Cerebrovascular hemodynamics, gait, and falls in an elderly population: MOBILIZE Boston Study.

OBJECTIVE: To determine whether alterations in cerebral blood flow regulation are associated with slow gait speed and falls in community-dwelling elderly individuals. METHODS: The study sample consisted of 419 individuals from the MOBILIZE Boston Study (MBS) who had transcranial Doppler ultrasound measures of cerebral blood flow velocity. The MBS is a prospective cohort study of a unique set of risk factors for falls in seniors in the Boston area. We measured beat-to-beat blood flow velocity in the middle cerebral artery in response to 1) changes in end-tidal CO(2) (cerebral vasoreactivity) and 2) blood pressure changes during a sit-to-stand protocol (cerebral autoregulation). Gait speed was measured during a 4-meter walk. Falls were tracked by monthly calendars, and demographic and clinical characteristics were assessed at baseline. RESULTS: A multivariate linear regression analysis showed that cerebral vasoreactivity was cross-sectionally related to gait speed (p = 0.039). Individuals in the lowest quintile of vasoreactivity had lower gait speeds as compared to those in the highest quintile (p = 0.047). In a negative binomial regression analysis adjusted for relevant covariates, the relationship between cerebral vasoreactivity and fall rate did not reach significance. However, when comparing individuals in the lowest to highest quintile of cerebral vasoreactivity, those in the lowest quintile had a higher fall rate (p = 0.029). CONCLUSIONS: Impaired cerebral blood flow regulation, as measured by cerebral vasoreactivity to CO(2), is associated with slow gait speed and may lead to the development of falls in elderly people.

Delirium accelerates cognitive decline in Alzheimer disease.

OBJECTIVE: To examine the impact of delirium on the trajectory of cognitive function in a cohort of patients with Alzheimer disease (AD). METHODS: A secondary analysis of data collected from a large prospective cohort, the Massachusetts Alzheimer's Disease Research Center's patient registry, examined cognitive performance over time in patients who developed (n = 72) or did not develop (n = 336) delirium during the course of their illnesses. Cognitive performance was measured by change in score on the Information-Memory-Concentration (IMC) subtest of the Blessed Dementia Rating Scale. Delirium was identified using a previously validated chart review method. Using linear mixed regression models, rates of cognitive change were calculated, controlling for age, sex, education, comorbid medical diagnoses, family history of dementia, dementia severity score, and duration of symptoms before diagnosis. RESULTS: A significant acceleration in the slope of cognitive decline occurs following an episode of delirium. Among patients who developed delirium, the average decline at baseline for performance on the IMC was 2.5 points per year, but after an episode of delirium there was further decline to an average of 4.9 points per year (p = 0.001). Across groups, the rate of change in IMC score occurred about three times faster in those who had delirium compared to those who did not. CONCLUSIONS: Delirium can accelerate the trajectory of cognitive decline in patients with Alzheimer disease (AD). The information from this study provides the foundation for future randomized intervention studies to determine whether prevention of delirium might ameliorate or delay cognitive decline in patients with AD.

Abdominal aortic calcification and exostoses at the hand and lumbar spine: the Framingham Study.

Bony proliferation (exostoses) and vascular calcification are common in elderly men and women, but it is unclear whether they have a common etiology. Lateral lumbar and hand radiographs were obtained (1967-1970) in 777 men and 1,241 women (mean age 59, range 47-80 years) from the Framingham Heart Study. Each group of hand exostoses, specifically apiostoses (tufting), enthesophytes, and osteophytes, was graded on a scale of 0-3 (absent to severe) and summed across phalanges of digits 2-5. Anterior lumbar osteophytes were assessed in intervertebral spaces T12-L5 and abdominal aortic calcification (AAC) at lumbar segments L1-L4. Information on age, sex, body mass index, smoking, alcohol consumption, physical activity, systolic blood pressure, total cholesterol level, diabetes, and estrogen replacement therapy in women was obtained at the time of radiography and adjusted for in multivariate analyses. We used multivariable logistic regression models to assess the relationship between AAC (dependent variable) and exostoses for each sex. Multivariable adjusted logistic regression revealed a significant association between increased anterior lumbar osteophytes and prevalent AAC in men [odds ratio (OR) = 1.20, 95% confidence interval (CI) 1.1-1.3 per unit increase in osteophytes] and in women (OR = 1.25, 95% CI 1.1-1.4). There also was an inverse association between enthesophytes and AAC in women only (OR = 0.82, 95% CI 0.73-0.92). Apiostoses were weakly associated with AAC in men only. Hand osteophytes were not associated with AAC. In conclusion, in this cross-sectional study, anterior lumbar osteophytes and AAC occurred in the same individuals after adjustment for age and other covariates. In general, hand exostoses were not associated with aortic calcification.

Differing perceptions of end-of-life care in long-term care.

BACKGROUND: Care team members may have different views on end-of-life care, which may influence perceptions of that care. METHODS: Twenty-seven consecutive deaths at a long-term care facility were identified. A structured interview of primary care team members (physician, nurse, and aide) was administered. The interview asked comparable questions to each group on a Likert scale (1 = least satisfied; 4 = most satisfied) regarding the resident's experience in the last 3 days of life. Areas assessed were pain, comfort, emotional support, adequacy of information provided to families, whether direct care needs were met, supportive care, time spent with resident, number of symptoms present at the end of life, and quality of death. Repeated measures analysis of variance was used to determine if the mean values of various response measures differed significantly by rater group (i.e., physicians, nurses, or aides). RESULTS: Aides perceived more resident pain compared to physicians or nurses. Physicians' perceptions of emotional support provided to families were lower than those of aides or nurses. CONCLUSIONS: This study demonstrates differing perceptions by care team members regarding end-of-life care. Areas of difference include pain and emotional support provided to families. Because effective team functioning requires understanding and recognition of different perceptions of team members, clarifying and addressing the reasons for these differences may improve both job satisfaction on the part of care team members, as well as the quality of end-of-life care delivered.

Racial and state differences in the designation of advance directives in nursing home residents.

OBJECTIVES: To examine racial and state differences in the use of advance directives and surrogate decision-making in a nursing home population. DESIGN: A retrospective cohort study. SETTING: Nursing homes in the states of California (CA), Massachusetts (MA), New York (NY), and Ohio (OH). PARTICIPANTS: Nursing home residents: 130,308 in CA, 59,691 in MA, 112,080 in NY, and 98,954 in OH. MEASUREMENTS: Minimum Data Set information concerning resident race and whether or not residents have a living will (LW), a do not resuscitate (DNR) order, or a surrogate decision-maker (SDM). RESULTS: The proportion of LWs, DNR orders, and SDMs varied significantly (P < .0001) by racial categories in each state. In general, whites were distinctly different from other racial categories. Whites were significantly more likely to have a LW (odds ratio (OR) = 1.9 (CA), OR = 2.2 (NY), OR = 4.9 (OH)), a DNR order (OR = 2.4 (CA), OR = 2.4 (MA), OR = 3.3 (NY), OR = 3.2 (OH)), and a SDM (OR = 1.1 (CA), OR = 1.2 (NY), OR = 1.6 (OH)) than were nonwhites, after adjusting for potentially confounding factors. Significant state differences (P < .0001) were observed in LWs, DNR orders, and SDMs and were most pronounced in residents of Ohio, who were significantly more likely to have a LW than were residents in other states (OR = 9.3). CONCLUSIONS: Various resident characteristics explain some of the racial differences, although whites are still more likely to have a LW, a DNR order, or an SDM independent of various resident characteristics included in the adjusted analyses. This pattern is observed in all states, although the ORs varied by state. Some of these differences may be due to distinct cultural approaches to end-of-life care and lack of knowledge and understanding of advance directives. The distinctly higher rates of LWs among all racial groups in Ohio than in other states suggest that states can potentially increase the use of advance directives through intervention.

A cross-national comparison of institutionalized tube-fed older persons: the influence of contrasting healthcare systems.

OBJECTIVE: Different health care settings may influence the type of patients selected for long-term tube-feeding. Clinical characteristics of older, tube-fed institutionalized subjects living in Ontario, Canada were compared with those in the United States (US). DESIGN: A cross-sectional cohort study Setting: Nursing homes in the states of Mississippi, Texas, and Vermont (US) and chronic care facilities in Ontario. PARTICIPANTS: Tube-fed residents older than age 65 living in facilities in the US between January 1, 1996, and March 31, 1997 (n = 859), and in institutions in Ontario between January 1, 1996, and December 31, 1997 (n = 913). MEASUREMENTS: Data were obtained from Minimum Dataset assessments at both sites. Demographic and clinical characteristics were compared between tube-fed subjects living in the US and those in Canadian facilities. RESULTS: In a logistic regression model, the following characteristics were significantly more likely to be found among tube-fed subjects in the US than in those in Ontario: greater impairment of cognitive performance, cardiopulmonary disease, a diagnosis of dementia, female, and age greater than 80 years. Characteristics that were significantly less likely to be present among the US tube-fed subjects included: recurrent lung aspirations, a chewing or swallowing problem, do not resuscitate status, restraint use, weight loss, and stroke. CONCLUSIONS: Clinical characteristics differ between older, institutionalized tube-fed subjects in Ontario and in US nursing homes. In order to put these differences into context, consideration must be given to how the contrasting healthcare systems in these two countries may drive decision-making for long-term tube-feeding.

Resident characteristics associated with wandering in nursing homes.

OBJECTIVES: This retrospective cohort study examined the association between resident characteristics and the development of wandering behavior. METHODS: Subjects included a total of 8982 residents from the states of Mississippi, Texas, and Vermont who had baseline and 3-month follow-up Minimum Data Set assessments between 1 January 1996 and 31 December 1997. RESULTS: Residents who had a short-term memory problem (Odds Ratio (OR) = 3.05), had pneumonia (OR = 3.15), asked repetitive questions (OR = 2.19), had a long-term memory problem (OR = 2.06), exhibited dementia (OR = 19.4), constipation (OR = 1.82), expressed sadness or pain (OR = 1.65), and used antipsychotic medication (OR = 1.70), were at an increased risk for developing wandering behavior compared to residents without these characteristics. Residents with functional impairment (OR = 0.28) and women (OR = 0.61) were less likely to develop wandering behavior. CONCLUSIONS: Results of this study may be useful in constructing causal theories for the development of wandering behavior.

The protective effect of social engagement on mortality in long-term care.

OBJECTIVES: To examine the effect of social engagement (SE) on mortality in long-term care. DESIGN: A retrospective cohort study. SETTING: A 725-bed long-term care facility. PARTICIPANTS: A total of 927 long-term care residents who had SE measurements and did not have a serious communication problem. MEASUREMENTS: Minimum Data Set information including psychosocial items comprising an internally reliable and valid SE scale, and mortality risk factor measurements. Mortality data during the 1,721-day follow-up period was obtained from facility records. RESULTS: Life table analyses indicate that higher levels of SE are associated with longer survival (P = .0001). Unadjusted proportional hazards analyses show that residents who did not engage socially were 2.3 times more likely to die during the follow-up period compared with residents who were the most socially engaged. Multivariate adjusted analyses showed the protective effect of SE on mortality remained even after simultaneously adjusting for mortality risk factors. Residents who did not engage socially were 1.4 times as likely to die during the follow-up period compared with residents who were the most socially engaged. CONCLUSIONS: Increased levels of SE were associated with longer survival independent of mortality risk factors. SE may be a modifiable risk factor for death among long-term care residents. More research is needed to understand psychological factors that may influence residents' desire and ability to engage socially.

Autonomic and neurohumoral control of postprandial blood pressure in healthy aging.

BACKGROUND: Postprandial hypotension (PPH) is a common and morbid problem in elderly people that is associated with an impaired vascular response to meal digestion. Healthy aging in the absence of blood pressure elevation is associated with autonomic and neurohumoral changes that may influence the vascular response to meal ingestion. However, it is not known whether these age-related changes are associated with the development of PPH. METHODS: We measured hemodynamic (blood pressure, heart rate, and forearm vascular resistance), autonomic (power spectral analysis of heart rate and blood pressure variability), and neurohumoral (plasma norepinephrine, renin, aldosterone, and endothelin) responses to a mixed 425 kilocalorie (kcal) meal in 89 rigorously screened healthy subjects aged 20-39, 40-59, and 60-83 years. RESULTS: After the meal, supine mean arterial blood pressure fell significantly only in the middle-aged group by 5.4 +/- 7.9 mm Hg at 30 minutes (p = .02). Forearm vascular resistance fell after the meal in all age groups ( p = .0001). Older groups had higher plasma norepinephrine (p = .02), lower heart rate (p = .03), lower cardiovagal activity (p = .0001), and lower sympathetic vasomotor (p = .000) activity, but there was no difference in the response of these variables to a meal. CONCLUSION: Healthy aging, in the absence of blood pressure elevation, alters the level of autonomic activity without further impairing the ability to maintain blood pressure during meal digestion. Hemodynamic, autonomic, and neurohumoral responses to meal ingestion remain unchanged in very healthy, normotensive elderly adults.

Development of constipation in nursing home residents.

PURPOSE: Constipation is a common complaint among geriatric patients and may result in significant morbidity, especially among nursing home residents. The prevalence of constipation increases with advancing age and may be a result of the aging process, but the exact cause is unknown. The aim of this study was to describe the prevalence of constipation and to determine risk factors for the development of constipation in a large population of nursing home residents. METHODS: The Minimum Data Set is an assessment instrument used in nearly all Medicare-certified and Medicaid-certified nursing facilities. Nursing home residents who were at least 65 years of age and who had assessments at baseline and at three months were included in the study (N = 21,012). Baseline risk factors were included in a multivariate logistic regression to determine their association with the development of constipation. To allow causal implications, nursing home residents with constipation at baseline were excluded. The variables examined included medications, mobility, comorbid illness, and nutrition. RESULTS: The mean age (+/- standard deviation) of nursing home residents was 83 +/- 8 years, and the population was 70 percent female and 83 percent white. At baseline, the prevalence of constipation was 12.5 percent (N = 2,627). By the three-month assessment, 7 percent (N = 1,291) of nursing home residents had developed constipation. The factors associated independently with the development of constipation were, in order of magnitude, race, decreased fluid intake, pneumonia, Parkinson's disease, and the presence of allergies. Congestive heart failure and the use of a feeding tube were two factors identified as having a protective effect. CONCLUSION: The variables associated with the development of constipation may be used to identify geriatric nursing home residents at risk and to prevent constipation and its potential complications. Further study is needed to demonstrate a causal relationship between the risk factors and the development of constipation.

Predicting fractures using bone mineral density: a prospective study of long-term care residents.

Bone mineral density (BMD) has been shown to predict fracture risk in community-dwelling older persons; however, no comparable prospective study has been performed in the long-term care setting where the role of BMD testing is uncertain. To determine the ability of a single BMD measurement to predict the risk of subsequent fracture in long-term care residents, we designed a prospective study in a 725-bed long-term care facility. A total of 252 Caucasian nursing home residents (mean age 88 years, 74% women) were recruited between 1992 and 1998. BMD of the hip, radius or both sites was measured using dual-energy X-ray absorptiometry. Participants were followed through September 1999 for the occurrence of fracture. Cox proportional hazards regression models were constructed to determine the relationship between BMD and the risk of fracture controlling for potentially confounding variables. Sixty-three incident osteoporotic fractures occurred during a median follow-up time of 2.3 years. The multivariate-adjusted risk of fracture for each standard deviation decrease in BMD was 2.82 (95% CI 1.81-4.42) at the total hip, 2.79 (95% CI 1.69-4.61) at the femoral neck, 2.26 (95% CI 1.51-3.38) at the trochanter, 1.83 (95% CI 1.14-2.94) at the radial shaft and 1.84 (95% CI 1.21-2.80) at the ultradistal radius. Subjects in the lowest age-specific quartile of femoral neck BMD had over 4 times the incidence of fracture compared with those in the highest quartile. BMD at either hip or radius was a predictor of osteoporotic fracture, although in women, radial BMD did not predict fracture. Knowledge of BMD in long-term care residents provides important information on subsequent fracture risk.

Resident characteristics associated with mortality in long-term care nursing homes: is there a gender difference?

OBJECTIVE: To examine the gender-specific association between characteristics in established long-term care residents and 1-year risk of mortality. DESIGN: A retrospective cohort study. SETTING: The Hebrew Rehabilitation Center for Aged, a 725-bed long-term care facility in Boston, Massachusetts. The 778 participants included 188 men (24%) and 590 women (76%). MEASUREMENTS: Minimum Data Set (MDS) information, including items from the following sections: cognition, communication, psychosocial, functional, diseases, health conditions and medication use. RESULTS: Survival curves were significantly different for men and women (log rank test, P = 0.004). Based on proportional hazards analyses, increased age, (RR(m)=1.07, RR(w)=1.05), functional impairment (RR(m)=1.07, RR(w)=1.04), and weight loss (RR(m)=2.03, RR(w)=2.24) were associated with increased mortality in men and women. Additionally, shortness of breath (RR = 2.87) and lower body mass index (RR = 2.25) were associated with higher mortality in men, and diabetes (RR = 2.42), pressure ulcers (RR = 1.99), anemia (RR = 1.98), congestive heart failure (RR = 1.87), and a recent fall (RR = 1.88) were associated with higher mortality in women. CONCLUSIONS: Characteristics associated with 1-year mortality differ between men and women. These readily available data could be useful in making medical decisions and advance directives planning. Furthermore, these data may be beneficial in developing quality improvement initiatives and mortality prediction modeling.

Nursing rehabilitation and exercise strategies in the nursing home.

BACKGROUND: The purpose of this study was to evaluate how weight training or nursing-based rehabilitative care programs in nursing homes impact on resident performance of Activities of Daily Living (ADL) and objectives tests of physical performance. METHODS: This study involved a quasi-experimental control, longitudinal comparison of functional status over a 10-month period, where baseline status was adjusted through a weighting procedure based on functional status, cognitive status, and age. All residents from six residential care nursing home facilities were eligible except those with a terminal prognosis, a projected stay of less than 90 days, or with health complications that prohibited contact. Homes were placed into matched triplets based on patient characteristics: two members of each triplet were randomly designated to be experimental sites, the third became the control site. Baseline data were available for 468 subjects, follow-up for 392. ADL self-performance measures derived from the Minimum Data Set, including indicators of early loss ADL, locomotion, and late loss ADL; a number of objective functional tests (including measures of balance, power, and endurance); and mood state as measured by the Geriatric Depression Scale. RESULTS: Mean ADL values in the two experimental groups declined at a significantly lower rate than did rates for the controls. Functional decline was also lower in more specific measures: locomotion, early loss ADL, and late loss ADL. CONCLUSIONS: With both interventions, facilities were able to implement a broad-based intervention that resulted in a significant reduction in ADL decline rates. A facility-wide nursing rehabilitation program can play a useful role in reversing functional decline, helping residents to maintain their involvement in a broad spectrum of ADL activities.

Effects of postprandial walking exercise on meal-related hypotension in frail elderly patients.

The purpose of this study was to assess the hemodynamic effects of a postmeal walk in frail elderly patients with postprandial hypotension. We demonstrated that frail elderly patients with postprandial hypotension are able to increase their blood pressure and heart rate in response to a postmeal walking exercise, but this effect is limited to the exercise period only and is not sustained during subsequent rest.

Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure.

OBJECTIVE: To develop a condition-specific measure for assessing the impact of urge urinary incontinence (UI) on the quality of life (QoL) of older persons. DESIGN: A 32-item Urge Impact Scale (URIS) was drafted using content area data from focus groups composed of urge incontinent older persons. Pilot testing in 21 urge incontinent persons (mean age 67.7 years) resulted in the elimination of eight items by internal consistency, skew, and patient response criteria. The resulting scale (URIS-24) was tested for reliability (internal consistency and test-retest correlation) and construct validity (correlation with UI severity from voiding records) in a separate group of 27 urge incontinent persons (89% women, mean age 72 years). Factor analysis of URIS-24 data from the combined 48 persons was used to explore the conceptual structure underlying urge UI-related QoL. SETTING: University-affiliated community-based practice and tertiary hospital. PARTICIPANTS: Community-dwelling women and men, older than age 60 and with urge incontinence at least twice weekly, recruited from newspaper, newsletter, and radio advertisements. RESULTS: Cronbach's alpha for URIS-32 was 0.84, and for URIS-24 it was 0.94. When administered (mean +/- standard deviation) 9.2 +/- 5.1 days apart, URIS-24 had good test-retest reliability for total scores (interclass coefficient = .88, concordance coefficient = .88), and individual item scores at time 2 were within 1 point (on a 5-category Likert scale) of time 1 answers for 89% of responses. URIS-24 scores had modest but nearly significant correlation with the number of UI episodes (r = -0.39, P = .05). Factor analysis revealed a three component structure corresponding to psychological burden, perception of personal control, and self concept. CONCLUSIONS: The URIS-24 is an internally-consistent, highly reproducible tool for the assessment of the QoL impact of urge UI on older persons. It can be used to evaluate QoL impact by specific items as well as by overall score. Compared with other UI-specific QoL measures, the URIS-24 had similar or superior internal consistency, test-retest reliability, and validity, but it is the first measure designed and tested specifically for older persons with urge UI. These results also highlight the multifactorial structure of urge UI-related QoL and the importance of its psychological dimensions.

Effects of age and gender on autonomic control of blood pressure dynamics.

Both age and gender influence cardiovascular autonomic control, which in turn may influence the ability to withstand adverse cardiac events and respond to orthostatic stress. The purpose of this study was (1) to quantify age- and gender- related alterations in autonomic control of blood pressure (BP) and (2) to examine the impact of these autonomic alterations on BP response to orthostatic stress. We measured continuous BP and R-R intervals and vasoactive peptide levels in the supine and 60 degrees head-up tilt positions during paced respiration (0.25 Hz) in 89 carefully screened healthy subjects (41 men, 48 women, aged 20 to 83 years). Data were analyzed by gender (age adjusted) and by age group (gender adjusted). During tilt, women had greater decreases in systolic BP than men (-10.2+/-2 versus -1.2+/-3 mm Hg; P=0.02) and smaller increases in low-frequency (sympathetically mediated) BP power (P=0.02). Upright plasma norepinephrine was lower in women (P=0.02). Women had greater supine high-frequency R-R interval power than men (P=0.0001). In elderly subjects, the tilt-induced increase in low-frequency BP power was also diminished (P=0.01), despite higher supine (P=0.02) and similar upright norepinephrine levels compared with younger subjects. Thus, healthy women have less sympathetic influence on BP and greater parasympathetic influence on R-R interval than men. Elderly subjects also have reduced sympathetic influence on BP, but this appears to be more consistent with a reduction in vasomotor sympathetic responsiveness.

Atrial natriuretic peptide and the development of congestive heart failure in the oldest old: a seven-year prospective study.

BACKGROUND: Atrial natriuretic peptide (ANP) levels are elevated in symptomatic heart failure and correlate with invasively measured left heart pressures. OBJECTIVE: To examine the association between plasma ANP level and the subsequent development of congestive heart failure (CHF) in older subjects with no history of CHF. DESIGN: A 7-year, prospective, blinded, cohort study. SETTING: A life care facility in Boston, Massachusetts. PARTICIPANTS: Two hundred fifty-six frail older subjects (mean age 88 +/- 7) with no history of CHF at study entry. MAIN OUTCOME MEASURE: Clinical episodes of CHF with confirmatory chest roentgenogram findings. Cox proportional hazard analyses were performed to examine the relationship between ANP levels and the development of CHF while controlling for 19 clinical, physical, and laboratory parameters. A Kaplan-Meier estimator (log-rank test) was used to determine if the development of CHF differed by tertile of ANP. RESULTS: During the follow-up period, 32% of the cohort developed CHF. The mean ANP level in the CHF group was 95 pmol/L +/- 11 pmol/L versus 60 pmol/L +/- 5 pmol/L in the no CHF group (two tailed t test P = .005). On multivariate analysis, a high ANP level was found to be associated significantly (P = .01) with the development of CHF. CONCLUSIONS: There is a statistically significant association between ANP level and the subsequent development of CHF in frail older individuals with no history of CHF.

A practical approach to identifying mortality-related factors in established long-term care residents.

OBJECTIVE: Determining prognosis is an important part of medical planning for long-term care residents. Clarifying the resident characteristics associated with increased mortality has received little attention from investigators, and many approaches that have been suggested are unsuitable for widespread use. Using a readily available database, we sought to determine factors associated with 1-year mortality in established long-term care residents. DESIGN: A retrospective cohort study. SETTING: A 725-bed long-term care facility. MEASUREMENTS: We examined Minimum Data Set (MDS) information on 780 residents from April 1994 through August 1997. The association between death and 65 resident factors, covering a broad array of physical, functional, medical, and psychosocial measures, was examined initially in bivariate proportional hazards models. Putative factors with P values < .10 in bivariate analysis were considered in the multivariate analysis. Using these factors, we employed a forward step-wise multivariate proportional hazards regression method to select the set of factors associated independently with mortality at a P value < .05. A mortality score was developed by assigning points to each factor based on the risk ratio in the multivariate proportional hazards model. The performance characteristics of the model were examined using logistic regression. RESULTS: Forty-four of the 65 factors examined were associated with 1-year mortality in bivariate proportional hazards analysis. Eight of these 44 factors were associated with 1-year mortality in the multivariate proportional hazards regression. These factors were functional impairment, weight loss, shortness of breath, male gender, low body mass index, swallowing problems, congestive heart failure, and advanced age. A higher mortality score was associated with a higher death rate in the subsequent year. The model demonstrated good performance with an area under the ROC curve of 0.77. CONCLUSIONS: Using a widely available database that requires no additional medical testing or staff training, a useful model for identifying factors associated with 1-year mortality in established long-term care residents can be developed. Widespread use of such a practical approach to assess mortality risk could be of benefit to patients, their families, and physicians for informing care plan decisions.

Does artificial enteral nutrition prolong the survival of institutionalized elders with chewing and swallowing problems?

BACKGROUND: There is a lack of prognostic data regarding tube feeding of institutionalized elderly people. The objective of this study was to determine the impact of feeding tubes on the survival of nursing home residents with chewing and swallowing problems, and to follow the course of the tube-fed residents over one year. METHODS: We conducted a cohort study with 12-month follow-up using Minimum Data Set resident assessments from 1991. Participants included 5,266 nursing home residents over the age of 65 with chewing and swallowing problems living in 272 Washington state nursing homes. Residents who had a feeding tube were identified. Baseline clinical characteristics and 12-month survival were compared for residents with and without feeding tubes. The proportion of tube-fed residents who became tube-free during the follow-up period was determined, and clinical features that predicted this outcome were examined. RESULTS: Among the residents with chewing and swallowing problems, 10.5% had a feeding tube. After adjusting for potential confounding covariates, tube-fed residents had a significantly higher one-year mortality rate than those without feeding tubes (risk ratio, 1.44; 95% CI, 1.17-1.76). Of the 430 residents with feeding tubes who survived the follow-up period, 25.1% became free of a feeding tube. Age less than 87 years was associated with a significantly greater likelihood of becoming tube-free (odds ratio, 1.66; 95% CI, 1.03-2.6). CONCLUSIONS: Residents selected for feeding tube placement have poorer survival after one year than residents who are not tube-fed. However, the feeding tubes are removed in a significant proportion of residents who survive one year. Residents with a potentially reversible condition, for whom the feeding tubes are a temporary intervention, need to be identified.

Identifying nursing home residents at risk for falling.

OBJECTIVES: To develop a fall risk model that can be used to identify prospectively nursing home residents at risk for falling. The secondary objective was to determine whether the nursing home environment independently influenced the development of falls. DESIGN: A prospective study involving 1 year of follow-up. SETTING: Two hundred seventy-two nursing homes in the state of Washington. PARTICIPANTS: A total of 18,855 residents who had a baseline assessment in 1991 and a follow-up assessment within the subsequent year. MEASUREMENTS: Baseline Minimum Data Set items that could be potential risk factors for falling were considered as independent variables. The dependent variable was whether the resident fell as reported at the follow-up assessment. We estimated the extrinsic risk attributable to particular nursing home environments by calculating the annual fall rate in each nursing home and grouping them into tertiles of fall risk according to these rates. RESULTS: Factors associated independently with falling were fall history, wandering behavior, use of a cane or walker, deterioration of activities of daily living performance, age greater than 87 years, unsteady gait, transfer independence, wheelchair independence, and male gender. Nursing home residents with a fall history were more than three times as likely to fall during the follow-up period than residents without a fall history. Residents in homes with the highest tertile of fall rates were more than twice as likely to fall compared with residents of homes in the lowest tertile, independent of resident-specific risk factors. CONCLUSIONS: Fall history was identified as the strongest risk factor associated with subsequent falls and accounted for the vast majority of the predictive strength of the model. We recommend that fall history be used as an initial screener for determining eligibility for fall intervention efforts. Studies are needed to determine the facility characteristics that contribute to fall risk, independent of resident-specific risk factors.