Resident contact with family and friends following nursing home admission.

PURPOSE: This study explored factors that are related to the level of contact (number of visits and calls) between newly admitted nursing home residents and their family and friends. In addition to reexamining factors studied previously, several new factors were explored: contact level prior to nursing home placement, dementia status, and resident race. DESIGN AND METHODS: Interviews were conducted with the significant others of 1,441 residents from a representative sample of nursing homes in Maryland. RESULTS: Contact decreased by approximately half following admission, compared to reported preadmission contact. Rates of contact are positively related to nonuse of Medicaid, kinship closeness, support network proximity, nondemented status, and White race. After controlling for preadmission contact, postadmission contact is positively associated with kinship closeness, support network proximity, nondemented status, and White race. IMPLICATIONS: The study identifies factors that are useful to consider when designing interventions to increase family involvement with nursing home residents.

Serum and urine markers of bone metabolism during the year after hip fracture.

OBJECTIVE: As part of a larger study to describe indices of recovery during the year after hip fracture, the current prospective study investigated longitudinal changes in serum and urine markers of bone metabolism for the year after hip fracture and related them to bone mineral density (BMD). DESIGN: A representative subset of participants provided serum and urine samples and had bone density measured at 3, 10, 60, 180, and 365 days postfracture. SETTING: Two Baltimore hospitals. PARTICIPANTS: The subjects were 205 community-dwelling, white women age 65 and older with fresh proximal femur fractures. MEASUREMENTS: Samples were assayed for specific bone-related proteins and bone turnover markers, including serum osteocalcin (OC), procollagen type 1 carboxy-terminal extension peptide (PICP), bone-specific alkaline phosphatase (BAP), and urinary deoxypyridinoline (DPD) cross-links. Selected hormonal regulators of bone metabolism, including parathyroid hormone (PTH), calcitonin (CT), 1,25-dihydroxy vitamin D(3) (1,25 (OH)(2)D), and estrone (E(1)) were measured from serum samples. Repeated measures analyses were used to evaluate postfracture changes in each of the markers. RESULTS: BAP, OC, and PICP were most active during the early postfracture period (3-60 days). BAP and OC remained elevated at 365 days compared with 3 days. DPD rose 48% from 3 days to 60 days, but this difference was not statistically significant. PTH and 1,25 (OH)(2)D increased steadily and significantly from 3 to 365 days. E(1) was highest at baseline and decreased at each time point, whereas CT showed no significant changes. When subjects were stratified into high-, medium-, and low-BMD groups based on their measurement at 3 days, both osteoclastic and osteoblastic markers in the low-BMD group displayed exaggerated and different patterns over time compared with the other groups. CONCLUSION: Currently, the standard treatment of care for hip fractures still results in high morbidity and mortality and failure to regain prefracture quality of life. Gaining an understanding of bone cell activity in these patients after hip fracture, derived by measuring markers longitudinally during recovery, provides a baseline by which to measure the effectiveness of new interventions to improve recovery from hip fracture.

Extending gerontological research through linking investigators' studies to public-use datasets.

PURPOSE: Public-use datasets can extend data collected by individual investigators in various ways: making external comparisons, providing additional data on individual respondents, and creating internal comparison groups. The authors describe the advantages and limitations of these methods and practical and conceptual issues in combining investigator-initiated and public-use datasets. DESIGN AND METHODS: These issues are illustrated with a study of functional decline among 674 patients following hospitalization for hip fracture that was augmented with data from a public-use dataset, the Established Populations for Epidemiologic Studies of the Elderly (EPESE). RESULTS: By creating an internal comparison group of EPESE respondents, frequency matched to hip fracture patients on age, sex, and baseline functional limitations, the authors formed a single dataset and performed multivariable analyses of factors associated with functional decline. IMPLICATIONS: Gerontological research may benefit by applying these methods to program evaluations and longitudinal analyses of health outcomes with numerous public-use datasets.

The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group.

This study estimated the prevalence of dementia in 2,285 new admissions age 65+ to a statewide sample of 59 nursing homes in Maryland, 1992-1995. Dementia was ascertained according to DSM-III-R criteria by an expert panel of geriatric psychiatrists, neurologists, and a geriatrician using detailed information collected by trained lay evaluators from residents, family, staff, and medical records. Admissions to Maryland nursing homes are similar to admissions to nursing homes elsewhere in the United States. The prevalence of dementia was 48.2% (CI: 43.6-52.8) with an upper bound estimated at 54.5% (CI: 49.9-59.1). Prevalence is highest in facilities with <50 beds versus 200+ beds (65.5% vs 39.6%) and those in urban versus rural areas (50.0% vs 39.1%). Those who are non-White, married, and with fewer years of education are more likely to be demented. Prevalence is highest among those with 4+ physical impairments versus 0-1 (60.3% vs 27.7%) and lowest in those with 4+ comorbidities versus 0-1 (44.8% vs 52.0%). There was considerable overlap in the comorbid status of demented and nondemented admissions, and both groups contained members with only a few functional limitations. Results suggest that the level of medical supervision provided in nursing homes may not be required for some residents with dementia.

The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes.

OBJECTIVES: This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument. DESIGN: A cross-sectional comparisons of the MDS measures, with scales provided by the resident, a proxy person, and nursing staff. SETTING: Subjects residing in 59 nursing homes (NHs) in Maryland from 1992 to 1995. PARTICIPANTS: Subjects were 1939 new admissions to NHs, aged 65 and older, with complete MDS information at admission. MEASUREMENTS: Two MDS scales, the Cognitive Performance Scale (CPS) and the MDS Cognition Scale (MDS-COGS), were compared with the Mini-Mental State Examination (MMSE) and the staff rating on the Psychogeriatric Dependency Rating Scale (PGDRS) Orientation scale, as well as measures of functioning and functional decline. RESULTS: The CPS and the MDS-COGS were highly correlated (r = 0.92). Both correlated moderately well with the MMSE (r = -0.65 and -0.68) and with staff's rating on the PGDRS Orientation scale (r = 0.63 and r = 0.66). Correlations with the MMSE (r < 0.70) are lower than previously reported (r > or = 0.80). The proportion of cognitively impaired residents in this NH admission cohort was higher using the MDS-COGS than the CPS (65% vs 57%), but both MDS scales produced lower proportions than the MMSE (70%) and higher proportions than the PGDRS (47%). The internal consistency of the CPS was better without the comatose item (alpha = 0.80 vs 0.70). The MDS-COGS had higher internal consistency (alpha = 0.85) and was simpler to compute. CONCLUSIONS: This is the first study to examine the validity of the MDS in a large sample of residents and NHs in situations where the MDS was not completed by research-trained staff. Compared with other instruments, the MDS-COGS and the CPS had moderate and similar validity for assessing cognitive impairment. Differences in the scales could provide different estimates of impairment among persons admitted to nursing homes.

Outcome expectations for exercise scale: utility and psychometrics.

OBJECTIVES: The purpose of this study was to develop a measure of outcome expectations for exercise specifically for the older adult (The Outcome Expectations for Exercise [OEE] Scale), and to test the reliability and validity of this measure in a sample of older individuals. This scale was developed based on Bandura's theory of self-efficacy and the work of prior researchers in the development of measures of outcome expectations. METHODS: The OEE scale, which was completed during a face-to-face interview, was tested in a sample of 175 residents in a continuing care retirement community. RESULTS: There was support for the internal consistency of the OEE scale (alpha coefficient of .89), and some support for reliability based on a structural equation modeling approach that used R2 estimates, although less than half of these were greater than 0.5. There was evidence of validity of the measure based on: (a) a confirmatory factor analysis in which the model fit the data (normed fit index [NFI] = .99, root mean square error of approximation [RMSEA] - .07, chi2/df = 2.8); (b) support for the hypothesis that those who exercised regularly had higher OEE scores than those who did not (F = 31.3, p < .05, eta squared = .15); and (c) a statistically significant relationship between outcome expectations and self-efficacy expectations (r = .66). DISCUSSION: This study provides some initial support for the reliability and validity of the OEE scale. Outcome expectations for exercise were related to exercise behavior in the older adult, and the OEE scale can help identify older adults with low outcome expectations for exercise. Interventions can then be implemented to help these individuals strengthen their outcome expectations, which may subsequently improve exercise behavior.

Racial differences in the prevalence of dementia among patients admitted to nursing homes.

OBJECTIVE: The purpose of this study was to determine the prevalence of dementia among black and white residents on admission to nursing homes and to determine whether demographic and health characteristics known to be associated with dementia were correlated with dementia in this population. METHODS: Data from medical records and structured interviews with family members, nursing staff, and nursing home residents were gathered for 2,285 persons newly admitted to nursing homes in Maryland from 1992 to 1995. A stratified sample of 59 nursing homes was used. An expert panel of five physicians classified each resident as demented, nondemented, or indeterminate. Associations between dementia status, race, and selected characteristics were examined. RESULTS: Black residents (77 percent) were significantly more likely than white residents (57 percent) to be classified as demented. Older age was associated with dementia in both races. Less education, male gender, and a history of a cerebrovascular accident were associated with an increased prevalence of dementia among white residents only. After demographic and health characteristics associated with dementia were controlled for, black race remained independently associated with a diagnosis of dementia. CONCLUSIONS: The rate of dementia on admission to nursing homes was higher among black residents than among white residents, a finding that has implications for the delivery of care. The higher rate may be due to psychosocial factors operating differently in blacks and whites that influence the timing of admission to a nursing home.

Recovery from hip fracture in eight areas of function.

BACKGROUND: This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. METHODS. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990-1991 were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. RESULTS: Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months). CONCLUSIONS: Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.

Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes.

BACKGROUND: Hip fracture patients are at increased risk of confusion or delirium due to the trauma associated with the injury and the rapid progression to hospitalization and surgery, in addition to the pain and loss of function experienced. Hip fracture patients who develop delirium may require longer hospital stays, are more often discharged to long-term care, and have a generally poor prognosis for returning home or regaining function in activities of daily living (ADL). METHODS: The present study examines the impact of delirium present on hospital admission in a sample of 682 non-demented, aged hip fracture patients residing in the community at the time of their fracture. In-hospital assessments designed to assess both prefracture and postfracture functioning, as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were obtained from participants. RESULTS: Analyses indicate that baseline or admission delirium is an important prognostic predictor of poor long-term outcomes in persons without known cognitive impairment, after controlling for age, gender, race, comorbidity, and functional status. Delirium at admission (i.e., prior to surgery) was associated with poorer functioning in physical, cognitive, and affective domains at 6 months postfracture and slower rates of recovery. Impairment and delays in recovery may be further exacerbated by increased depressive symptoms in confused patients over time. Delirium on hospital admission was not a significant predictor of mortality after adjustment for confounding factors. CONCLUSIONS: The present findings further emphasize the significance of immediate detection and treatment of delirium in hip fracture patients to ameliorate the short and long-term effects of acute confusion on functional outcomes.

Change in muscle mass and muscle strength after a hip fracture: relationship to mobility recovery.

BACKGROUND: Hip fracture in elderly persons has a serious impact on long-term physical function. This study determines the change in muscle strength and muscle mass after a hip fracture, and the associations between these changes and mobility recovery. METHODS: Ninety community-dwelling women aged 65 years and older who had recently experienced a fracture of the proximal femur were included in the study. At 2 to 10 days after hospital admission, the women's grip strength, ankle dorsiflexion strength, and regional muscle mass (by dual-energy x-ray absorptiometry) were measured, and the prefracture level of independence for five mobility function items was assessed. All measurements were repeated at 12 months. RESULTS: At follow-up, only 17.8% of the women had returned to their prefracture level of mobility function for all five items. Mobility function recovery was not related to change in skeletal muscle mass of the nonfractured leg or the arms. However, women who lost grip strength (mean loss of -28.7%, SD = 16.9%), or who lost ankle strength of the nonfractured leg (mean loss of -21.5%, SD = 14.7%), had a worse mobility recovery compared with those who gained strength (p = .04 and p = .09, respectively). In addition, chronic disease (p = .03), days hospitalized (p = .04), and self-reported hip pain (p = .07) were independent predictors of decline in mobility function. CONCLUSIONS: The results suggest that loss of muscle strength, but not loss of muscle mass, is an independent predictor of poorer mobility recovery 12 months after a hip fracture. When confirmed by other studies, these findings may have implications for rehabilitation strategies after a hip fracture.

Low bone mineral density and risk of fracture in white female nursing home residents.

CONTEXT: Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear. OBJECTIVE: To assess the relative contribution of low BMD to fracture risk in nursing home residents. DESIGN: Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PATIENTS: A total of 1427 white female nursing home residents aged 65 years or older. MAIN OUTCOME MEASURE: Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors. RESULTS: A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship. CONCLUSIONS: Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977

Professional environmental assessment procedure for special care units for elders with dementing illness and its relationship to the therapeutic environment screening schedule.

The Professional Environmental Assessment Procedure (PEAP) was developed as a global quality-assessment measure for use by trained professionals in special care units for older people in dementia units of nursing homes. The PEAP consists of nine ratings whose relationship to another assessment device, the Therapeutic Environment Screening Schedule (TESS), is reported. Although designed to be multidimensional, the PEAP as tested in 43 special care units seems to reflect primarily a single evaluative dimension. It correlates highly with the TESS and may be used either separately or in combination with the TESS.

Loss of bone density and lean body mass after hip fracture.

Few studies of bone loss have assessed the amount of loss directly after a hip fracture. The present prospective study was conducted to determine changes in bone mineral density (BMD) and muscle mass shortly after fracture and through 1 year to assess short-term loss and related factors. The setting was two acute care teaching hospitals in Baltimore, Maryland, and subjects were 205 community-dwelling women with a new fracture of the proximal femur between 1992 and 1995. Bone density of the nonfractured hip and whole-body and body composition were measured by dual-energy X-ray absorptiometry at 3 and 10 days and 2, 6 and 12 months after admission. Mean BMD of the femoral neck was 0.546 +/- 0.007 g/cm(2) at baseline. Average loss of femoral neck BMD from baseline was 2.1% at 2 months, 2.5% at 6 months and 4.6% at 12 months. The average loss of BMD in the intertrochanteric region was 2.1% at 12 months. Total lean body mass decreased by 6% while fat mass increased by 3. 6% by 1 year after the fracture. These findings indicate that significant loss in BMD and lean body mass occur shortly after hip fracture while body fat increases. Continued loss was evident throughout the 1 year of follow-up. This loss of both bone density and muscle mass may lead to new fractures.

Spinal anesthesia versus general anesthesia for hip fracture repair: a longitudinal observation of 741 elderly patients during 2-year follow-up.

The Baltimore Hip Studies, a multicenter, noninterventional, observational trial, provided an opportunity to investigate the effects of anesthetic technique on the long-term outcome of elderly patients after hip fracture repair. Detailed interviews assessing functional status and pain were conducted during the hospital stay. Out-of-hospital evaluations were repeated after the procedure at 2, 6, 12, 18, and 24 months with a portable gait and balance laboratory. Multivariate analysis was done to determine the effects of anesthetic technique on functional and other outcomes, after controlling for multiple baseline variables. Of 741 enrolled patients who completed the study, 430 and 311 patients received spinal anesthesia or general anesthesia, respectively. Subgroup analysis of three spinal anesthetics, tetracaine, lidocaine, and epinephrine, was also done. In the present large observational study, general anesthesia was at least as efficacious as spinal anesthesia, and possibly better, in affording good long-term outcome.

Serum concentrations of steroids, parathyroid hormone, and calcitonin in postmenopausal women during the year following hip fracture: effect of location of fracture and age.

BACKGROUND: Hip fracture in the aged is a major health problem, especially considering the increasing proportion of the elderly in the population. This study examines changes in circulating levels of hormones, which are purported to affect bone metabolism, in response to hip fracture in postmenopausal women. METHODS: Patients consisted of women ages 65 and older who had surgery within 2 days of fracture. Serum samples were obtained at 3, 10, 60, 180, and 360 days postfracture. Healthy women without hip fractures from the same age range served as a control group (n = 17). Hormones were determined by radioimmunoassay. Subjects with fractures in the neck region of the femur (n = 78) were compared to subjects with fractures in the trochanteric region (n = 88). RESULTS: Estrone concentration (47.6 +/- 5.7 pg/mL; mean +/- SEM) at 3 days postfracture was elevated (p < .001) compared to control levels of 20.7 +/- 4.6 pg/mL. By 2 months, levels had declined to control levels. Androstenedione and the adrenal hormones, DHEAS and cortisol, displayed similar responses. Parathyroid hormone (PTH) levels were not significantly different from the control concentration at 3 days following fracture, but increased (p < .001) during the year following fracture. Calcitonin concentrations were much higher (p < .001) 3 days postfracture (42.1 +/- 3.7 pg/mL) compared to controls without fracture (9.8 +/- 3 pg/mL). Except for testosterone, no differences could be attributed to fracture location. Only PTH, with concentrations higher in the older age groups (p < .001), showed an age-related response. CONCLUSIONS: Following hip fracture, there are some dramatic responses in hormones that purportedly are mechanistically important in bone metabolism. These changes include transient increases in steroid hormones, chronic elevations in calcitonin, and rising levels of PTH during the year after fracture.

The prevalence of osteoporosis in nursing home residents.

This study describes the prevalence of osteoporosis in a statewide sample of nursing home residents. Composite forearm bone mineral density (BMD) (including the distal radius and the distal ulna) of 1475 residents aged 65 years and older from 34 randomly selected, stratified nursing homes was assessed. BMD was expressed with reference to World Health Organization diagnostic criteria. Trends with age, gender and race were consistent with other populations. However, prevalence estimates were higher than community-based age-specific rates. The prevalence of osteoporosis for white female residents increased from 63.5% for women aged 65-74 years to 85.8% for women over 85 years of age. Only 3% had composite forearm BMD within 1 standard deviation of the young adult mean. The significance of the high prevalence of low BMD in nursing home residents is the increased fracture risk it may confer. In community cohorts of white women, the risk of hip fracture increases approximately 50% for every 1 standard deviation decrease in bone mass. However, the degree to which BMD contributes to fracture risk in this population has not been well established.

Depressive symptoms and 6-year mortality among elderly community-dwelling women.

Depression is associated with an increased risk of mortality in studies that included adults of all ages, but results of studies restricted to older adults are less consistent. This study evaluated the association between depressive symptoms and mortality among 764 white women aged 65+ years in Baltimore, Maryland, and examined methodologic and conceptual issues regarding this association. The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered in face-to-face interviews in 1984. Mortality data were collected through 1990. The 6-year risk of death was 14.5% among women with CES-D scores of 0-1, 24% to 28% among women with scores of 2-24, and 47% among those with scores over 24. The adjusted hazards ratio (RR) comparing women with the highest (25-58) vs lowest (0-1) scores was 1.77 (95% confidence interval (CI) = 0.91-3.42). Depressive symptoms were only weakly associated with mortality when using the CES-D scale dichotomized at the traditional cutpoint of 16 (RR = 1.10, CI = 0.73-1.66), or when the follow-up period was 2 years. Furthermore, depressive symptoms were associated with mortality only among women in poor health. The association between depressive symptoms and mortality risk appeared to be affected by baseline physical health, length of follow-up, and measurement of depression.

Use of the Apathy Evaluation Scale as a measure of motivation in elderly people.

Motivation plays an important part in an elderly individual's ability to recover from a disabling event. On the other hand, apathy is a lack of motivation. The Apathy Evaluation Scale (AES) is an 18-item instrument that rates a person's thoughts, actions, and emotions over the previous 4 weeks. The purpose of this study was to use the AES with 102 patients in a geriatric rehabilitation program to determine if it predicted improved function after rehabilitation. In addition, a short 7-item version of the AES was tested. A strong correlation was demonstrated between the 18-item AES and the 7-item AES, the Mini-Mental State Examination, and the Geriatric Depression Scale. In separate regression analyses, we found that admission function and both the 18-item and 7-item AES were significant predictors of discharge function, and that functional level at admission to rehabilitation accounted for 31% of the variance in function after rehabilitation. The findings suggest that the AES might be an appropriate measure of motivation in older adults and might predict success in rehabilitation. Moreover, the ability to identify patients with low motivation can alert healthcare providers to develop interventions to improve older adults' motivation and help them attain and maintain their highest functional level.