Pinosylvin methyl ether deters snowshoe hare feeding on green alder.

Pinosylvin methyl ether (PME), a toxic phenol, is a potent deterrent to showshoe hare feeding on green alder. Concentrations of PME found in green alder parts can account for the low palatability of winter-dormant foliar buds and staminate catkins but cannot affect internode palatability. The lack of a PME-related defense system in internodes suggests that green alder has at least a two-level defense system: defense of growth stages and defense of parts within growth stages.

Improved survival for frail elderly inpatients on a geriatric evaluation unit (GEU): who benefits?

Previously reported data from a randomized controlled trial showed that admission to the geriatric evaluation unit (GEU) and follow-up clinic at the Sepulveda VA Medical Center leads to significantly improved outcomes for frail elderly hospital patients--including a 50% reduction of one-year mortality (p less than 0.005). In the present paper, two-year survival curves for GEU and control groups are reported. In addition, we subdivided the population by potential baseline risk factors (both patient- and treatment-related) and examined one-year survival using 12-month survival curves and odds ratios. There is evidence for GEU-related survival effects in specific subgroups of patients (e.g. patients with heart and pulmonary disease, patients with low baseline scores in functional status and mental status, and patients with high baseline morale scores). Finally, employing stepwise logistic regression, we determined the predictors of one-year survival in the pooled study population. These factors were: assignment to the GEU (adjusted odds ratio = 2.45; p less than 0.001); not having a heart diagnosis (2.24; p less than 0.001); and having primarily "geriatric/rehabilitation" problems (1.95; p less than 0.005). A predictive model derived from the regression defines patient subgroups likely to survive only when assigned to the GEU: cardiac patients with primarily "geriatric" or "rehabilitation" problems, and non-cardiac patients whose problems are primarily "medical". The dramatic effect of the GEU on survival appears to be concentrated on certain identifiable subgroups of patients who might be targeted to maximize program cost-effectiveness.

Predictors of immediate and 6-month outcomes in hospitalized elderly patients. The importance of functional status.

This article presents results of a prospective multivariate study of hospitalized elderly patients at an acute-care Veterans Administration (VA) hospital to identify factors on hospital admission predictive of several short- and long-term outcomes: in-hospital and 6-month mortality, immediate and delayed nursing home admission, length of hospital stay, and 6-month rehospitalization. All patients aged 70 years and over admitted to acute-care beds on the medical service wards during a 1-year period were included in the study (N = 396). Factors most predictive of 6-month mortality (using logistic regression) were decreased functional status, admitting diagnosis, and decreased mental status. Factors most predictive of nursing home admission were decreased functional status, living location, and decreased mental status. Functional status was a stronger predictor of length of stay, mortality, and nursing home placement than was principal admitting diagnosis--of relevance to the current emphasis on diagnosis-related groups (DRGs). These data may be helpful in improving discharge planning, in resource allocation, and in targeting patients for different specialized geriatric programs.

Ethnicity and decision-makers in a group of frail older people.

OBJECTIVE: To assess the relationship between ethnicity and decision-makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All-inclusive Care for the Elderly (PACE). DESIGN: A retrospective chart review of 1193 participants in the PACE program. SETTING: Program of All-inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation. PARTICIPANTS: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non-Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian. MEASUREMENTS: Demographic characteristics of the patients and the presence or absence of an alternative decision-maker; the characteristics of alternative decision-makers included the relationship to the participant as recorded in the patient's medical record. RESULTS: Ninety-one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision-maker was identified for about 15% of Asians and Hispanics and for one-third of blacks, but only about 8% of whites had an alternative decision-maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision-maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision-maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision-maker. CONCLUSIONS: In this population, we found significant ethnic variation in the person identified to be the decision-maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross-cultural patterns in identified or de facto decision-makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.

Differential prognosis and utilization patterns among clinical subgroups of hospitalized geriatric patients.

While screening elderly inpatients on acute Veterans Administration (VA) hospital wards for a special geriatric program, we prospectively classified all patients age 65 and over, who had been hospitalized at least a week, into five clinical subgroups using specific diagnostic, prognostic, and functional criteria. These five subgroups were "geriatric evaluation unit (GEU) candidate", "severely demented", "medical", "terminal", and "independent". Medical record data from the initial admission and a full year of follow-up were collected from random samples of each subgroup and of nonscreened patients who had been hospitalized for less than a week. Analysis revealed that each subgroup had a distinctive pattern of survival, living location, and use of institutional services during the follow-up period. For one major subgroup ("GEU candidate"), a specific intervention (the GEU) has proved very effective in reducing mortality, increasing patient functioning, improving placement, and decreasing use of institutional services. Moreover, there are specific treatment and intervention strategies appropriate for each of the other subgroups (e.g., hospital-based home care, hospice, respite, and day treatment programs), although these services are not universally available nor clearly proved effective. The process of identifying patient subgroups illustrated in this study may be useful in needs assessment, in planning new intervention programs for frail elderly patients, and for identifying appropriate patients for these programs.

The development of health and social services for the elderly in Iceland: an overview.

In the present paper, we provide a general overview of the changing position of the aged population in Iceland. After a long history of subsistence, Icelandic society has evolved only recently from pre-industrial conditions compared with other Western developed nations. The 1000-year preindustrial record is in large part one of a struggle for survival in which formal and informal measures to support the frail and disabled were often overwhelmed by disease and famine; this history is outlined to provide a baseline for recent changes. Both the speed and propinquity of Iceland's transition from these conditions have left a unique stamp on the present-day society: development has driven a quick elaboration of occupational roles and other social status shifts, vast health status improvements, and great population and urban growth. Public and personal health services have grown in scope and adequacy in comparatively recent decades, contributing to the now unsurpassed health status of the general population. The effect of these trends on the condition of elderly is described. As the birth rate in Iceland has dropped in recent decades, the proportion and number of Icelanders in the older and especially the oldest age-strata has been steadily rising. The current and planned organization of health and social services is reviewed, as Iceland faces new tasks of caring for elderly.

Geriatric assessment on a subacute hospital ward.

The authors collected data on all patients admitted to the Sepulveda Veterans Administration Geriatric Evaluation Unit (GEU) during its first 6 years of operation. Analysis of these data indicate several beneficial effects associated with this type of specialized geriatric care: improved diagnostic accuracy, reduced use of drugs, improved functional status, and improved placement location. The authors also analyzed additional data from a previously published, randomized controlled trial to compare better process of care between patients randomized to the GEU and those receiving usual services. During their initial hospitalizations, GEU patients received significantly more specialty evaluations than controls (4.9 versus 1.7, p less than .001), had longer lengths of stay (85.1 days versus 44.3 days, p less than .001), had more new diagnoses discovered (2.9 versus 0.6, p less than .001), and had more drugs discontinued from their regimens (4.6 versus 2.3 p less than .001). These process differences were probably related to the previously reported outcome differences: GEU patients were more likely than controls to show improvements in functional status, affect, placement location, use of institutional services, and survival.

[Preserving of independence: effectiveness of multi-dimensional geriatric assessment]. / Erhaltung der Selbständigkeit: Wirksamkeit des multidimensionalen geriatrischen Assessment.

Comprehensive geriatric assessment (CGA) is defined as the process of determining an elderly person's medical, psychosocial, functional, and environmental resources and problems, linked with an overall plan for treatment and follow-up. The principles of geriatric assessment, including the advantages and disadvantages of using quantitative instruments for multi-dimensional evaluation, are reviewed. The findings of a recently published meta-analysis on comprehensive geriatric assessment are discussed and its policy implications addressed. The meta-analysis includes data of 28 controlled trials comprising 4959 subjects allocated to one of five CGA types, and 4912 control subjects. Original investigators provided additional unpublished data from published reports to supplement the data base of this meta-analysis. The combined odds ratios of outcomes in CGA-assessed patients versus control patients were obtained by pooling data from individual trials with a multivariate logistic regression approach. The combined odds ratio (95% confidence interval) of home survival at 1 to 4-year follow-up was 1.7 (1.2-2.3) for inpatient geriatric evaluation and management units, 1.5 (1.1-2.0) for post-discharge home assessment services, and 1.2 (1.1-1.4) for preventive in-home assessment services. Based on these research findings, the establishment of interdisciplinary units with staff trained in multidimensional geriatric assessment for inpatient evaluation and management of frail elderly patients, is recommended. In addition, research to improve geriatric assessment technology and promote its integration into primary care has a great potential for disability prevention and nursing home use reduction in older persons.

Systematic biases in functional status assessment of elderly adults: effects of different data sources.

Measuring functional status using specific instruments is an important part of geriatric assessment. These instruments, however, often rely on data sources different from those with which they were originally validated. To study possible biasing effects of different data sources on functional status scores, we examined scores for two widely used instruments (the Lawton Personal Self-Maintenance Scale, PSMS, and Instrumental Activities of Daily Living, IADL, Scale) on a group of hospitalized elderly (n = 61) using three different data sources (the patients themselves, the patients' nurses, and significant others). Analysis showed that PSMS scores derived from patients were significantly higher than scores derived from significant others (p less than .025) and that patient-derived IADL scores were significantly higher than both nurse-derived scores (p less than .001) and significant-other-derived scores (p less than .001). We also compared scores for a group of nursing home patients (n = 68) on the Katz Activities of Daily Living (ADL) Scale, using data obtained from patients and their nurses. Again, the patient-derived scores were significantly higher than those from nurses (p less than .001). We conclude that data sources for determining patient functional ability are not interchangeable and that patients may overstate their functional abilities, whereas significant others may understate them, relative to judgments of skilled nursing personnel.

Comprehensive geriatric assessment: a meta-analysis of controlled trials.

There is disagreement on the usefulness of comprehensive geriatric assessment (CGA) due to conflicting results from individual trials. We did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five CGA types and 4912 controls. Published data were supplemented with reanalysed data provided by the original investigators. We calculated combined odds ratios of important outcomes by pooling data from individual trials with multivariate logistic regression. Combined odds ratio (95% confidence interval) of living at home at follow-up was 1.68 (1.17-2.41) for geriatric evaluation and management units, 1.49 (1.12-1.98) for hospital-home assessment services, and 1.20 (1.05-1.37) for home assessment services. Covariate analysis showed that programmes with control over medical recommendations and extended ambulatory follow-up were more likely to be effective. Our analysis suggests that CGA programmes linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons.

Effectiveness of a geriatric evaluation unit. A randomized clinical trial.

We randomly assigned frail elderly inpatients with a high probability of nursing-home placement to an innovative geriatric evaluation unit intended to provide improved diagnostic assessment, therapy, rehabilitation, and placement. Patients randomly assigned to the experimental (n = 63) and control (n = 60) groups were equivalent at entry. At one year, patients who had been assigned to the geriatric unit had much lower mortality than controls (23.8 vs. 48.3 per cent, P less than 0.005) and were less likely to have initially been discharged to a nursing home (12.7 vs. 30.0 per cent, P less than 0.05) or to have spent any time in nursing home during the follow-up period (26.9 vs. 46.7 per cent, P less than 0.05). The control-group patients had substantially more acute-care hospital days, nursing-home days, and acute-care hospital readmissions. Patients in the geriatric unit were significantly more likely to have improvement in functional status and morale than controls (P less than 0.05). Direct costs for institutional care were lower for the experimental group, especially after adjustment for survival. We conclude that geriatric evaluation units can provide substantial benefits at minimal cost for appropriate groups of elderly patients, over and above the benefits of traditional hospital approaches.