Geriatrics and the limits of modern medicine.
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Biomedical subjects
J S Goodwin
Publications and source records attributed to J S Goodwin.
Ethnic variation in attitudes toward hypertension in adults ages 75 and older.
BACKGROUND: Although critical to the management of hypertension, the attitudes of geriatric patients and possible ethnic group differences in attitudes concerning the disease are poorly understood. METHODS: Data from a 1995-1996 population-based survey of 507 Hispanic American, African American, and non-Hispanic white adults ages 75 and older were used to assess ethnic differences in perceptions regarding the cause, prevention, and treatment of hypertension, as well as associations between perceptions and use of preventive health services. RESULTS: African Americans were more likely to attribute hypertension to health behaviors and stress. In contrast, Hispanic Americans were more likely consider the disease a normal part of aging, whereas non-Hispanic whites were more likely to attribute hypertension to heredity or mechanistic causes. Non-Hispanic whites were less likely to perceive hypertension as preventable, whereas Hispanic Americans were less likely to feel that hypertension was treatable. The odds of having a primary care physician, blood pressure checked, or glaucoma checked were lower among older African Americans and Hispanic Americans than older non-Hispanic whites. The odds of having had a recent physical and of emergency room use were higher among African Americans and lower among Hispanic Americans, in relation to non-Hispanic whites. CONCLUSION: Ethnic differences regarding hypertension were clearly evident in this sample of older adults. In addition, attitudes regarding the cause and treatment of hypertension were found to be associated with both the use and the underuse of preventive health services in all three ethnic groups.
Black or African American↗
Information on radiation treatment in patients with breast cancer: the advantages of the linked medicare and SEER data. Surveillance, Epidemiology and End Results.
Several studies have found underutilization of radiotherapy in patients with breast cancer; but there are concerns about the completeness of various databases on radiotherapy. We used the linked Medicare-SEER (Surveillance, Epidemiology and End Results) database to compare information on receipt of radiotherapy after diagnosis of breast cancer. More than 18% of women identified by Medicare data as receiving radiotherapy were not so identified by SEER, and 7% of those identified as receiving radiotherapy by SEER were not identified by Medicare. Risk of discordance on radiotherapy information between the two data sets was especially high in women receiving breast-conserving surgery. The combined SEER-Medicare database gives a more complete picture on the use of radiotherapy. The previously reported geographic variations in the use of radiotherapy for breast cancer may be due in part to underreporting of radiotherapy in some areas.
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The declining use of axillary dissection in patients with early stage breast cancer.
OBJECTIVES: To determine any changes in usage of axillary dissection over time from 1983 to 1993, and to characterize those patients who do not receive axillary node dissection. METHODS: A total of 129,946 female patients receiving cancer-directed surgery for early stage breast cancer, who were identified from the SEER (Surveillance, Epidemiology and End Results) program and diagnosed from 1983 to 1993, were included in the study. The surgical treatment and axillary dissection were based on treatment data collected by the SEER during the first course of therapy. Logistic regression analyses were used to assess the effect of patient and tumor characteristics on the likelihood of not receiving different types of treatment. RESULTS: The percentage of women not receiving axillary dissection has increased over time, from 14.4% in 1983 to 16.8% in 1993. Nearly a quarter of women undergoing breast conserving surgery for local stage breast cancer receive neither axillary dissection nor radiotherapy. Older, unmarried, and non-white women and those with very small (< 0.5 cm) or very large (> or = 4 cm) tumors were most likely to receive neither axillary node dissection nor irradiation. Among those not receiving axillary dissection, 42% had tumors 1-3 cm in size and were not receiving radiation therapy. CONCLUSIONS: There is an apparent divergence between the type of patient who has been recommended as an appropriate candidate for avoiding axillary dissection (those with small tumors and those who will receive adjuvant therapy) and those who are actually not receiving axillary dissection in the community.
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Disability in older adults. 1: Prevalence, causes, and consequences.
The effects of disability on an aging population's health and welfare are an important issue in gerontological research. The rapid growth of the elderly population and increases in longevity have led to an ongoing debate about whether longer lives can be matched by longer active lives that are free from disability. After a detailed review of current disability literature, the authors discuss the impact of disability in the elderly, defining disability and reviewing three classes of disability--physical, mental, and social. Both subjective and objective disability measures are described, and disability trends and prevalence rates are reviewed and compared cross culturally, by gender, by age, and over time. The path from chronic disease to disability is described and the consequences of living with disability are discussed in terms of family burdens and the increased need for medical care.
Activities of Daily Living↗
Disability in older adults. 2: Physical activity as prevention.
In this 2nd article in the series on older adults (persons aged > or = 65 years), the role of physical activity in preventing disability associated with aging in the absence of specific illnesses is discussed, and different types of activities and the measures of outcome are described. Evidence for physical activity as a prevention measure is restricted to primary and secondary prevention because the application of physical activity for tertiary prevention of disability is limited. Chronic disease is considered in the context of its influence on disability only when physical activity offers some potential benefit to elderly persons.
Activities of Daily Living↗
Temporal and regional variation in the use of breast-conserving surgery and radiotherapy for older women with early-stage breast cancer from 1983 to 1995.
BACKGROUND: Authorities recommend radiation therapy after breast-conserving surgery for breast cancer. Numerous studies have reported that older women diagnosed with breast cancer are less likely to receive radiation after breast-conserving surgery. It is unclear how care of older women with breast cancer has changed over time. METHODS: Women with local or regional stage breast cancer diagnosed between 1983-1995 were identified from the Surveillance, Epidemiology, and End Results (SEER) Cancer Registries. The treatment information in SEER includes type of surgical procedures and receipt of radiation therapy. RESULTS: There were small increases in the percentage of women receiving breast-conserving surgery during the 1980s followed by substantial increases in the 1990s. Age was a major factor in determining receipt of radiation therapy after breast-conserving surgery. A large increase in use of radiotherapy after surgery was observed in women aged > or = 75, from below 30% in 1983 to over 50% in 1995. Women aged > or = 75 diagnosed in 1992-1995 were 1.76 and 2.34 times more likely to receive radiation for local and regional stage respectively, as compared to those in 1983-1987. There was no increase in use of radiation for women aged < 65. CONCLUSIONS: There has been a substantial increase in use of breast-conserving surgery and in receipt of radiation therapy after breast-conserving surgery in older women. However, there was a net increase in the percentage of all women with breast cancer who received this surgery without radiotherapy, due to the large increase in the overall percentage of women receiving this surgery.
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Aging versus disease: the opinions of older black, Hispanic, and non-Hispanic white Americans about the causes and treatment of common medical conditions.
BACKGROUND: Little is known about how older people interpret disease and how those interpretations might relate to use of medical services. OBJECTIVE: To assess opinions of older subjects about the cause and treatment of common diseases and how they are related to health behaviors. DESIGN: In-home interview of a population-based sample (n = 601) of noninstitutionalized black, Hispanic, and non-Hispanic white American men and women aged 75 and older in Galveston County, Texas. RESULTS: Substantial proportions of the subjects considered heart disease, arthritis, or difficulty sleeping to be a normal part of aging. In multivariate analyses including age, gender, education, marital status, living arrangement, global self-rating of health, and comorbidity, older black subjects were less likely to view heart disease (OR = 0.41; 95% CI, 0.26-0.64), arthritis (OR = 0.48; 95% CI, 0.31-0.73), or sleep problems (OR = 0.50; 95% CI, 0.32-0.77) as a normal part of aging than were non-Hispanic whites. Blacks were more than three times as likely to attribute heart disease to overwork or stress than were non-Hispanic whites. In multivariate analyses, subjects who considered all three of the medical conditions to be a normal part of aging ("fatalistic") were less likely to have received preventive medical services in the previous year (OR = 0.13; 95% CI, 0.02-0.96), and subjects who felt that nothing could be done to treat any of the conditions ("nihilistic") were less likely to have a regular physician (OR = 0.24; 95% CI, 0.08-0.74). CONCLUSIONS: Substantial numbers of older subjects are fatalistic about the cause of disease and/or nihilistic about its treatment. These attitudes are associated with decreased utilization of health services. Attempts to improve the health of underserved groups should employ interventions that are sensitive to the health beliefs of the targeted group.
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Changes in blood pressure and risk factors for cardiovascular disease among older Mexican-Americans from 1982-1984 to 1993-1994.
OBJECTIVE: To determine the 10-year changes in blood pressure and cardiovascular risk factors among older Mexican-Americans. DESIGN: Comparative analyses of the Hispanic Health and Nutrition Examination Survey (HHANES) and the Hispanic EPESE (Established Populations for Epidemiologic Studies of the Elderly). Both of these were population-based studies using a multistage stratified probability sampling design of noninstitutionalized persons. SETTING: Five US states in the southwest: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 216 Mexican-Americans aged 65 to 74 from the 1982-1984 HHANES and 3050 Mexican-Americans aged 65+ from the 1993-1994 Hispanic EPESE. MEASUREMENTS: Mean systolic and diastolic blood pressure; cigarette smoking; high levels of alcohol use; body mass index and obesity; self-reported heart attack, stroke, and diabetes; hypertension. RESULTS: Among 65- to 74-year-old Mexican-Americans, there was a decrease over time in the percent of those who smoked cigarettes from 27.60% to 13.96% and a decrease in mean systolic blood pressure level. The percent of subjects categorized as obese or severely obese increased significantly, as did the prevalence of diagnosed diabetes, increasing from 20.06% in 1982-1984 to 29.82% in 1993-1994. Mean diastolic blood pressure increased from 77.15 mm Hg in 1982-1984 to 81.21 mm Hg in 1993-1994. CONCLUSIONS: Our findings suggest major changes in cardiovascular risk factors between 1982-1984 and 1993-1994 among older Mexican-Americans.
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Battling quackery: attitudes about micronutrient supplements in American academic medicine.
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Ascorbic Acid↗
Switching sides.
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Attitude of Health Personnel↗
Effect of Nancy Reagan's mastectomy on choice of surgery for breast cancer by US women.
CONTEXT: While the actions of popular figures are believed to influence the behavior of the general public, including health care decisions, little research has examined such an effect. OBJECTIVE: To determine whether a temporal association exists between use of breast-conserving surgery (BCS) for treatment of breast cancer and Nancy Reagan's mastectomy in October 1987. DESIGN/SETTING: Population-based observational cohort study. PATIENTS: Two sources of data: (1) 82 230 women aged 30 years and older who were included in the Surveillance, Epidemiology, and End Results tumor registry because of a diagnosis of local or regional breast cancer from 1983 to 1990; and (2) 80057 female Medicare beneficiaries aged 65 to 79 years who received inpatient surgery for local or regional breast cancer in 1987 or 1988. MAIN OUTCOME MEASURE: Percentage of use of BCS vs mastectomy over time. RESULTS: Compared with women undergoing surgery for breast cancer in the third quarter of 1987 (just prior to Mrs Reagan's mastectomy), women were 25% less likely to undergo BCS in the fourth quarter of 1987 (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.66-0.85) and in the first quarter of 1988 (OR, 0.76; 95% CI, 0.67-0.86). In subsequent quarters, the rate returned to the baseline. In multivariate analyses, the decline was significant among white but not nonwhite women. It was most prominent among women aged 50 to 79 years in the central and southern regions of the country, and most sustained among women living in areas with lower levels of income and education. CONCLUSIONS: Celebrity role models can influence decisions about medical care. The influence appears strongest among persons who demographically resemble the celebrity, and those of lower income and educational status.
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Complications of acute myocardial infarction in patients > or = 90 years of age.
Forty consecutive 90-year-old persons with an acute myocardial infarction were studied to describe the noncardiac complications of their care. Common negative consequences of hospitalization of these patients included delirium, pressure ulcers, and poor ambulatory status at discharge.
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The association between chronic diseases and depressive symptomatology in older Mexican Americans.
BACKGROUND: Among the elderly population, the risk for psychological distress increases with the number of chronic diseases and accompanying functional disability. The prevalence of chronic medical conditions and functional disability varies substantially across ethnocultural groups, however. Using data from the Hispanic EPESE, we previously reported that among older Mexican Americans, the total number of chronic medical conditions and the presence of functional impairment are strong predictors of depressive symptoms. METHODS: Using multiple regression, we examined the association between specific chronic diseases, individual functional disabilities, and depressive symptoms in this group of ethnic elders. RESULTS: Multiple regression models indicated that diabetes (OR = 1.25, 95% CI = 1.03-1.56), arthritis (OR = 1.42, 95% CI = 1.17-1.72), urinary incontinence (OR = 1.94, 95% CI = 1.46-2.59), bowel incontinence (OR = 2.28, 95% CI = 1.15-4.55), kidney disease (OR = 3.11, 95% CI = 1.13-8.58), and ulcers (OR = 2.56, 95% CI = 1.23-5.29) were predictive of high levels of depressive symptoms. Hip fracture, although recognized as having a substantial impact on functional status, was not found to be associated with depressive symptoms. History of stroke was not significantly associated with depressive symptoms in bivariate or multivariate analyses, but history of stroke with residual speech problems was predictive (OR = 2.16, 95% CI = 1.01-4.79). Among specific activities of daily living, only impaired ability to walk across a room (OR = 1.65, 95% CI = 1.04-2.73) or to bathe oneself (OR = 1.87, 95% CI = 1.12-3.12) proved to be predictive in multivariate analyses. CONCLUSIONS: This constellation of chronic medical conditions and functional disabilities is very different from those reported to be associated with depressive symptoms in older non-Hispanic White and African Americans, and appears to comprise those conditions most associated with substantial physical impairment, pain, and discomfort.
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Lower body functioning as a predictor of subsequent disability among older Mexican Americans.
BACKGROUND: Disability measures among elderly non-Hispanic White populations have traditionally been associated with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). More recently, performance-based measures have increasingly been used to predict the onset of disability in initially nondisabled elderly populations. METHODS: We used data from two waves (1993-94 and 1995-96) of the Hispanic Established Populations for the Epidemiologic Studies of the Elderly (EPESE) to assess the degree with which lower mobility performance measures predict future disability in a representative sample of older Mexican Americans from the Southwestern United States. RESULTS: Performances on an 8-foot walk, repeated chair stands, and standing balance among nondisabled subjects at baseline were significantly associated with the onset of ADL and lower body disability 2 years later, controlling for age, gender, and the presence of medical conditions. The results were significant for each performance measure and for a measure combining all three. CONCLUSION: This study offers further evidence that performance-based measures of lower body function are able to predict future disability in older Mexican Americans, as has been found with other elderly populations. These measures were able to detect changes over a relatively short period of time (2 years). In addition, the study found that the short (8-foot) walk was the most sensitive measure in predicting future disability.
Activities of Daily Living↗
Undertreatment of hypertension in older Mexican Americans.
OBJECTIVE: To identify the prevalence of hypertension and factors associated with nontreatment and poor control of hypertension in Mexican Americans aged 65 years and older. DESIGN: A population-based survey of older Mexican Americans conducted in 1993-1994. SETTING: Subjects residing in five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: An area probability sample of 3050 noninstitutionalized Mexican American men and women aged 65 and older took part in a 90-minute in-home interview, which included review of all medications taken and two sitting blood pressure measurements. OUTCOME MEASURES: Measured were previous diagnoses of hypertension, current medication for hypertension, and current blood pressure RESULTS: Sixty-one percent of older Mexican-Americans were hypertensive, and 51% of those with hypertension were taking antihypertensive medications. Only 25% of hypertensive subjects (18% of males and 30% of females) were in good blood pressure control (i.e., systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg). In multivariate analyses, factors associated with increased likelihood of treatment included female gender (OR = 1.9), history of heart disease (OR = 2.4), possessing a regular source of health care (OR = 2.7), and having seen a physician two or more times in the previous year (OR = 3.8). These were also independent predictors of good blood pressure control. CONCLUSION: Nontreatment of hypertension is still a major public health concern in older Mexican Americans. We estimate that adequate blood pressure control in this population would prevent approximately 30,000 adverse cardiovascular events over 10 years, affecting approximately 6% of the entire Mexican American older population.
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Lower-extremity functioning in older Mexican Americans and its association with medical problems.
OBJECTIVE: To describe lower-extremity functioning in community-dwelling older Mexican Americans and to examine its relationship with medical problems. DESIGN: Cross-sectional analyses of survey and performance-based data obtained in a population-based study employing area probability sampling. SETTING: Households within selected census tracts of five Southwestern states: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 2873 Mexican Americans aged 65 years and older. MEASUREMENTS: A multidimensional questionnaire assessing demographic, sociocultural, and health variables. Standardized tests of lower-extremity physical functioning included measures of standing balance, repeated chair stands, walking, and an overall summary measure. RESULTS: Regression analyses revealed that being more than age 75 and female, having arthritis diabetes, visual impairments, or being obese or underweight were all significantly associated with performance on both individual and summary tests of lower-extremity functioning. In separate regression analyses, the total number of medical conditions was also associated with performance. CONCLUSIONS: The likelihood of predicting performance or inability to complete tests of lower-extremity functioning was greatest for those aged 80 and older, those with arthritis or diabetes, and those with three or more medical conditions. Because of the high prevalence of diabetes in Mexican Americans, documentation of the association of diabetes with performance-based tests of lower-extremity functioning may help guide early interventions targeted to prevent progression to more severe limitations or disability.
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Geographic variations in breast cancer mortality: do higher rates imply elevated incidence or poorer survival?
OBJECTIVES: Mortality rates from breast cancer are approximately 25% higher for women in the northeastern United States than for women in the South or West. This study examined the hypothesis that the elevation is due to decreased survival rather than increased incidence. METHODS: Data on breast cancer incidence, treatment, and mortality were reviewed. RESULTS: The elevated mortality in the Northeast is apparent only in older women. For women aged 65 years and older, breast cancer mortality is 26% higher in New England than in the South, while incidence is only 3% higher. Breast cancer mortality for older women by state correlates poorly with incidence (r = 0.28). CONCLUSIONS: Those seeking to explain the excess breast cancer mortality in the Northeast should assess survival and should examine differences in cancer control practices that affect survival.
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