Persistent pain in nursing home residents.
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Chronic Disease↗
Biomedical subjects
V Mor
Publications and source records attributed to V Mor.
Gender differences in predictors of mortality in nursing home residents with AD.
OBJECTIVE: To evaluate whether the excess mortality in men with AD can be explained by a gender difference in the predictors of mortality. METHODS: The authors studied 2,838 men and 6,385 women over 65 years of age with AD admitted, between 1992 and 1995, to 1 of nearly 1,500 nursing homes in five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). Resident level data including sociodemographic characteristics, dementia severity, measures of physical disability, comorbidity, and other clinical variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare enrollment files; the median follow-up was 23 months. Baseline characteristics were used to predict age at time of death in Cox proportional hazard models. RESULTS: Men with AD had an increased risk of mortality relative to women, adjusted for differences in the distribution of age and race. The most important predictors of death in men were those related to the disease itself. These were the severity of dementia and the occurrence of episodes of delirium. Instead, death among women was associated with measures of disability, namely, impairment in performing the activities of daily living, presence of pressure sores, malnutrition, and comorbidity. CONCLUSION: These data suggest that the underlying mechanisms for AD may be different in men and women. Future studies of survival and progression of AD need to examine men and women separately.
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Hospice enrollment and hospitalization of dying nursing home patients.
PURPOSE: This study's purpose was to evaluate whether Medicare hospice care provided in nursing homes is associated with lower hospitalization rates. SUBJECTS AND METHODS: This retrospective cohort study included nursing home residents in five states who enrolled in hospice between 1992 and 1996 (n = 9202), and who died before 1998. For each hospice patient, 3 nonhospice residents (2 in 106 instances) were chosen (n = 27,500). Medicare claims identified hospice enrollment and acute care hospitalizations. RESULTS: Twenty-four percent of hospice and 44% of nonhospice residents were hospitalized in the last 30 days of life. Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (odds ratio 0.43; 95% confidence interval [CI]: 0.39 to 0.46). Considering all of nonhospice residents who died (n = 226,469), those in facilities with no hospice had a 47% hospitalization rate, whereas rates were 41% in facilities with low hospice use and 39% in facilities with moderate hospice use (5%+ of patients in hospice). Hospitalization was less likely for nonhospice residents in facilities with low hospice use (odds ratio 0.82; 95% CI: 0.80 to 0.84) and moderate hospice use (odds ratio 0.71; 95% CI: 0.69 to 0.74), compared with those in facilities with no hospice. CONCLUSIONS: When integrated into the nursing home care processes, hospice care is associated with less hospitalization for Medicare hospice patients. Additionally, possibly through diffusion of palliative care philosophy and practices, nonhospice residents who died in nursing homes having a hospice presence had lower rates of end-of-life hospitalizations.
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Pharmacologic treatment of diabetes in long-term care.
The majority of patients with diabetes are elderly, but little is known about their disease management. This study evaluates the prevalence and correlates of treatment of elderly diabetics residing in long-term care. We performed a retrospective, cross-sectional study of 75,829 elderly diabetics residing in nursing homes from 1992 to 1996. Nearly half (47%) of the residents received no antidiabetic medications. Independent predictors not receiving antidiabetic medications included age, race, impaired physical ability, and impaired cognitive function. Although the absence of resident's blood glucose or glycosylated hemoglobin (HbA1c) values prevents us from passing judgment about the adequacy of diabetic care, further research is needed to understand why some residents do not receive antidiabetic medications in the long-term care setting.
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External threats and nursing home administrator turnover.
External threats and volatility in the long-term-care sector in recent decades have posed serious challenges for nursing home administrators. Greater job complexity and administrative responsibilities resulting from public policies and more specialization and competitiveness in nursing home markets have made turnover a significant issue. This article examines administrator turnover from 1970 through 1997 in New York State and describes how turnover increased markedly in the late 1980s and early 1990s.
Attitude of Health Personnel↗
Hospital diversification into long-term care.
In the 1990s, acute care hospitals in the United States encountered an unstable operating environment created by a series of transformations in the health care delivery system and long-term-care market. Confronted with an array of economic pressures and demographic changes, hospitals were motivated to engage in long-term-care diversification, such as establishing a long-term-care unit or providing home health services, as a means of entering new markets and ensuring financial stability. This article examines the organizational, market, and community factors associated with this strategic activity among a national sample of urban and rural hospitals.
Catchment Area, Health↗
Effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among a population of elderly nursing home stroke survivors.
BACKGROUND AND PURPOSE: Anticoagulants and antiplatelet agents are underutilized in the nursing home setting, perhaps because trials demonstrating treatment efficacy excluded people resembling those with long-term care needs. We sought to quantify the effect of antiplatelet and anticoagulant agents on risk of hospitalization for bleeding among an elderly nursing home population. METHODS: We used a case-control design and identified first hospitalizations for bleeds using Medicare claims data from 1992 to 1997 as potential cases. Cases had at least one minimum data set (MDS) assessment within the 6 months before that hospitalization and a diagnosis of stroke. We identified up to 5 controls residing in the same facility during the same year and quarter as the case with a diagnosis of stroke. Our sample consisted of 3433 cases and 13 506 controls. Using the MDS, we identified standing orders for aspirin, dipyridamole, ticlopidine, or warfarin and used conditional logistic regression modeling to estimate the effect of these agents on risk of hospitalization for a bleed. RESULTS: After adjustment, use of warfarin (odds ratio [OR], 1.26; 95% CI, 1.11 to 1.43) and combination therapy (OR, 1.34; 95% CI, 0.99 to 1.82) were associated with an increased risk of hospitalization for a bleed compared with nonusers. The odds of aspirin use was greater among cases than controls (OR, 1.07; 95% CI, 0.96 to 1.18) after adjustment. CONCLUSIONS: Although present, the risk associated with use of these agents is small. The numbers needed to treat to harm 1 resident with aspirin and warfarin were 467 and 126, respectively.
Age Distribution↗
The effect of less than definitive care on breast carcinoma recurrence and mortality.
BACKGROUND: Risk factors for breast carcinoma offer few opportunities for prevention; thus, the reduction of morbidity and mortality among breast carcinoma patients must remain a priority. The objective of this study was to measure the effects of less than definitive care for patients with breast carcinoma on disease recurrence and mortality. METHODS: The prognostic evaluation and treatment received by an inception cohort of 494 women was characterized. Three hundred ninety women ages 45-90 years with local or regional breast carcinoma who were diagnosed between 1984 and 1986 and were treated at one of eight Rhode Island hospitals comprised the final cohort. Disease recurrence and mortality were ascertained through December 31, 1996. Candidate determinants of outcomes were a less than definitive prognostic evaluation and less than definitive primary therapy-adjusted for confounding by patient age, extent of disease, and comorbid diseases. RESULTS: During the first 5 years of follow-up, patients who received a less than definitive prognostic evaluation had an adjusted relative hazard of recurrence of 1.7 (95% confidence interval, 1.0-2.7) and an adjusted relative hazard for breast carcinoma mortality of 2.2 (95% confidence interval, 1.2-3.9). Patients who received less than definitive therapy had an adjusted relative hazard of recurrence of 1.6 (95% confidence interval, 1.0-2.5), and an adjusted relative hazard of breast carcinoma mortality of 1.7 (95% confidence interval, 1.0-2.8). CONCLUSIONS: Breast carcinoma patients who receive less than definitive care are at excess risk for disease recurrence and mortality. Women with early stage breast carcinoma should be treated in accordance with existing guidelines.
Age Factors↗
Building evidence on chronic disease in old age. Standardised assessments and databases offer one way of building the evidence.
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Aged↗
Effects of angiotensin-converting enzyme inhibitors and digoxin on health outcomes of very old patients with heart failure. SAGE Study Group. Systematic Assessment of Geriatric drug use via Epidemiology.
BACKGROUND: Randomized trials have shown that angiotensin-converting enzyme (ACE) inhibitors reduce mortality and morbidity, and improve symptoms and exercise tolerance in selected patients with congestive heart failure (CHF). There is, however, no evidence on the effectiveness of ACE inhibitors in the typical, very old and frail patients with CHF. OBJECTIVE: To compare the effects of ACE inhibitors and digoxin on 1-year mortality, morbidity, and physical function among patients aged 85 years. METHODS: We conducted a retrospective cohort study using the SAGE database, a long-term care database linking patient information with drug utilization data. Among 64637 patients with CHF admitted to all nursing homes in 5 states between 1992 and 1995, we identified 19492 patients taking either an ACE inhibitor (n = 4911) or digoxin (n = 14890). Record of date of death was derived from Medicare enrollment files, and we used the part A Medicare files to identify hospital admissions and discharge diagnoses. As a measure of physical function, we used a scale for activities of daily living performance. The effect of ACE inhibitors was estimated using Cox proportional hazards models with digoxin users as the reference group. RESULTS: The overall mortality rate among ACE inhibitor recipients was more than 10% less than that of digoxin users (relative rate, 0.89; 95% confidence interval, 0.83-0.95). Mortality was equally reduced regardless of concomitant cardiovascular conditions and baseline physical function. Treatment with ACE inhibitors was associated with a tendency toward reduced hospital admissions that was more evident among patients with greater functional impairment. The adjusted relative rate for hospitalization for any reason was 0.96 (95% confidence interval, 0.91-1.01). The rate of functional decline was greatly reduced among ACE inhibitor recipients (relative rate, 0.74; 95% confidence interval, 0.69-0.80), and this effect was consistent and independent of background comorbidity and baseline physical function. CONCLUSIONS: These data suggest that survival and functional benefits of ACE inhibitor therapy extend to patients with CHF 85 years and older, and mostly women, both systematically underrepresented in randomized trials. Alternatively, digoxin has a detrimental effect in this population.
Activities of Daily Living↗
Management of heart failure among very old persons living in long-term care: has the voice of trials spread? The SAGE Study Group.
BACKGROUND: Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. METHODS: Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. RESULTS: The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities. CONCLUSIONS: Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics.
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Impact of breast cancer treatment guidelines on surgeon practice patterns: results of a hospital-based intervention.
BACKGROUND: Despite evidence regarding the effectiveness of post-surgical treatments for early-stage breast cancer, older women are less likely to receive appropriate therapy. We evaluated the impact of surgeon-specific "performance reports" on adherence to treatment guidelines among older women with breast cancer. METHODS: We obtained diagnostic and treatment data from hospital tumor registries supplemented with self-reported adjuvant therapy information on 1099 patients with stage I or II breast cancer diagnosed between November 1, 1992, and January 31, 1997, at 6 Rhode Island hospitals. We compared rates of appropriate treatment receipt before and after distribution of performance reports. Hierarchical analysis was used to account for the nesting of patients within surgeons. Separate analyses of mastectomy and breast-conserving surgery were performed. RESULTS: Age was negatively associated with post-surgical treatment, with patients who had breast-conserving surgery and who were older than 80 years significantly less likely to undergo radiation therapy (adjusted odds ratio = 0.08 [0.04, 0.14]) or appropriate adjuvant therapies (adjusted odds ratio = 0.14 [0.08, 0.22]) or both relative to 70- to 79-year-old patients. This effect did not improve post-intervention. While there was much variability in compliance with guidelines, surgeons' characteristics did not explain this variation. CONCLUSIONS: In Rhode Island, advanced age continues to be associated with less than adequate breast cancer therapy. Providing surgeons with "feedback" on the appropriateness of adjuvant treatment for older patients was insufficient to alter established practices. Using guideline compliance data as standard "quality indicators" of physician practice may be required.
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Oxidative and nonoxidative benzodiazepines and the risk of femur fracture. The Systematic Assessment of Geriatric Drug Use Via Epidemiology Study Group.
Benzodiazepine use is a well-identified risk factor for falls and the resulting femur fractures in elderly adults. Benzodiazepines not requiring hepatic biotransformation may be safer than agents undergoing oxidation because oxidative activity has been shown to decline with age. The association between the use of either oxidative or nonoxidative benzodiazepines and the risk of femur fracture among elderly adults living in nursing homes was studied. A nested case-control study was conducted using the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) database; the records of 9,752 patients hospitalized for incident femur fracture during the period 1992 to 1996 were extracted, matching by age, gender, state, and index date to the records of 38,564 control patients. Conditional logistic regression models were conducted to estimate the odds ratios (ORs) for femur fracture with adjustment for potential confounders. The adjusted OR for the overall use of benzodiazepines was 1.10 (95% confidence interval [CI], 0.98-1.20); the risk seemed of only slightly greater magnitude for exposure to nonoxidative agents (1.18; 95% CI, 1.03-1.36) than to oxidative benzodiazepines (1.08; 95% CI, 0.95-1.23). Among the latter, the effect was mainly accounted for by the use of agents with a long elimination half-life. A dose relationship was observed exclusively among users of long half-life oxidative benzodiazepines. The risk associated with the use of nonoxidative benzodiazepines showed no relationship to the age of the patients. In contrast, patients aged 85 years or older receiving oxidative benzodiazepines at high dosages or as needed had a two- to three-fold increased risk of femur fracture than did patients in the younger age group. Among older individuals, the use of benzodiazepines slightly increased the risk of femur fracture, mainly irrespective of the metabolic fate of the drug. Our results suggest that the use of nonoxidative benzodiazepines does not carry a lower risk for femur fracture than does the use of oxidative benzodiazepines. However, the latter agents may be associated with a somewhat higher risk of side effects among the oldest old, especially at higher dosages.
Accidental Falls↗
Prevalence and predictors of unmet need for supportive services among HIV-infected persons: impact of case management.
BACKGROUND: Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood. OBJECTIVES: To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons. RESEARCH DESIGN: National probability sample. PARTICIPANTS: A total of 2,832 HIV-infected adults receiving care. MEASURES: Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services. RESULTS: Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home healthcare (OR =0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need. CONCLUSIONS: Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.
Adult↗
Influence of facility characteristics on use of antipsychotic medications in nursing homes.
OBJECTIVES: This study investigated the effect of facility and resident characteristics on the use of antipsychotic medications in the long-term care setting. RESEARCH DESIGN: This research used data available from the On-Line Survey and Certification of Automated Records (OSCAR) for all Medicare/Medicaid-certified nursing homes in the contiguous United States in 1997. The data consisted of 14,631 facilities. MEASURES: A multiple linear regression model was used to determine the effects of selected facility and resident characteristics on antipsychotic drug use while simultaneously controlling for the effects of resident characteristics and stratifying by ownership type. beta-Coefficients provided measures of effect and represented the per-unit change in the prevalence of antipsychotic use corresponding to the per-unit change in each independent variable. RESULTS: In for-profit facilities, both the presence of special care units and mental health professionals were associated with increased antipsychotic use (beta = 1.70, SE = 0.23; beta = 0.24, SE = 0.17, respectively), while other facility factors such as increasing size, being part of a chain, and higher occupancy rate were associated with decreased antipsychotic drug use. In the nonprofit environment, facility characteristics (eg, increasing occupancy rate, certified nurses' aides per 100 beds) were associated with decreasing antipsychotic use. Increasing percentages of residents covered by Medicare, those with dementia, and residents with mental retardation (beta = 0.05, SE = 0.01; beta = 0.03, SE = 0.01; beta = 0.08, SE = 0.08, respectively) were predictive of increased drug use. CONCLUSIONS: Facility and resident characteristics are associated with use of antipsychotic medications, although the extent to which these factors explain variability in use of anti-psychotics may vary on the basis of the underlying financial incentives of the institution.
Antipsychotic Agents↗
The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective.
OBJECTIVES: To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation. DESIGN: A retrospective cross-sectional study SETTING: Nursing homes in five US states and selected nursing homes in Denmark, Iceland, Italy, Japan, and Sweden. PARTICIPANTS: Residents in nursing homes in five US states and the aforementioned countries during 1993-1996. MAIN OUTCOME MEASURES: Using data collected using the Minimum Data Set, logistic regression provided estimates of the legislative effects on the use of antipsychotics and antianxiety/hypnotics while simultaneously adjusting for potential confounders. The occurrence of falls was evaluated similarly. RESULTS: Prevalence of antipsychotic and/or antianxiety/ hypnotic use varied substantially across countries. After adjustment for differences in age, gender, presence of psychiatric/neurologic conditions, and physical and cognitive functioning, residents in Denmark, Italy, and Sweden were at least twice as likely to receive these drugs (Denmark Odds Ratio (OR)=2.32; 95% Confidence Intervals (CI), 2.15-2.51; Italy OR=2.05; 95% CI, 1.78-2.34; Sweden OR=2.50; 95% CI, 2.16-2.90); in Iceland, the risk was increased to greater than 6 times (OR=6.54; 95% CI, 5.75-7.44) that of the US. Residents were less likely to fall in Italy, Iceland, and Japan compared with the US, despite more extensive use of psychotropic medication, whereas residents in Sweden and Denmark were more likely to fall. CONCLUSIONS: Policy has had an impact on the prescribing of psychotropic medication in US nursing homes compared with other countries, but it is unclear if this is translated into better outcomes for residents.
Accidental Falls↗
Impact of legislation on nursing home care in the United States: lessons for the United Kingdom.
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Gender differences in the relation between comorbidity and mortality of patients with Alzheimer's disease. Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) Study Group.
OBJECTIVE: To investigate whether differences in the number and type of comorbid conditions may help explain the gender gap in mortality among patients with AD. BACKGROUND: The prevalence and incidence of AD are higher among women, who also have more severe cognitive impairment and accelerated decline. However, men have an exceedingly higher mortality. METHODS: The authors conducted a retrospective cohort study on 5,831 men and 17,918 women with a diagnosis of AD. Data were from the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) database, which includes information on residents of 1,492 nursing homes in five US states (1992-1995). Men and women were compared with respect to demographic characteristics, dementia severity, psychiatric and behavioral symptoms, indicators of physical disability, and general health status. Also compared were age- and race-adjusted prevalence of all comorbid conditions at each level of cognitive impairment. In survival analyses, the risk of death and of hospitalization were determined by gender and level of cognitive impairment. Finally, gender-related differences in the intensity of pharmacologic treatment were examined. RESULTS: Women were older than men (83+/-7 versus 81+/-7 years) and were more likely to exhibit severe cognitive deterioration (27% versus 19% among men). Overall, there were no significant gender-related differences on several measures of physical disability (activities of daily living performance, gait and history of falls, incontinence, pressure sores), but significantly more women were underweight (45% versus 37% among men). However, the age- and race-adjusted 1-year mortality rate was 17% for women and 31% for men. The mortality rate of women at the highest degree of dementia severity was lower than the rate for men with minimal cognitive impairment. At any level of cognitive impairment, the prevalence of arrhythmia, chronic obstructive pulmonary disease, PD, and cancer was higher among men. Women were also less likely to be hospitalized, and they received fewer medications for each given disease. CONCLUSIONS: The survival advantage of women with AD relative to men may occur as a result of fewer comorbid clinical conditions associated with the diagnosis of dementia.
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