Adult protective service use and nursing home placement

PURPOSE: Adult Protective Services (APS) is the official state entity charged with advocacy for older adults who are victims of elder abuse or self-neglect. However, it has been speculated that APS intervention may lead disproportionately to nursing home placement (NHP). These analyses seek to determine if APS use is an independent risk factor for NHP. DESIGN AND METHODS: The sample was 2,812 community-dwelling older adults who were aged 65 years or older in 1982 in the New Haven Established Populations for Epidemiologic Studies in the Elderly cohort, a subset of whom were referred to elder protective services over a 9-year follow-up period from cohort inception. NHP of cohort members over that time period was determined. RESULTS: Rates of subsequent NHP were: 69.2% for self-neglecting subjects, 52.3% for mistreated subjects, and 31.8% for subjects who had no contact with APS (p <.001, both comparisons). In proportional hazard models that included other demographic, medical, functional, and social factors associated with NHP, the strongest risk factors for placement were APS referral for self-neglect (hazard ratio [HR], 5.23; 95% confidence interval [CI], 4.07-6.72), and for elder mistreatment (HR, 4.02; 95% CI, 2.50-6.47). These hazards far exceeded those for other medical, functional, and social factors. IMPLICATIONS: APS use is an independent risk factor for nursing home placement; persons identified by APS as self-neglecting are at the highest risk.     

Patterns and predictors of nursing home placement over 14 years: Dubbo study of elderly Australians

Objective: To describe patterns and predictors of nursing home placement. Methods: This is a longitudinal study of an elderly cohort living in Dubbo, New South Wales, Australia. A total of 1233 men and 1572 women aged 60 years and older living in the community were examined in 1988 and followed for 14 years. The incidence of nursing home placement and underlying clinical diagnoses were assessed. Results were modelled for baseline predictors of placement using Cox proportional hazards regression. Results: From 2805 subjects in the study there were 244 (8.7%) nursing home placements, 95 in men (7.7%) and 149 in women (9.5%). A total of 44% placements were primarily due to dementia, but dementia was a secondary diagnosis in another 20% of cases. The other principal diagnoses were stroke (16%) and coronary heart disease (14%). Median time to death in a nursing home was 10.5 months in men and 9.0 months in women. In a Cox proportional hazards model using baseline characteristics, the hazard of nursing home placement increased significantly with age (hazard ratio = 1.13), urinary incontinence (1.66), impaired peak expiratory flow (3.19), physical disability (1.59) and depression (1.85). The hazard of placement was significantly reduced by alcohol intake (0.55) and female gender (0.55). Socioeconomic factors were not significant. Conclusions: Dementia and disability‐related care burdens rather than other health conditions are the dominant causes of nursing home placement in an unselected elderly community. Risk factors such as incontinence, impaired respiratory function and depression have been identified and these are potentially amenable to intervention.     

General practice encounters with older Australians

Objectives: To describe the content of general practitioners’ (GP) encounters with patients aged 65 years or more, and to determine any differences in the way problems are managed between the 65–74 and 75 years and over age groups. Method: A secondary analysis of data collected through the Bettering the Evaluation and Care of Health (BEACH) program was carried out. Results: Encounters with older patients accounted for 25.0% of a GP's total workload. Circulatory conditions, in particular hypertension, were the most frequently managed, with cardiovascular medications the most frequently prescribed. Numerous differences exist in the characteristics and management of older patients when divided into those aged 65–74 and 75 years and over, with patients aged 75 years or more receiving investigations and non‐pharmacological treatments significantly less often. Conclusion: The present study provides a baseline measure of the management of older patients in general practice.     

The Influence of Long-Term Care Insurance on the Likelihood of Nursing Home Admission

OBJECTIVES: To determine the effect of long-term care (LTC) insurance on nursing home use.
DESIGN: Longitudinal analysis, 1998 to 2006 waves of the Health Retirement Study.
SETTING: Community-dwelling nationally representative sample.
PARTICIPANTS: Nineteen thousand one hundred seventy adults aged 50 and older, 1998 wave.
METHODS: Two groups of respondents were created at baseline: those with and without an LTC insurance policy. Respondents admitted to the nursing home from 1998 to 2006 were identified. Propensity scores were used to control for known predictors of LTC insurance possession. A Cox proportional hazards model was used to compare the probability of nursing home admission over 8 years of follow-up for respondents possessing LTC insurance and those without a policy.
RESULTS: Of the 19,170 respondents aged 50 and older in 1998, 1,767 (9.2%) possessed LTC insurance. A total of 1,778 (8.5%) were admitted to a nursing home during the 8-year period: 149 (8.7%) of those with LTC insurance and 1,629 (8.4%) of those without LTC insurance. The hazard ratio, adjusted for propensity score, for those with LTC insurance entering a nursing home compared with those without was 1.07 (95% confidence interval=0.83–1.38). Likelihood of nursing home admission was relatively low because the low-risk population included in the study, limiting the power to detect small differences in risk of nursing home utilization between groups.
CONCLUSION: There was no difference in nursing home utilization between low-risk older adults who did and did not possess an LTC insurance policy.     

Problems of older adults living alone after hospitalization

OBJECTIVE: To describe functional deficits among older adults living alone and receiving home nursing following medical hospitalization, and the association of living alone with lack of functional improvement and nursing home utilization 1 month after hospitalization. DESIGN: Secondary analysis of a prospective cohort study. PARTICIPANTS: Consecutive sample of patients age 65 and over receiving home nursing following medical hospitalization. Patients were excluded for new diagnosis of myocardial infarction or stroke in the previous 2 months, diagnosis of dementia if living alone, or nonambulatory status. Of 613 patients invited to participate, 312 agreed. MEASUREMENTS: One week after hospitalization, patients were assessed in the home for demographic information, medications, cognition, and self-report of prehospital and current mobility and function in activities of daily living (ADLs) and independent activities of daily living (IADLs). One month later, patients were asked about current function and nursing home utilization. The outcomes were lack of improvement in ADL function and nursing home utilization 1 month after hospitalization. RESULTS: One hundred forty-one (45%) patients lived alone. After hospital discharge, 40% of those living alone and 62% of those living with others had at least 1 ADL dependency (P=.0001). Patients who were ADL-dependent and lived alone were 3.3 (95% confidence interval [95% CI], 1.4 to 7.6) times less likely to improve in ADLs and 3.5 (95% CI, 1.0 to 11.9) times more likely to be admitted to a nursing home in the month after hospitalization. CONCLUSION: Patients who live alone and receive home nursing after hospitalization are less likely to improve in function and more likely to be admitted to a nursing home, compared with those who live with others. More intensive resources may be required to continue community living and maximize independence. This work was supported by grants from the American Physical Therapy Foundation, the Dean Foundation, and the University of Wisconsin Medical School and Graduate School. Dr. Mahoney was the recipient of a Clinical Investigator Award from the NIA (K08AG00623).     

Trends in the Prevalence and Comorbidities of Diabetes Mellitus in Nursing Home Residents in the United States: 1995–2004

OBJECTIVES: To estimate trends in the prevalence and comorbidities of diabetes mellitus (DM) in U.S. nursing homes from 1995 to 2004. DESIGN: SAS callable SUDAAN was used to adjust for the complex sample design and assess changes in prevalence of DM and comorbidities during the study period in the National Nursing Home Surveys. Trends were assessed using weighted least squares linear regression. Multiple logistic regressions were used to calculate predictive margins. SETTING: A continuing series of two‐stage, cross‐sectional probability national sampling surveys. PARTICIPANTS: Residents aged 55 and older: 1995 (n=7,722), 1997 (n=7,717), 1999 (n=7,809), and 2004 (n=12,786). MEASUREMENTS: DM and its comorbidities identified using a standard set of diagnosis codes. RESULTS: The estimated crude prevalence of DM increased from 16.9% in 1995 to 26.4% in 2004 in male nursing home residents and from 16.1% to 22.2% in female residents (all P<.05). Male and female residents aged 85 and older and those with high functional impairment showed a significant increasing trend in DM (all P<.05). In people with DM, multivariate‐adjusted prevalence of cardiovascular disease increased from 59.6% to 75.4% for men and from 68.1% to 78.7% for women (all P<.05). Prevalence of most other comorbidities did not increase significantly. CONCLUSION: The burden of DM in residents of U.S. nursing homes has increased since 1995. This could be due to increasing DM prevalence in the general population or to changes in the population that nursing homes serve. Nursing home care practices may need to change to meet residents' changing needs.     

Prevalence of anemia in the nursing home: contribution of chronic kidney disease

OBJECTIVES: To assess the independent contribution of chronic kidney disease (CKD) and age to anemia in older nursing home residents. DESIGN: Retrospective. SETTING: Skilled nursing facility. PARTICIPANTS: Nursing home residents with records in the Beverly Healthcare Data Warehouse who were admitted to a nursing home between January 1, 2002, and December 31, 2003; were alive as of January 31, 2004; and had hemoglobin and serum creatinine (SCr) values available for analysis. MEASUREMENTS: Prevalence of anemia (hemoglobin <13 g/dL for men and <12 g/dL for women) and CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m(2), according to Modification of Diet in Renal Disease criteria) and the contribution of CKD and age to the prevalence of anemia. RESULTS: Six thousand two hundred resident records were analyzed (70% female, 85% Caucasian). Overall, 59.6% of residents were anemic, and 43.1% had CKD, and residents with CKD were more likely to have anemia (64.9% with vs 55.7% without CKD; odds ratio (OR)=1.47, 95% confidence interval (CI)=1.33-1.63). Although older age was associated with lower hemoglobin values primarily in residents without CKD (Spearman rank correlation coefficient (r)=-0.10, P<.001), age had no association with hemoglobin in CKD (Spearman r=0.01, P=.60). The greater risk of anemia in the presence of CKD persisted in each age category (OR=2.07, 95% CI=1.53-2.80, aged 65-74; OR=1.44, 95% CI=1.21-1.70, aged 75-84; and OR=1.35, 95% CI=1.15-1.57, aged > or =85). CONCLUSION: Overall, these results suggest that CKD contributes more strongly than older age to the high prevalence of anemia in older nursing home residents.     

Comorbidities alone do not explain the undertreatment of colorectal cancer in older adults: a French population-based study

OBJECTIVES: To investigate the influence of comorbidities on treatment modalities of colorectal cancer according to the age of patients and French recommendations. DESIGN: Population‐based study SETTING: French Digestive Cancer Registry, Burgundy. PARTICIPANTS: Two thousand nine hundred twenty‐one incident colorectal cancers diagnosed between 2004 and 2007. MEASUREMENTS: The independent influence of comorbidities (recorded according to the Charlson index) on treatment was analyzed using multivariate logistic regressions controlling for age, sex, and their interaction. RESULTS: The association between comorbidities and resection for cure was significant only in patients younger than 75 (P interaction=.008). For Stage III colon cancer, 40.4% of the patients aged 75 and older had adjuvant chemotherapy, versus 90.5% of those younger than 75 (P<.001). The association between comorbidities and adjuvant chemotherapy for Stage III colon cancer was significant only in patients younger than 75 (P interaction=.004). Patients aged 75 and older were less likely to receive chemotherapy, even when they had few or no comorbidities. Overall, 29.3% of patients aged 75 and older with advanced colorectal cancer had palliative chemotherapy, versus 77.1% of those younger than 75 (P<.001). Whatever the age, palliative chemotherapy was less frequent for a Charlson comorbidity index of 2 or greater (P interaction=.16). Radiotherapy was administered in 59.0% of patients aged 75 and older with rectal cancer, versus 85.3% of those younger than 75 (P<.001). Whatever the age, patients with a Charlson score of 2 or greater were less likely to receive radiotherapy for rectal cancer than were patients without comorbidities (P interaction=.86). CONCLUSION: Further studies are warranted to identify more precisely the reasons for lower treatment rates for colorectal cancer in the older population.     

Unprovoked and glyceryl trinitrate-provoked head-up tilt table test is safe in older people: a review of 10 years' experience

OBJECTIVES: To test the safety of the head-up tilt test (HUT) in older adults. DESIGN: Direct observation and measurements. SETTING: Tests performed in a quiet room with dim lighting in a laboratory setting. PARTICIPANTS: One thousand ninety-six subjects aged 60 to 74; 873 aged 75 and older. MEASUREMENTS: Blood pressure and pulse at baseline for 10 minutes and 70 degrees tilt for maximum of 45 minutes. Subjects with unprovoked HUT had test repeated on a separate day after 800 mg glyceryl trinitrate (GTN). RESULTS: One thousand four hundred ninety-five drug-free and 474 GTN-provoked HUTs were studied. In those aged 60 to 74, the proportion of hypotensive unprovoked HUT was 16% (27% in those aged > or =75); this was higher with GTN provocation (43% in those aged 60-74, 44% in those aged > or =75; P<.01). Systolic blood pressure decreased during provoked HUT (lowest mean+/-standard deviation=67+/-20 in those aged 60-74, 63+/-24 in those aged > or =75; P<.01). There was one cardiovascular and no neurological complications. CONCLUSION: This study included 10 times as many people as previous studies and demonstrates the safety of HUT in older people.     

Length of Stay for Older Adults Residing in Nursing Homes at the End of Life

OBJECTIVES: To describe lengths of stay of nursing home decedents. DESIGN: Retrospective cohort study. SETTING: The Health and Retirement Study (HRS), a nationally representative survey of U.S. adults aged 50 and older. PARTICIPANTS: One thousand eight hundred seventeen nursing home residents who died between 1992 and 2006. MEASUREMENTS: The primary outcome was length of stay, defined as the number of months between nursing home admission and date of death. Covariates were demographic, social, and clinical factors drawn from the HRS interview conducted closest to the date of nursing home admission. RESULTS: The mean age of decedents was 83.3±9.0; 59.1% were female, and 81.5% were white. Median and mean length of stay before death were 5 months (interquartile range 1–20) and 13.7±18.4 months, respectively. Fifty‐three percent died within 6 months of placement. Large differences in median length of stay were observed according to sex (men, 3 months vs women, 8 months) and net worth (highest quartile, 3 months vs lowest quartile, 9 months) (all P<.001). These differences persisted after adjustment for age, sex, marital status, net worth, geographic region, and diagnosed chronic conditions (cancer, hypertension, diabetes mellitus, lung disease, heart disease, and stroke). CONCLUSION: Nursing home lengths of stay are brief for the majority of decedents. Lengths of stay varied markedly according to factors related to social support.     

Aged Care Assessment Teams in Australia: a General Practice Perspective

To explore the interaction between general practitioners (GPs) and Aged Care Assessment Teams (ACATs) from the GP's perspective, structured telephone interviews were held with the GPs of 77 people consecutively admitted to nursing homes in the Hunter region of New South Wales. Overall, GPs expressed satisfaction with the assessment process. However, on 37 (48%) occasions, GPs claimed not to have been asked for information prior to assessment, on 36 (47%) occasions no feedback was received, and on 58 (75%) occasions, GPs claimed they were not informed of their patient's admission to a nursing home. Some solutions to these perceived deficiencies were offered by the GPs interviewed. These indicate practical ways in which cooperation between GPs and ACATs can be enhanced.     

Nursing home resident and facility characteristics associated with pneumococcal vaccination: national nursing home survey, 1995-1999

Objectives: To assess Advisory Committee for Immunization Practices recommendations for the pneumococcal vaccine in nursing home residents using national surveys to examine factors associated with vaccination. Design: Cross‐sectional national sample surveys of nursing homes and nursing home residents with a two‐stage probability design, stratified on size and Medicare and Medicaid certification status. Setting: U.S. nursing homes during 1995, 1997, and 1999. Participants: Six current residents were randomly selected from each facility (n=approximately 8,000 each year). Measurements: Residents' pneumococcal vaccination status was obtained by asking the facility respondent for each resident: “Has [the resident] EVER had a pneumococcal vaccine, that is a pneumonia vaccination?” Vaccination status was coded as yes, no, and unknown. Results: The proportion of residents aged 65 and older that received pneumococcal vaccination increased significantly, from 23.6% in 1995 to 28.2% in 1997 to 37.4% in 1999 (P<.001). The proportion of residents in homes with pneumococcal immunization programs increased significantly, from 65.2% in 1995 to 88.9% in 1999. Conclusion: The proportion of nursing home residents aged 65 and older receiving the pneumococcal vaccine increased significantly from 1995 to 1999. Residents living in nursing homes with programs for pneumococcal immunizations were significantly more likely to be vaccinated.     

Free and Protein-Bound Cobalamin Absorption in Healthy Middle-aged and Older Subjects

OBJECTIVE: To study free- and protein-bound cobalamin absorption and the correlation with atrophic gastritis in healthy middle-aged and older subjects. DESIGN: A cross-sectional study. PARTICIPANTS: Fifty-two healthy subjects, aged 26 to 87 years, apparently free from conditions known to influence the cobalamin status. Middle-aged subjects were defined as those younger than 65 years of age (median age 57 years) and older subjects as those 65 years and older (median age 75 years). MEASUREMENTS: Protein-bound cobalamin absorption was assessed by 48-hour urinary excretion method following oral administration of scrambled egg yolk, labeled in vivo with ⁵⁷Co-cobalamin by injecting a hen with ⁵⁷Co-cyanocobalamin. The percentage of ⁵⁷Co-cobalamin bound to protein was 65%. Free cobalamin absorption was assessed by 48-hour urinary excretion method following oral administration of crystalline ⁵⁷Co-cyanocobalamin. Plasma cobalamin, folate and fasting plasma gastrin, and pepsinogen A and C concentrations were determined. RESULTS: The median urinary excretion of egg yolk ⁵⁷Co-cobalamin in middle-aged subjects was 12.3% (25th and 75th percentiles 10.5%-14.5%) compared with 11.7% (25th and 75th percentiles 9.8%-13.6%) in older subjects (P = .283). The median urinary excretion after administration of free ⁵⁷Co-cobalamin in middle-aged subjects was 25.7% (25th and 75th percentiles 20.6%-30.7%) compared with 27.9% (25th and 75th percentiles 21.4%-34.5%) in older subjects (P = .694). Neither egg yolk nor free ⁵⁷Co-cobalamin excretion correlated with age. A ratio of pepsinogen A to pepsinogen C less than 1.6, indicating atrophic gastritis, was found in 13 subjects. Within the atrophic gastritis group, 11 subjects had a pepsinogen A concentration greater than or equal to 17 μg/L, indicating mild to moderate atrophic gastritis, and two subjects had a pepsinogen A concentration less than 17 μg/L, indicating severe atrophic gastritis or gastric atrophy. All subjects had normal fasting plasma gastrin concentrations. Free and egg yolk ⁵⁷Co-cobalamin excretions were not reduced in the atrophic gastritis group when compared with the non-atrophic gastritis group. Median plasma cobalamin concentration was not significantly lower in older subjects (P = .205). Nonetheless, plasma cobalamin concentration correlated negatively with age (r = -.36; P = .008). CONCLUSIONS: We demonstrated no significant difference in either free or protein-bound cobalamin absorption between healthy middle-aged and older adults. In addition, no alteration in cobalamin absorption was found in subjects identified as having mild to moderate atrophic gastritis. Therefore, based on our results, the high prevalence of low cobalamin levels in older people cannot be explained by either the aging process or mild to moderate atrophic gastritis. J Am Geriatr Soc 44:949–953, 1996.     

Factors contributing to fecal incontinence in older people and outcome of routine management in home,hospital and nursing home settings

Objective:

Fecal loading, cognitive impairment, loose stools, functional disability, comorbidity and anorectal incontinence are recognized as factors contributing to loss of fecal continence in older adults. The objective of this project was to assess the relative distribution of these factors in a variety of settings along with the outcome of usual management.

Methods:

One hundred and twenty adults aged 65 years and over with fecal incontinence recruited by convenience sampling from four different settings were studied. They were either living at home or in a nursing home or receiving care on an acute or rehabilitation elderly care ward. A structured questionnaire was used to elicit which factors associated with fecal incontinence were present from subjects who had given written informed consent or for whom assent for inclusion in the study had been obtained.

Results:

Fecal loading (Homes 6 [20%]; Acute care wards 17 [57%]; Rehabilitation wards 19 [63%]; Nursing homes 21 [70%]) and functional disability (Homes 5 [17%]; Acute care wards 25 [83%]; Rehabilitation wards 25 [83%]; Nursing homes 20 [67%]) were significantly more prevalent in the hospital and nursing home settings than in those living at home (P < 0.01). Loose stools were more prevalent in the hospital setting than in the other settings (Homes 11 [37%]; Acute care wards 20 [67%]; Rehabilitation wards 17 [57%]; Nursing homes 6 [20%]) (P < 0.01). Cognitive impairment was significantly more common in the nursing home than in the other settings (Nursing homes 26 [87%], Homes 5 [17%], Acute care wards 13 [43%], Rehabilitation wards 14 [47%]) (P < 0.01). Loose stools were the most prevalent factor present at baseline in 13 of the 19 (68%) subjects whose fecal incontinence had resolved at 3 months.

Conclusion:

The distribution of the factors contributing to fecal incontinence in older people living at home differs from those cared for in nursing home and hospital wards settings. These differences need to be borne in mind when assessing people in different settings. Management appears to result in a cure for those who are not significantly disabled with loose stools as a cause for their fecal incontinence, but this would need to be confirmed by further research.     

A randomized clinical trial on preventing pressure ulcers with wheelchair seat cushions

OBJECTIVES: To determine the efficacy of skin protection wheelchair seat cushions in preventing pressure ulcers in the elderly nursing home population. DESIGN: Clinical trial with participants assigned at random to a skin protection or segmented foam cushion. Two hundred thirty‐two participants were recruited between June 2004 and May 2008 and followed for 6 months or until pressure ulcer incidence. SETTING: Twelve nursing homes. PARTICIPANTS: Nursing home residents aged 65 and older who were using wheelchairs for 6 or more hours per day and had a Braden score of 18 or less and a combined Braden activity and mobility score of 5 or less. Participants were recruited from a referred sample. INTERVENTION: All participants were provided with a fitted wheelchair and randomized into skin protection (SPC, n=113) or segmented foam (SFC, n=119) cushion groups. The SPC group received an air, viscous fluid and foam, or gel and foam cushion. The SFC group received a 7.6‐cm crosscut foam cushion. MEASUREMENTS: Pressure ulcer incidence over 6 months for wounds near the ischial tuberosities (IT ulcers) were measured. Secondary analysis was performed on combined IT ulcers and ulcers over the sacrum and coccyx (sacral ulcers). RESULTS: One hundred eighty participants reached a study end point, and 42 were lost to follow‐up. Ten did not receive the intervention. There were eight (6.7%) IT ulcers in the SFC group and one (0.9%) in the SPC group (P=.04). There were 21 (17.6%) combined IT and sacral ulcers in the SFC group and 12 (10.6%) in the SPC group (P=.14). CONCLUSION: Skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence for elderly nursing home residents and should be used to help prevent pressure ulcers.     

Predictors of nursing home placement in Parkinson's disease: a population-based, prospective study

OBJECTIVES: To examine the rate and predictors of nursing home placement in patients with Parkinson's disease. DESIGN: Four-year prospective study. SETTING: A population-based study in western Norway PARTICIPANTS: 178 community-dwelling subjects with Parkinson's disease. MEASUREMENTS: Main outcome measure was the time from baseline to nursing home admission. Baseline evaluation of motor symptoms (Unified Parkinson's Disease Rating Scale, UPDRS), cognition (clinical dementia interview, Gottfries, Brane & Steen dementia scale, and Mini-Mental State Examination), depression (clinical interview and the Montgomery & Asberg Depression Rating Scale), and psychotic symptoms (UPDRS Thought Disorder item) were performed. RESULTS: Forty-seven patients (26.4%) were admitted to a nursing home during the 4-year study period. Institutionalized patients were older, had more advanced Parkinson's disease with more severe motor symptoms and impairment of activities of daily living, were cognitively more impaired, were more often living alone, and had more hallucinations than those who continued to live at home. Duration of disease, levodopa dose, and gender distribution did not differ between the two groups. A Cox proportional hazards linear regression analysis showed that old age, functional impairment, dementia, and hallucinations were independent predictors of nursing home admission. CONCLUSIONS: Both motor and neuropsychiatric symptoms contributed to institutionalization, but the presence of hallucinations was the strongest predictor. This finding indicates it is possible that effective treatment of hallucinations may reduce the need for institutionalization in patients with Parkinson's disease.     

Relatives’ experience of nursing home admissions: preliminary study

Objective: As the first of a three‐phase study examining nursing home admissions, the current paper reports on relatives’ subjective experience of admitting an older family member to a nursing home. Methods: Fifty‐eight relatives from northern New South Wales (NSW) and South Australia who had admitted a family member into an aged care home were interviewed. Results: A broad range of positive and negative experiences were recounted by relatives who had been involved in a nursing home admission of a family member. Although there was a diversity of responses, a number of common themes were identified in the interviews. These included the inability to cope with supporting an older person, difficulties in finding a nursing home, disheartening admission processes, and a broad range of emotional responses including guilt, distress and relief. Conclusions: Admission of a family member to a nursing home can be a difficult and emotional time for relatives. The complex and sensitive nature of this process highlights the importance of recognition and support for relatives from health care professionals in aged care.     

Age is not a significant risk factor for failed trial of beta-blocker therapy in older patients with chronic heart failure

OBJECTIVES: To evaluate how well older heart failure patients tolerate beta-blockers in everyday clinical practice. DESIGN: Retrospective casenote analysis. SETTING: Specialist heart failure clinic in a large teaching hospital. PARTICIPANTS: 226 patients with a clinical diagnosis of heart failure and evidence of left ventricular systolic dysfunction. MEASUREMENTS: Data on age, sex, comorbid illness, other medications, duration of beta-blocker therapy, side-effects and reasons for discontinuation. RESULTS: Patients aged 75 years and over had a higher level of comorbid disease and worse New York Heart Association status. Despite this, 60.4% of those aged 75 or over had been tried on a beta-blocker (versus 69% of those aged <75), and of those tried, 80% of those aged 75 or over were still taking a beta-blocker at the time of survey (versus 86% of those aged <75). Forty-seven percent of those aged 75 or over had at least one side-effect recorded (versus 48% of those aged <75). Significant risk factors for failing a trial of beta-blocker therapy were worse New York Heart Association status and worse left ventricular function, but importantly not age. CONCLUSIONS: A high proportion of older heart failure patients tolerate beta-blockers. Side-effects and failure rates are comparable to younger patients. Left ventricular function and worse New York Heart Association class, rather than age, predict low tolerability of therapy. Further studies are warranted to evaluate whether frail patients with heart failure can improve their quality of life by taking beta-blockers.     

Extrapyramidal signs in cognitively intact elderly people

AIM: to investigate the prevalence of extrapyramidal signs in elderly people and their relationship to disease. SETTING AND SUBJECTS: 151 non-demented subjects age 65 and over living within a defined geographical area in Nottingham who were participating in the MRC multicentre Cognitive Function and Ageing Study. MEASUREMENTS: subjects were assessed at home. Extrapyramidal signs were rated according to a standardized neurological examination using items from the Unified Parkinson's Disease Rating Scale. RESULTS: bradykinetic and hypokinetic abnormalities are a frequent finding, especially in the oldest old. Over 50% of subjects aged 80 or over demonstrated at least one such sign. Only 10% of subjects had any recorded neurological disease. CONCLUSIONS: the frequency of recognized neurological and other disease is insufficient to account for the rate of subtle extrapyramidal abnormalities found. These findings may thus represent intrinsic age-related changes in neurological functioning, this being consistent with previously described pathological changes in the substantia nigra and striatum in normal ageing.     

Effect of an inpatient geriatric consultation team on functional outcome, mortality, institutionalization, and readmission rate in older adults with hip fracture: a controlled trial

OBJECTIVES: To evaluate the effect of an inpatient geriatric consultation team (IGCT) on end points of interest in people with hip fracture: length of stay, functional status, mortality, new nursing home admission, and hospital readmission. DESIGN: Controlled trial based on assignment by convenience. SETTING: Trauma ward in a university hospital. PARTICIPANTS: One hundred seventy‐one people with hip fracture aged 65 and older. INTERVENTION: Participants were assigned to a multidisciplinary geriatric intervention (n=94) or usual care (n=77) during hospitalization after hip fracture. MEASUREMENTS: End points were functional status, length of stay, mortality, new nursing home admission, and hospital readmission 6 weeks, 4 months, and 12 months after surgery. RESULTS: Mean length of stay was 11.1 ± 5.1 days in the intervention group and 12.4 ± 8.5 days in the control groups (P=.24). Complete adherence to IGCT recommendations was 56.8%. A significant benefit of intervention on functional status in univariate analyses (P=.02) 8 days after surgery disappeared in a linear mixed model. Participants with dementia had better functional status in a linear mixed model than those without (P=.03), but this effect was no longer significant after Bonferroni correction for multiple testing. After 6 weeks, 4 months, and 12 months, no between‐group differences could be documented for mortality, new nursing home admission, or readmission rate. CONCLUSION: This trial could not document functional benefits of an IGCT intervention in people with hip fracture. More research is needed to investigate whether a more‐intensive approach with more‐direct control over patient management, more‐specific recommendations, and more‐intense education would be effective.