Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention.

Little is known about the characteristics of elderly persons who present to an ED after a fall or about the nature of the care received for the fall itself. We identified elders presenting to a large urban United States ED after a fall, determined risk factors that may have contributed to the fall, and assessed the extent to which falls were addressed in the ED setting. One hundred seventeen fallers were identified. Nearly half were aged 80 years or older. After age, polypharmacy was the most common fall risk factor, followed by more than 1 contributing medical condition and cognitive impairment. Fall risk factors differed significantly for older compared with younger subgroups. More than half (57%) who had fallen were admitted. Of the remainder who fell and were discharged, more than half were scheduled for follow-up of their fall-related injury only, with no follow-up scheduled to address prevention of future falls. In summary, elders who present to an ED after having fallen have a variety of risk factors for falls that can be addressed to reduce their risk of future falls and injury; however, many may not receive such follow-up care. There must be increased awareness among ED providers of the need for a medical evaluation of a fall. Randomized trials evaluating the effect of a focused fall risk factor assessment after presentation to the ED may be warranted.

BMI and low bone mass in an elderly male nursing home population.

INTRODUCTION: Little is known about osteoporosis in institutionalized older adults. Risk factors such as low body mass index (BMI) have been investigated in female populations, but remain understudied in men. The objective of this study was to examine characteristics of older men residing in a nursing home who received bone mineral density evaluations. METHODS: 57 male Miami Veterans Affairs Medical Center (VAMC) nursing home residents were screened for osteoporosis using a peripheral dual X-ray (pDXA) technique. T-scores were categorized into three groups: normal (0 > -1); osteopenic (-1 to -2.49); osteoporotic (< -2.5). RESULTS: Average age was 76.2 years (standard deviation = 11.5; range: 48-100). T-scores indicated that 37.3% of the population was normal, 35.6% osteopenic, and 27.1% osteoporotic. 35.6% of patients had normal BMIs, 3.4% were underweight, 47.5% were overweight, and 13.6% were considered obese. There was a high prevalence of overweight and obese individuals (61.1%) in the osteopenic and osteoporotic groups. CONCLUSION: As expected, there was a high prevalence of low bone mass in our population (62%). However, overweight and obese men were more likely to have osteoporosis and osteopenia, contrary to literature and clinical knowledge. This finding may be partially explained by the prevalence of sedentary lifestyle and relative lack of weight-bearing activity in this group of men.

A statewide case-control study of spousal homicide-suicide in older persons.

OBJECTIVE: Homicide-suicides are rare relative to suicides and homicides, but these lethal events are an emerging public health concern. They have a mortality count similar to meningitis, pulmonary tuberculosis, influenza, and viral hepatitis, and the rate may be increasing in the United States, especially among older persons. The goal of this case-control study was to identify factors that differentiate older married men who commit homicide-suicide from those who commit suicide only. METHODS: A total of 20 spousal homicide-suicides involving persons age 55 years and older were ascertained in Florida between January 1, 1998 and December 31, 1999 from medical examiner records. Two suicide controls were matched to each homicide-suicide perpetrator by age, race, marital status, method of death, and medical examiner district. Perpetrator groups were compared on sociodemographic characteristics, medical variables, and autopsy findings. RESULTS: Homicide-suicide perpetrators displayed significantly more domestic violence or were caregivers for their wives, in contrast to suicide perpetrators, who had health problems and were receiving care from their spouses. Both groups of perpetrators had reported depressed mood, and there were no differences in sociodemographic factors. CONCLUSIONS: Depression plays a significant role in both homicide-suicide and suicide, but the associated factors are different: we see caregiving strain in perpetrators of homicide-suicide, and living with physical health disorders as a care-recipient in men who commit suicide. Marital conflict is a significant factor in some spousal homicide-suicides.

Antecedents of euthanasia and suicide among older women.

OBJECTIVES: To identify the characteristics of older women who sought Jack Kevorkian's assistance in dying and to compare them with those of an age-matched sample who committed suicide. METHOD: This retrospective case-control study compared all 18 women age 55 and older who died with the assistance of Jack Kevorkian and whose deaths were investigated in Oakland County, Michigan from 1995 to 1997 with all 15 women age 55 and older who committed suicide in the same county during the same time period. We coded 203 variables in 7 domains from medical examiner files, including autopsy findings. RESULTS: Significantly more of Kevorkian's cases had amyotrophic lateral sclerosis or multiple sclerosis (p = .018), a recent decline in health (p = .031), or inadequately controlled pain (p = .041). Women who committed suicide had more prevalent chronic illnesses and were more likely to have been diagnosed with clinically significant depression or other psychiatric disorders (p = .023). Both groups were significantly less likely to be married (p < .001) and more likely to be divorced (p < .001) than US Census data would predict. CONCLUSIONS: The different vulnerabilities of older women who want to die and either commit suicide or seek assistance deserve continued careful research. Poorly controlled pain was a factor in seeking assistance in dying, and depression and psychiatric disorders characterized older women who committed suicide in our study. Not having a spouse may increase isolation and reinforce the hopelessness of women who are living with catastrophic illness.

A newspaper surveillance study of homicide-suicide in the United States.

The objective of this study was to identify the number and subtypes of homicide-suicides in the United States by age group and state over a 3-year period from 1997 through 1999. A total of 673 homicide-suicides, including 674 perpetrators and 779 victims, were identified from Internet searches of 191 national newspapers, and they were classified according to a modified Hanzlick-Koponen typology. One quarter of the homicide-suicides were perpetrated by persons 55 years or older, and 77% were spousal/consortial, higher than the 57% observed in the younger age group; 11% of the older homicide-suicides were familial, compared with 16% in the younger age group. Whereas only 3% of older homicide-suicides were infanticide/pedicide, 16% of the younger homicide-suicides involved parents killing their children. Forty-five states, including the District of Columbia, reported a homicide-suicide during the 3-year period, and they occurred most frequently in Florida (163), California (98), Texas (36), and New York (35). Newspaper surveillance is useful to identify where homicide-suicides are occurring most frequently, but they are underestimates of the true prevalence. However, the number of incidents detected is large enough that the cases detected may be a fairly representative sample.