State variation in nursing home mortality outcomes according to do-not-resuscitate status.

BACKGROUND: This study compares mortality outcomes of Medicaid-reimbursed nursing home residents with and without do-not-resuscitate (DNR) orders in two diverse states. METHODS: We used 1994 Minimum Data Set Plus (MDS+) information on 3215 nursing home residents from two states. We used Kaplan-Meier analyses to examine unadjusted mortality among those with and without DNR orders across states. We used a proportional hazard regression with main and interaction variables to model the likelihood of survival in the nursing home. RESULTS: Approximately 27% of nursing home residents with DNR orders in State A die within the year, and approximately 40% of nursing home residents with DNR orders in State B die within the year. Regression results indicate that neither having a DNR order nor state of residence were independently associated with mortality. However, residing in State B and having a DNR order was associated with an increased risk of mortality compared with all others in the sample (risk ratio = 1.73; 95% confidence interval = 1.09, 2.75). CONCLUSION: This study demonstrates that DNR orders are associated with varying mortality across states. Future research is needed to identify the reasons why state level differences exist.

Effectiveness of feeding tubes in nursing home residents with swallowing disorders.

BACKGROUND: Among nursing home residents who stop eating, a common decision for residents, caregivers, and families is the decision to begin tube feeding. This study examines the effectiveness of feeding tubes at reducing mortality among nursing home residents with swallowing disorders and feeding disabilities. METHODS: Data from a version of the Minimum Data Set+ (MDS +) encompassing three different states from calendar years 1993 and 1994 were analyzed. Residents were included in the study if they were not totally dependent on staff for eating upon their first assessment but became totally dependent on staff for eating and had a swallowing disorder at some point during their nursing home stay. We used a proportional hazard regression to examine the relationship of feeding tubes with mortality after total eating dependence occurred. RESULTS: Unadjusted Kaplan-Meier curves found that those with feeding tubes were less likely to die than comparable residents without feeding tubes (p < .001). Estimated survival at 1 year was 39% for those without feeding tubes and 50% for those with feeding tubes. The multivariate results indicated that feeding tubes were associated with a reduced risk of death (risk ratio, 0.71; 95% confidence interval, 0.59, 0.86). CONCLUSIONS: This study provides evidence that tube feeding can be life-prolonging, even if the gain in life is not substantial. Such information can be useful to nursing home staff, residents, and families when trying to decide whether to place a feeding tube in a resident with swallowing disorders and eating disabilities.

Nursing home resident use of care directives.

BACKGROUND: The Patient Self-Determination Act of 1991 requires that nursing homes reimbursed by Medicare or Medicaid inform all residents upon admission of their rights to enact care directives in the event of terminal illness. This study investigated the relationship between care directive use and resident functional status. METHODS: We analyzed a version of the Minimum Data Set (MDS+) from a single state. We selected residents who were admitted to a nursing home in the first half of 1993 and followed them in the nursing home through the end of 1994. We created logistic models to examine independent correlates associated with having an advance directive or a do-not-resuscitate (DNR) order on admission. We then created similar logistic models to examine independent correlates associated with writing an advance directive or DNR order subsequent to admission. RESULTS: Of the 2,780 residents, 11% (292) had advance directives and 17% (466) had DNR orders upon admission. Of those without care directives upon admission, 6% (143) subsequently had an advance directive and 15% (339) subsequently had a DNR order. Cross-sectionally, older individuals and whites were more likely to have a care directive. Having poor cognitive and physical function was associated with having a DNR order upon admission. Longitudinally, longer stayers and whites were more likely to have an advance directive. Residents who lost physical function were more likely to have an advance directive and those who lost cognitive function were more likely to have a DNR order. CONCLUSIONS: Care directive use is influenced by a number of sociodemographic and functional characteristics.

Prior living arrangements and nursing home resident admission ADL characteristics: a study of two states.

OBJECTIVES: This study examines the relationship between prior living arrangements and average activities of daily living (ADL) function upon nursing home admission across two states. METHODS: Minimum Data Set Plus records from 1993 and 1994 on 4,837 Medicaid reimbursed nursing home residents aged 65 years and older from two states were used. Medicaid reimbursed residents were chosen because Medicaid reimbursement policies differ at the state level, and such differences might affect admission characteristics across states. Ordinary least squares models were used to examine the correlates of the number of ADL limitations (range 0-7) upon nursing home admission. RESULTS: Residents in state A had a mean of 5.36 ADL limitations, whereas residents in state B had a mean of 4.83 limitations. Those who lived alone entered the nursing home with 0.61 fewer ADL limitations (p < .001) than those who lived with others. Living alone in state A reduced this association through an increase of 0.31 ADL limitations (p = .012). DISCUSSION: Older Medicaid recipients who live alone enter the nursing home with better physical function than those who live with others. The difference in function between those who live alone and those who live with others varies across the two states.

Functional decline associated with hospitalization for acute illness.

Functional change as a result of hospitalization is common, dynamic, and costly in both economic and human terms. It, however, is not an inevitable outcome of illness and aging. Older persons are substantial users of hospital care, and yet providers subject them to hospital practices that are more appropriate for younger patients. The information presented in this article suggests that our knowledge base regarding functional decline associated with hospitalization now allows us to identify high-risk patients and intervene both during and after hospitalization in order to maintain patient functioning.

Gastrostomy placement and mortality among hospitalized Medicare beneficiaries.

CONTEXT: Although the use of feeding tubes among older individuals stirs considerable controversy, population-based descriptive data regarding patient outcomes are scarce. OBJECTIVE: To describe hospitalized Medicare beneficiaries having gastrostomies placed and their associated mortality rates. DESIGN: Retrospective cohort study. SETTING AND PATIENTS: Hospitalized Medicare beneficiaries aged 65 years or older discharged in 1991 following gastrostomy placement (excluding individuals in health maintenance organizations). MAIN OUTCOME MEASURES: Mortality at 30 days, 1 year, and 3 years following gastrostomy and characteristics of individuals undergoing gastrostomy placement. RESULTS: In 1991, claims reflecting gastrostomy insertion were submitted for 81105 older Medicare beneficiaries following hospital discharge. The in-hospital mortality rate was 15.3%. Cerebrovascular disease, neoplasms, fluid and electrolyte disorders, and aspiration pneumonia were the most common primary diagnoses. The overall mortality rate at 30 days was 23.9% (95% confidence interval [CI], 23.65%-24.2%), reaching 63.0% (95% CI, 62.7%-63.4%) at 1 year and 81.3% (95% CI, 81.0%-81.5%) by 3 years. One in 131 white and 1 in 58 black Medicare beneficiaries aged 85 years or older was discharged alive or deceased from a hospital in 1991 following gastrostomy placement. CONCLUSIONS: Gastrostomies are frequently placed in older individuals and more often in blacks; mortality rates following placement are substantial.

The natural history of delirium in older hospitalized patients: a syndrome of heterogeneity.

OBJECTIVES: To determine the presentation, course and duration of delirium in hospitalized older people. DESIGN: Observational cohort study. SETTING: Inpatient surgical and medical wards at a university hospital. PARTICIPANTS: 432 people over the age of 65. MEASUREMENTS: All participants were screened daily for confusion and, in those who were confused, delirium was ascertained using the Diagnostic and Statistical Manual of Mental Disorders (DSM) III-R criteria. Those who were found to be delirious were followed daily while in hospital for evidence of delirium. The Delirium Rating Scale (DRS) was used to describe the clinical characteristics of delirium. RESULTS: About 15% of subjects had delirium. Sixty-nine percent of delirious subjects had delirium on a single day. The DRS total was higher on the first day of delirium for those with delirium on multiple days than those with delirium on a single day (P = 0.03). Among those with delirium on multiple days, there were no patterns of change over time in specific DRS items. CONCLUSIONS: Delirium in hospitalized older people is common and has a varied presentation and time course. Clinicians and researchers need to consider this great heterogeneity when caring for patients and when studying delirium.

Risk factors for nursing home use after hospitalization for medical illness.

BACKGROUND: Hospitalization, a sentinel event for many older persons, may mark a transition from independent living to either community-based or institutionalized long-term care. We determined the independent risk factors, including loss of function, of nursing home (NH) admission at hospital discharge and NH use at 3 months after hospital discharge among a diverse group of hospitalized older persons. METHODS: The subjects in this study were 1,265 noninstitutionalized persons from phase II of Hospital Outcomes Project for the Elderly. Using multiple logistic regression, we modeled NH admission with variables measured at the time of hospital admission as well as with length of stay (LOS) and decline in ADL independence from hospital admission to discharge. In addition, we modeled NH use at 3 months after hospital discharge with variables measured at the time of hospital discharge as well as with post-hospital measures of rehospitalization and decline in ADL independence following hospitalization. RESULTS: The independence risk factors of NH placement at discharge are geographic site, increasing age, living alone, and low baseline ADL independence, LOS, and decline in ADL independence during hospitalization. The independent predictors for NH use at 3-month follow-up are increasing age, living alone, mental status, low discharge ADL independence, LOS, and decline in ADL independence during the 3 months after discharge. CONCLUSIONS: Simple but different clinical variables predict NH use at hospital discharge and at 3 months. Furthermore, functional loss during and after hospitalization is an important independent risk factor of nursing home use and is a clinical outcome that may be modified to decrease the likelihood of NH admission.

Functional limitation pathways and transitions in community-dwelling older persons.

The focus of this article is to determine the probability of making transitions through various ADL limitation levels, controlling for gender, age, and baseline ADL level, and using death as a competing outcome. We use the four waves of the Longitudinal Study of Aging and categorical data techniques to model the probability of these transitions. We find much heterogeneity among the transitions, with significant age and functional limitation effects. We also find that death and functional limitations are not necessarily highly linked.

Functional outcomes of acute medical illness and hospitalization in older persons.

BACKGROUND: Short-stay hospitalization in older patients is frequently associated with a loss of function, which can lead to a need for postdischarge assistance and longer-term institutionalization. Because little is known about this adverse outcome of hospitalization, this study was conducted to (1) determine the discharge and 3-month postdischarge functional outcomes for a large cohort of older persons hospitalized for medical illness, (2) determine the extent to which patients were able to recover to preadmission levels of functioning after hospital discharge, and (3) identify the patient factors associated with an increased risk of developing disability associated with acute illness and hospitalization. METHODS: A total of 1279 community-dwelling patients, aged 70 years and older, hospitalized for acute medical illness were enrolled in this multicenter, prospective cohort study. Functional measurements obtained at discharge (Activities of Daily Living) and at 3 months after discharge (Activities of Daily Living and Instrumental Activities of Daily Living) were compared with a preadmission baseline level of functioning to document loss and recovery of functioning. RESULTS: At discharge, 59% of the study population reported no change, 10% improved, and 31% declined in Activities of Daily Living when compared with the preadmission baseline. At the 3-month follow-up, 51% of the original study population, for whom postdischarge data were available (n=1206), were found to have died (11%) or to report new Activities of Daily Living and/or Instrumental Activities of Daily Living disabilities (40%) when compared with the preadmission baseline. Among survivors, 19% reported a new Activities of Daily Living and 40% reported a new Instrumental Activities of Daily Living disability at follow-up. The 3-month outcomes were the result of the loss of function during the index hospitalization, the failure of many patients to recover after discharge, and the development of new postdischarge disabilities. Patients at greatest risk of adverse functional outcomes at follow-up were older, had preadmission Instrumental Activities of Daily Living disabilities and lower mental status scores on admission, and had been rehospitalized. CONCLUSION: This study documents a high incidence of functional decline after hospitalization for acute medial illness. Although there are several potential explanations for these findings, this study suggests a need to reexamine current inpatient and postdischarge practices that might influence the functioning of older patients.

Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization.

OBJECTIVES: To develop and validate an instrument for stratifying older patients at the time of hospital admission according to their risk of developing new disabilities in activities of daily living (ADL) following acute medical illness and hospitalization. DESIGN: Multi-center prospective cohort study. SETTING: Four university and two private non-federal acute care hospitals. PATIENTS: The development cohort consists of 448 patients and the validation cohort consists of 379 patients who were aged 70 and older and who were hospitalized for acute medical illness between 1989 and 1992. MEASUREMENTS: All patients were evaluated on hospital admission to identify baseline demographic and functional characteristics and were then assessed at discharge and 3 months after discharge to determine decline in ADL functioning. RESULTS: Logistic regression analysis identified three patient characteristics that were independent predictors of functional decline in the development cohort: increasing age, lower admission Mini-Mental Status Exam scores, and lower preadmission IADL function. A scoring system was developed for each predictor variable and patients were assigned to low, intermediate, and high risk categories. The rates of ADL decline at discharge for the low, intermediate, and high risk categories were 17%, 28%, and 56% in the development cohort and 19%, 31%, and 55% in the validation cohort, respectively. Patients in the low risk category were significantly more likely to recover ADL function and to avoid nursing home placement during the 3 months after discharge. CONCLUSION: Hospital Admission Risk Profile (HARP) is a simple instrument that can be used to identify patients at risk of functional decline following hospitalization. HARP can be used to identify patients who might benefit from comprehensive discharge planning, specialized geriatric care, and experimental interventions designed to prevent/reduce the development of disability in hospitalized older populations.

Ethical and legal issues in nursing home care.

Physicians who provide care for nursing home residents are regularly challenged by ethical and legal issues. Because nursing home care is complicated by numerous regulations and because nursing home residents have complex medical and social problems, some issues are unique to the long-term care setting and others present in unfamiliar ways. Some issues frequently encountered in this context are discussed: advance directives, competence and decision-making capacity, decisions about life-sustaining treatment, resident abuse, restraints, psychotropic medications, risk management, participation in research, and ethics committees. With knowledge of the legal and ethical framework and understanding of some of the common, complicated issues that arise, physicians should be better equipped to provide optimal care for nursing home residents.

Medical conditions differentially affect the development of IADL disability: implications for medical care and research.

Using The Longitudinal Study of Aging, we determined the independent effects of nine self-reported medical conditions on the likelihood of developing specific instrumental activities of daily living (IADLs) disabilities at three points in time. We controlled for demographic factors and self-reported health status. The various medical conditions differentially affect each specific IADL disability, and each IADL disability has its own set of predictors which, in general, do not vary over time. The differential effects of thse predictors need to be taken into consideration by researchers, clinicians, and policymakers when studying disability and when implementing and evaluating programs to reduce disability.

Delirium in hospitalized older persons: outcomes and predictors.

OBJECTIVE: The purpose of this study was fourfold; to determine the rate of delirium among hospitalized older persons, to contrast the clinical outcomes of patients with and without delirium, to identify clinical predictors of delirium, and to validate the predictive model in an independent sample of patients. DESIGN: Two prospective cohort studies SETTING: Medical and surgical wards of 2 university teaching hospitals. PATIENTS: In the derivation cohort, 432 patients were enrolled from the University of Chicago Hospitals. Patients 65 years of age or older admitted to 1 of 4 wards were eligible. Subjects were excluded if they were discharged within 48 hours of admission, unavailable to the research assistants during the first 2 days of hospitalization, or judged too impaired to participate in the daily interviews. In the test cohort, 323 patients 70 years of age or older admitted to Yale-New Haven Hospital were studied. MEASUREMENTS: Subjects were screened for delirium daily and referred to experienced clinician investigators if acute mental status changes were observed. The clinician investigators assessed the patient for delirium based on DSM-III-R criteria. Duration of hospitalization was adjusted for diagnosis-related groups (DRG) and mortality rates were determined at discharge and 90 days after discharge. Sociodemographic characteristics, cognitive and functional status, comorbidity, depression, and alcoholism were examined as predictors of delirium. MAIN RESULTS: The rate of delirium in the derivation cohort was 15%; subjects with delirium had longer hospital stays and an increased risk of in-hospital death. Cognitive impairment, burden of comorbidity, depression, and alcoholism were found to be independent predictors of delirium. The ability of the model to stratify patients as low, moderate, or high risk for developing delirium was validated in the test cohort in which the rate of delirium was 26%. CONCLUSIONS: This study confirms the high rate of delirium among hospitalized older persons and the associated adverse outcomes of prolonged hospital stays and increased risk of death. Patients can be stratified according to their risk for developing delirium using relatively few clinical characteristics which should be assessed, on all hospitalized older persons.

Guidelines, practice policies, and parameters: the case for geriatrics.

OBJECTIVE: As the population ages, the care of older persons becomes more important. At the same time, practice guidelines that provide recommendations for appropriate care are being published in greater numbers. The purpose of this work is to determine the proportion of guidelines that contain specific information about older persons. DESIGN: Through a random sample of published guidelines listed in the AMA Directory of Practice Parameters, 1992 Edition, we determined the proportion of guidelines that contain specific age-related information. We also determined if, over time, there was a difference in the proportion of practice guidelines containing information about older persons. RESULTS: 45.9% (95% CI, range 33.4-58.4) of guidelines that could conceivably pertain to older persons contain no age information; 24.6% (95% CI, range 13.8-35.4) of guidelines contain information only about persons less than 65 years of age; 29.5% (95% CI, range 18.1-41.0) of guidelines contain specific information about older persons. Moreover, there were no secular trends in the proportion of guidelines pertaining to older persons. CONCLUSIONS: Only a minority of practice guidelines contain information about older persons. Possible causes and solutions to this shortfall are discussed.

Do activities of daily living have a hierarchical structure? An analysis using the longitudinal study of aging.

BACKGROUND: It has long been thought that individual activities of daily living (ADLs) can be combined to form a hierarchy or Guttman scale. The purpose of this study is to determine if ADLs fit into a single hierarchical structure, and to examine how such a hierarchy should be evaluated. METHODS: We use data from the baseline year of the Longitudinal Study of Aging, a nationally representative survey of noninstitutionalized persons 70 years of age and older. For each of the 360 permutations of the ADLs within the Katz hierarchy, we calculate the standard measures of fit of ordered data to a Guttman scale: the coefficient of reproducibility, the minimum marginal reproducibility, the percentage improvement, and the coefficient scalability. RESULTS: We find that although the Katz hierarchy does satisfy the traditional requirements for scalability, many other ADL hierarchies also satisfy these criteria. Specifically, our analysis shows that there are 4 hierarchies at least as good as the Katz hierarchy, and 103 hierarchies which satisfy the minimum standard for scalability. CONCLUSIONS: We conclude that the typical scalogram methodology may not be sufficient to summarize data, and that a multiplicity of disability profiles may exist.

The relationship of visual and hearing impairments to disability: an analysis using the longitudinal study of aging.

BACKGROUND: Little is known about the relationships of visual impairment and hearing impairments to physical disability. The purpose of this work is to determine if persons 70 years of age and over with these impairments are at risk for increased disability in basic physical activities of daily living (ADLs) compared to persons without these impairments. METHODS: We used as our data source the baseline (1984) and the 1988 reinterview from the Longitudinal Study of Aging, a nationally representative survey of noninstitutionalized persons 70 years of age and older. To determine the relationships of visual impairment and hearing impairment to future four-year disability, we used multiple variable modeling, controlling for demographic variables, selected chronic conditions, and baseline disability. RESULTS: Persons with visual impairment were 1.37 (95% CI:1.20-1.57) times more likely to have increased disability in ADLs than those without visual impairment. Hearing impairment was not independently related to increased ADL disability. CONCLUSIONS: Visual impairment by itself is an independent risk factor for future ADL disability. In light of the enlarging older population, maneuvers to ameliorate visual impairment may help to minimize the increase in numbers of disabled persons.