care in Brazil is entering a new era of growth and development. Although the challenges remain great, there are opportunities for Brazilian geriatrics and gerontology.

Association between acculturation and structural assimilation and mini-mental state examination-assessed cognitive impairment in older Mexican Americans: findings from the San Antonio Longitudinal Study of Aging.

Older Mexican Americans (MAs) have consistently scored lower on the Folstein Mini-Mental State Examination (MMSE) than older European Americans (EAs). These lower scores may arise from factors other than those traditionally posited (age and education). Thus, this study examined the association between acculturation and structural assimilation and MMSE-assessed cognitive impairment, taking into account education, income, and other contextual factors. Subjects were participants in the San Antonio Longitudinal Study of Aging, a community-based study of chronic disease and functional status in 457 older MAs and 376 older EAs. Scales were used to measure two dimensions of acculturation: (family attitude, cultural values) and structural assimilation (functional integration into the broader American society). Logistic regression was used to examine the association between age, sex, acculturation, and structural assimilation and MMSE scores suggestive of cognitive impairment (<24). After adjusting for contextual factors (age, sex, education and household income), diseases (diabetes mellitus, stroke, and hypertension), and sensory impairments (hearing and vision), structural assimilation, but neither dimension of acculturation, was significantly and negatively associated with MMSE-assessed cognitive impairment. Older MAs in the lowest structural assimilation stratum were 1.89 times as likely to have MMSE-assessed cognitive impairment as those in the highest. Age, education, and visual impairment were also independently associated with cognitive impairment. These findings highlight the need for geriatricians to take contextual factors (including age, education, and structural assimilation) into account when interpreting MMSE scores of MA patients.

Inconsistent use of diabetes medications, diabetes complications, and mortality in older mexican americans over a 7-year period: data from the Hispanic established population for the epidemiologic study of the elderly.

OBJECTIVE: The aim of this study was to examine the relationship between inconsistency in use of diabetes drugs and risk of renal, eye, and circulation problems and death over a 7-year period in community-dwelling older Mexican Americans. RESEARCH DESIGN AND METHODS: Data are from the four waves of the Hispanic Established Population for the Epidemiologic Study of the Elderly. In-home interviewers assessed consistency in use of diabetes medications among 908 diabetic Mexican Americans, aged >or=65 years. Diabetes and complications were by self-report. Subjects with poor consistency in use of medication were those who, at any time during the 7-year follow-up, discontinued or inconsistently used their diabetes medications and those who had no diabetic medications at home despite self-report of taking medicine for diabetes. RESULTS: Thirty-six percent of our sample were inconsistent with diabetes medication usage. Older age and lack of supplemental health insurance were significantly associated with inconsistency of use of medication. In a multivariate logistic regression model, subjects with poor consistency in use of medication were more likely to report kidney problems (odds ratio [OR] 1.59; 95% CI 1.13-2.23; P = 0.008) at follow-up compared with those with good consistency, after controlling for age, sex, medication type, duration of diabetes, education, income, marital status, language of interview, insurance status, cognitive function, presence of depressive symptoms, activities of daily living, and instrumental activities of daily living. In Cox regression models, poor consistency with diabetic medication was also associated with increased all-cause mortality (hazard ratio [HR] 1.43; 95% CI 1.13-1.82; P = 0.003) and diabetes-related deaths (1.66; 1.20-2.30; P = 0.002) over a 7-year period after adjusting for relevant confounders. CONCLUSIONS: Inconsistent use of diabetic medication was associated with an increased risk of kidney problems and deaths over a 7-year period in older Mexican Americans.

Evaluation of the mini-mental state examination's internal consistency in a community-based sample of Mexican-American and European-American elders: results from the San Antonio Longitudinal Study of Aging.

This study examined the effect of scoring method, education, and language usage on internal consistency of the Folstein Mini-Mental State Examination (MMSE). Trained bilingual staff administered the MMSE in participants' homes as part of the San Antonio Longitudinal Study of Aging home-based assessment battery. Subjects included 833 community-dwelling Mexican-American (MA) and European-American (EA) elders, aged 65 and older, residing in three socioculturally distinct neighborhoods in San Antonio, Texas. Three methods of scoring the MMSE were examined: serial sevens only, spelling only, and serial sevens or spelling, whichever was higher. Mean MMSE scores+/-standard deviation ranged from 27.7+/-2.4 to 28.5+/-1.9 for EAs, from 25.6+/-3.2 to 27.2+/-2.9 for MAs interviewed in English, and from 22.5+/-4.5 to 25.5+/-3.5 for MAs interviewed in Spanish, depending on scoring method. Across the three ethnic-language subgroups, the lowest mean scores, largest coefficients of variation, and highest alpha coefficients were observed using serial sevens only. Stratification by educational level showed that alpha coefficients for all three scoring methods were consistently lower in high school graduates than in less-educated groups. Serial sevens only was the only scoring method that yielded acceptably high alpha coefficients across all ethnic, language, and education subgroups. Thus, clinicians should use the serial sevens-only method when administering the MMSE and be alert to the increased potential for false-negatives in more highly educated EA and MA elders, particularly in EAs and MAs proficient in English.

Cognitive impairment and mortality in older mexican americans.

OBJECTIVES: To examine the extent to which cognitive status and decline in cognitive status predict mortality in older Mexican Americans. DESIGN: Longitudinal cohort. SETTING: Older Mexican Americans residing in five southwestern states in the United States. PARTICIPANTS: Two thousand six hundred twenty-five persons aged 65 and older living in Texas, New Mexico, Colorado, Arizona, and California. MEASUREMENTS: The cognitive function of participants was assessed using the Mini-Mental State Examination (MMSE) in 1993-94 and again in 1995-96. Cognitive decline was defined using two sets of criteria: a drop to 17 or less (moderate-severe cognitive impairment) on the MMSE at 2-year follow-up and a decrease of at least four points, a threshold change in scores that was used to predict mortality in this sample. Cox proportional hazards models were conducted to examine the association between the MMSE and increased risk for mortality, after controlling for sociodemographic characteristics, medical conditions, and depressive symptoms. RESULTS: Five-year mortality risk was significantly associated with persons in the moderately-severely cognitively impaired category (hazard ratio (HR) = 2.35, P <.001). Moreover, mild cognitive impairment was also predictive of mortality in older Mexicans (HR = 1.45, P <.001). Two-year declines in cognitive functioning, particularly in persons who had declined to the moderate-severe impairment category (HR = 2.23, P <.001) and those who dropped at least four points on the MMSE (HR = 1.30, P <.001), were predictive of mortality 3 years later, after controlling for important variables. CONCLUSIONS: Baseline moderate-severe and mild cognitive status and 2-year decline in cognitive functioning independently predict mortality in older Mexican Americans. Although age and selected medical conditions have been reported as the more salient predictors of mortality, cognitive functioning should be considered part of identifying older persons at high risk for underlying medical conditions and mortality.

Prevalence and severity of urinary incontinence in elderly Mexican-American women.

OBJECTIVES: To measure prevalence and characteristics of urinary incontinence in older Mexican-American women. DESIGN: Cross-sectional analysis of a longitudinal survey of a representative sample of older Mexican Americans. SETTING: Five southwestern states in the United States. PARTICIPANTS: A total of 1589 Mexican-American women, aged 65 and older who were part of the Hispanic Established Population for the Epidemiologic Study of the Elderly. MEASUREMENTS: Self-reported psychosocial, demographic, and health variables; self-reported history of symptoms of urinary incontinence. RESULTS: Two hundred thirty-nine (15%) of the 1589 Mexican-American women reported having urinary incontinence. Almost 33% reported urge incontinence symptoms, 10% reported stress incontinence symptoms, and 42% had symptoms suggestive of mixed incontinence. Thirty-five percent of subjects reported incontinence episodes with moderate to large amounts of urine loss, and 15% reported that their urinary symptoms kept them from engaging in social activities. Age and body mass index were risk factors for incontinence (P=.02 and P=.03, respectively). CONCLUSION: This is the first community-based survey examining rates of urinary incontinence in Mexican-American women. The prevalence of urinary incontinence may be lower in older Mexican-American women than in the general population. They may also have a higher percentage of urge as opposed to stress incontinence symptoms and may suffer from moderate to large volumes of urine loss associated with their incontinence episodes.

Predictors of decline in MMSE scores among older Mexican Americans.

BACKGROUND: The purpose of this analysis was to examine the association of sociodemographic variables and health-related conditions with 5-year declines in cognitive function among Mexican American elderly persons. METHODS: The cognitive function of 1759 participants was assessed by using the Mini-Mental State Examination (MMSE) in 1993/1994 and again in 1998/1999. Cognitive decline was defined by two sets of criteria: (1) a drop to 17 or below on the MMSE at follow-up, and (2) a decline of at least three points, the mean change in MMSE scores among respondents who obtained scores at or above the 5th percentile distribution at baseline. RESULTS: Cognitive decline was significantly associated with sociodemographic variables including age, education, marital status, and household composition. In addition, respondents with reported vision impairment, stroke, and diabetes were at increased risk for cognitive decline after controlling for multiple potential confounders. CONCLUSION: Although age and education have been reported as the more salient predictors of cognitive deterioration, other sociodemographic and several medical conditions including stroke and diabetes should be considered as part of cognitive aging studies among Mexican American elders.

Characteristics of Mexican-American elders with dementia presenting to a community-based memory evaluation program.

OBJECTIVE: To determine sociodemographic characteristics associated with the initial presentation of Mexican-American elders to a community-based memory evaluation clinic. METHODS: Retrospective review of the charts of 89 Mexican Americans presenting consecutively to an outpatient memory evaluation clinic in San Antonio, Texas. PRINCIPAL FINDINGS: Mexican Americans presented for evaluation with more moderate-to-severe cognitive impairment than previously reported. They also tended to have high levels of IADL (83.1%) and gait/balance (52.3%) impairment, as well as high levels of depressive symptoms (63.1%). CONCLUSIONS: Mexican Americans present for initial evaluation for memory decline with moderate-to-severe cognitive decline and significant dementia-associated co-morbidities. In Mexican Americans, caregiver burden, fall risks, depressive symptoms, and need for IADL support should be addressed on the initial visit for memory decline.

The geriatrician and geriatric psychiatrist workforce in Texas: characteristics, challenges, and policy implications.

OBJECTIVE: This study provides a current analysis of the size and characteristics of the board-certified geriatrician and geriatric psychiatrist workforce in Texas, and thereby its capacity to meet increasing health needs of elders. METHOD: Secondary data on Texas board-certified geriatricians and geriatric psychiatrists from American Board of Medical Specialties database were analyzed. RESULTS: The study found 1 geriatrician per 5,132 elders, and 1 geriatric psychiatrist per 21,327 elders, in Texas. Over 62% of geriatricians had active certification, 30% were females and the average age was 55.2 years. Rural geriatricians were disproportionately scarce (p < .001). DISCUSSION: The study indicated a serious shortage of board-certified geriatricians and geriatric psychiatrists in Texas. This shortage is worse than that at the national level, and more marked along the Texas-Mexico border and counties lacking large health facilities. Addressing this workforce deficiency requires improvements in the geriatric training pipeline, reimbursements, and practice environments.

Characteristics of Mexican American elders admitted to nursing facilities in the United States: data from the Hispanic Established Populations for Epidemiologic Studies of the Elderly (EPESE) study.

OBJECTIVES: The purpose of the current study was to describe the factors associated with Mexican American elders in the Southwestern United States who have spent time in a skilled nursing facility (SNF) compared with those who have not. DESIGN: Data were collected on the Mexican American elders who reported an SNF stay within 10 years of baseline. PARTICIPANTS: A probability sample of 3050 Mexican American elders from five Southwestern states followed from 1993 to 2005 were examined. MEASURES: Variables examined included sociodemographics, language of interview, disabilities with instrumental activities of daily living, activities of daily living, self-reported health, cognitive status, and depression. RESULTS: A total of 78 (3.9%) of 2020 subjects resided in SNFs. Using univariate analyses, older age, English-language interview, poorer cognitive status, and functional disabilities were independently associated with SNF admissions. Logistic regression analyses controlling for age revealed that SNF patients were older (OR = 1.08, P = .001), had an activities of daily living disability (OR = 4.94, P < .001), scored in the depressed range in the Geriatric Depression Scale (OR = 2.72, P = .001), and were more likely to interview in English (OR = 1.95, P = .042), when compared with community counterparts. CONCLUSIONS: Mexican American elders who resided in an SNF at some point in the previous 10 years were older, and were more likely to be functionally impaired. They also were more likely to prefer English as their primary language, indicating they were more likely to agree to an SNF stay than their Spanish-speaking counterparts.

Cultural Considerations: Pharmacological and Nonpharmacological Means for Improving Blood Pressure Control among Hispanic Patients.

Cardiovascular disease is a leading cause of morbidity and mortality in the United States, and its prevention and treatment remain a priority for the medical community. Ethnic variations account for some differences in the prevalence of hypertension and blood pressure (BP) control rates among Hispanics, indicating the need for culturally appropriate management models. Aggressive treatment strategies are key to achieving optimal BP control in high-risk Hispanic patients. Hypertension in this ethnic group continues to be a major health concern. Of note, when provided access to comprehensive care, Hispanics demonstrate similar response rates to treatment as the majority of non-Hispanic whites. This highlights the importance of effective, culturally responsive hypertension management among high-risk Hispanic patients for achieving observable, positive health outcomes.