Decisions to forgo hospitalization in advanced dementia: a nationwide study

OBJECTIVES: To examine the prevalence and factors associated with decisions to forgo hospitalization in nursing home (NH) residents with advanced dementia. DESIGN: Cross-sectional study. SETTING: All Medicare- and Medicaid-certified NHs within the 48 contiguous U.S. states. PARTICIPANTS: NH residents with advanced dementia were identified using Minimum Data Set (MDS) assessments completed close to April 1, 2000 (N=91,521). MEASUREMENTS: Multilevel, multivariate logistic regression identified factors independently associated with having a do-not-hospitalize (DNH) directive. Independent variables included subject characteristics (MDS), facility factors (On-line Survey of Certification of Automated Records), and hospital referral region (HRR) features (Dartmouth Atlas). RESULTS: Nationwide, 7.1% (n=6,518) residents with advanced dementia had DNH orders (range 0.7% in Oklahoma to 25.9% in Rhode Island). Resident characteristics associated with having a DNH order were older age, white, living will, durable power of attorney for health care, and total functional dependence. Controlling for these factors, DNH orders were more likely in residents of facilities with the following features: not part of a chain, urban location, special care dementia unit, fewer black residents, nurse practitioner or physician assistant on staff, higher staffing ratios, and location in HRRs with fewer intensive care unit admissions during terminal hospitalizations. CONCLUSION: Directives to forgo hospitalization for U.S. NH residents with advanced dementia are uncommon and are associated with the organizational features of the facilities caring for them and the intensity of end-of-life care practiced in the region, as well as individual resident characteristics.     

Occurrence and treatment of suspected pneumonia in long-term care residents dying with advanced dementia

OBJECTIVES: To describe the occurrence and management of suspected pneumonia in end-stage dementia and to identify factors associated with aggressiveness of antibiotic treatment. DESIGN: Retrospective cohort study. SETTING: A 675-bed long-term-care facility in Boston, Massachusetts. PARTICIPANTS: Two hundred forty subjects aged 65 and older who died with advanced dementia between January 2001 and December 2003. Subjects who had suspected pneumonia during the last 6 months of life were identified. MEASUREMENTS: Independent variables included subject characteristics and features of suspected pneumonia episodes. These variables were obtained from medical records. Antibiotic treatment for each episode was determined. Multivariate analysis was used to identify independent variables associated with aggressiveness of treatment. RESULTS: One hundred fifty-four (64%) subjects with advanced dementia experienced 229 suspected pneumonia episodes during the last 6 months of life. Within 30 days of death, 53% of subjects had suspected pneumonia. Antibiotic treatment for the 229 episodes was as follows: none, 9%; oral only, 37%; intramuscular, 25%; and intravenous, 29%. Factors independently associated with more-invasive therapy were lack of a do-not-hospitalize order (adjusted odds ratio (AOR) = 3.24, 95% confidence interval (CI) = 2.02-5.22), aspiration (AOR = 2.75, 95% CI = 1.44-5.26), primary language not English (AOR = 2.21, 95% CI = 1.17-4.15), and unstable vital signs (AOR = 2.02, 95% CI = 1.10-3.72). CONCLUSION: Pneumonia is a common terminal event in advanced dementia for which many patients receive parenteral antibiotics. The aggressiveness of treatment is most strongly determined by advance care planning, the patient's cultural background, and clinical features of the suspected pneumonia episode.     

Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes

OBJECTIVES: To examine the relationship between insomnia, hypnotic use, falls, and hip fractures in older people. DESIGN: Secondary analysis of a large, longitudinal, assessment database. SETTING: Four hundred thirty-seven nursing homes in Michigan. PARTICIPANTS: Residents aged 65 and older in 2001 with a baseline Minimum Data Set assessment and a follow-up 150 to 210 days later. MEASUREMENTS: Logistic regression modeled any follow-up report of fall or hip fracture. Predictors were baseline reports of insomnia (previous month) and use of hypnotics (previous week). Potential confounds taken into account included standard measures of functional status, cognitive status, intensity of resource utilization, proximity to death, illness burden, number of medications, emergency room visits, nursing home new admission, age, and sex. RESULTS: In 34,163 nursing home residents (76% women, mean age+/-standard deviation 84+/-8), hypnotic use did not predict falls (adjusted odds ratio (AOR)=1.13, 95% confidence interval (CI)=0.98, 1.30). In contrast, insomnia did predict future falls (AOR=1.52, 95% CI=1.38, 1.66). Untreated insomnia (AOR=1.55, 95% CI=1.41, 1.71) and hypnotic-treated (unresponsive) insomnia (AOR=1.32, 95% CI=1.02, 1.70) predicted more falls than did the absence of insomnia. After adjustment for confounding variables, insomnia and hypnotic use were not associated with subsequent hip fracture. CONCLUSION: In elderly nursing home residents, insomnia, but not hypnotic use, is associated with a greater risk of subsequent falls. Future studies will need to confirm these findings and determine whether appropriate hypnotic use can protect against future falls.     

Patterns of presentation, diagnosis, and treatment in older patients with colon cancer and comorbid dementia

OBJECTIVES: To estimate patterns of colon cancer presentation, diagnosis, and treatment according to history of dementia using National Cancer Institute (NCI) Surveillance, Epidemiology, and End-Result (SEER) Medicare data. DESIGN: Population-level cohort study. SETTING: NCI's SEER-Medicare database. PARTICIPANTS: A total of 17,507 individuals aged 67 and older with invasive colon cancer (Stage I-IV) were identified from the 1993-1996 SEER file. Medicare files were evaluated to determine which patients had an antecedent diagnosis of dementia. MEASUREMENTS: Parameters relating to the cohort's patterns of presentation and care were estimated using logistic regressions. RESULTS: The prevalence of dementia in the cohort of newly diagnosed colon cancer patients was 6.8% (1,184/17,507). Adjusting for possible confounders, dementia patients were twice as likely to have colon cancer reported after death (i.e., autopsy or death certificate) (adjusted odds ratio (AOR)=2.31, 95% confidence interval (CI)=1.79-3.00). Of those diagnosed before death (n=17,049), dementia patients were twice as likely to be diagnosed noninvasively than with tissue evaluation (i.e., positive histology) (AOR=2.02 95% CI=1.63-2.51). Of patients with Stage I -III disease (n=12,728), patients with dementia were half as likely to receive surgical resection (AOR=0.48, 95% CI=0.33-0.70). Furthermore, of those with resected Stage III colon cancer (n=3,386), dementia patients were 78% less likely to receive adjuvant 5-fluorouracil (AOR=0.22, 95% CI=0.13-0.36). CONCLUSION: Although the incidences of dementia and cancer rise with age, little is known about the effect of dementia on cancer presentation and treatment. Elderly colon cancer patients are less likely to receive invasive diagnostic methods or curative-intent therapies. The utility of anticancer therapies in patients with dementia merits further study.     

Hospitalization of nursing home residents with cognitive impairments: the influence of organizational features and state policies

PURPOSE: The purpose of this study was to quantify the effect of specific nursing home features and state Medicaid policies on the risk of hospitalization among cognitively impaired nursing home residents. DESIGN AND METHODS: We used multilevel logistic regression to estimate the odds of hospitalization among long-stay (>90 days) nursing home residents against the odds of remaining in the nursing home over a 5-month period, controlling for covariates at the resident, nursing home, and county level. We stratified analyses by resident diagnosis of dementia. RESULTS: Of 359,474 cognitively impaired residents, 49% had a diagnosis of dementia. Of those, 16% were hospitalized. The probability of hospitalization was negatively associated with the presence of a dementia special care unit (adjusted odds ratio [AOR] = 0.90, 95% confidence interval [CI] = 0.86-0.94) and with a high prevalence of dementia in the nursing home (AOR = 0.96, 95% CI = 0.88-1.03). Higher Medicaid payment rates were associated with reduced likelihood of hospitalization (AOR = 0.95, 95% CI = 0.90-1.00), whereas any bed-hold policy substantially increased that likelihood (AOR = 1.44, 95% CI = 1.12-1.86). We observed similar results for residents without a dementia diagnosis. IMPLICATIONS: Directed management of chronic conditions, as indicated by facilities' investment in special care units, reduces the risk of hospitalization, but the effect of bed-hold policies illustrates how fragmentation in the financing system impedes these efforts.     

Urinary incontinence and its association with death, nursing home admission, and functional decline

OBJECTIVES: To determine whether urinary incontinence (UI) is an independent predictor of death, nursing home admission, decline in activities of daily living (ADLs), or decline in instrumental activities of daily living (IADLs). DESIGN: A population-based prospective cohort study from 1993 to 1995. SETTING: Community-dwelling within the United States. PARTICIPANTS: Six thousand five hundred six of the 7,447 subjects aged 70 and older in the Asset and Health Dynamics Among the Oldest Old study who had complete information on continence status and did not require a proxy interview at baseline. MEASUREMENTS: The predictor was UI, and the outcomes were death, nursing home admission, ADL decline, and IADL decline. Potential confounders considered were comorbid conditions, baseline function, sensory impairment, cognition, depressive symptoms, body mass index, smoking and alcohol, demographics, and socioeconomic status. RESULTS: The prevalence of UI was 14.8% (18.5% in women; 8.5% in men). At 2-year follow-up, subjects incontinent at baseline were more likely to have died (10.9% vs 8.7%; unadjusted odds ratio (OR)=1.29, 95% confidence interval (CI)=1.02-1.64), be admitted to a nursing home (4.4% vs 2.6%, OR=1.77; 95% CI=1.18-2.63), and to have declined in ADL function (13.6% vs 8.1%; OR=1.78, 95% CI=1.36-2.33) and IADL function (21.2% vs 13.8%; OR 1.69, 95% CI 1.39-2.05). However, after adjusting for confounders, UI was not an independent predictor of death (adjusted OR (AOR)= 0.90, 95% CI=0.67-1.21), nursing home admission (AOR=1.33, 95% CI=0.86-2.04), or ADL decline (AOR=1.24, 95% CI=0.92-1.68). Incontinence remained a predictor of IADL decline (AOR=1.31; 95% CI=1.05-1.63), although adjustment markedly reduced the strength of this association. CONCLUSION: Higher levels of baseline illness severity and functional impairment appear to mediate the relationship between UI and adverse outcomes. The results suggest that, although UI appears to be a marker of frailty in community-dwelling elderly, it is not a strong independent risk factor for death, nursing home admission, or functional decline.     

Is Dementia Special Care Really Special? A New Look at an Old Question

OBJECTIVES: To quantify differences in care provided to nursing home (NH) residents with dementia living on and off dementia special care units (SCUs).
DESIGN: Cross-sectional study using propensity score adjustment for resident and NH characteristics.
SETTING: Free-standing NHs in nonrural U.S. counties that had an SCU in 2004 (N=1,896).
PARTICIPANTS: Long-stay (≥90 days) NH residents with a diagnosis of Alzheimer's disease or dementia and at least moderate cognitive impairment (N=69,131).
MEASUREMENTS: Resident-level NH care processes such as physical restraints, bed rails, feeding tubes, psychotropic medications, and incontinence care.
RESULTS: There was no difference in the use of physical restraints (adjusted odds ratio (AOR)=0.94, 95% confidence interval (CI)=0.79–1.11), but SCU residents were less likely to have had bed rails (AOR=0.55, 95% CI=0.46–0.64) and to have been tube fed (AOR=0.36, 95% CI=0.30–0.43). SCU residents were more likely to be on toileting plans (AOR=1.23, 95% CI=1.08–1.39) and less likely to use pads or briefs in the absence of a toileting plan (AOR=0.73, 95% CI=0.61–0.88). SCU residents were more likely to have received psychotropic medications (AOR=1.23, 95% CI=1.05–1.44), primarily antipsychotics (SCU=44.9% vs non-SCU=30.0%).
CONCLUSION: SCU residents received different care than comparable non-SCU residents. Most strikingly, SCU residents had greater use of antipsychotic medications.     

Do-not-resuscitate and do-not-hospitalize directives of persons admitted to skilled nursing facilities under the Medicare benefit

OBJECTIVES: To determine prevalence and factors associated with do-not-resuscitate (DNR) and do-not-hospitalize (DNH) directives of residents admitted under the Medicare benefit to a skilled nursing facility (SNF). To explore geographic variation in use of DNR and DNH orders. DESIGN: Retrospective cohort study. SETTING: Nursing homes in the United States. PARTICIPANTS: Medicare admissions to SNFs in 2001 (n=1,962,742). MEASUREMENTS: Logistic regression was used to select factors associated with DNR and DNH directives and state variation in their use. RESULTS: Thirty-two percent of residents had DNR directives, whereas less than 2% had DNH directives. Factors associated with having a DNR or DNH directive at the resident level included older age, cognitive impairment, functional dependence, and Caucasian ethnicity. African-American, Hispanic, Asian, and North American Native residents were all significantly less likely than Caucasian residents to have DNR (adjusted odds ratio (OR)=0.35, 0.51, 0.61, and 0.62, respectively) or DNH (adjusted OR=0.26, 0.41, 0.43, and 0.67, respectively) directives. In contrast, residents in rural and government facilities were more likely to have DNR or DNH directives. After controlling for resident and facility characteristics, significant variation between states existed in the use of DNR and DNH directives. CONCLUSION: Ethnic minorities are less likely to have DNR and DNH directives even after controlling for disease status, demographic, facility, and geographic characteristics. Wide variation in the likelihood of having DNR and DNH directives between states suggests a need for better-standardized methods for eliciting the care preferences of residents admitted to SNFs under the Medicare benefit.     

Hospice use and outcomes in nursing home residents with advanced dementia

OBJECTIVES: To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life. DESIGN: Prospective cohort study. SETTING: Twenty‐two Boston‐area NHs. PARTICIPANTS: Three hundred twenty‐three NH residents with advanced dementia and their HCPs. MEASUREMENTS: Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care. RESULTS: Twenty‐two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57–6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37–7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life. CONCLUSION: A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.     

Unnecessary drug use in frail older people at hospital discharge

OBJECTIVES: To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients. DESIGN: Cross-sectional. SETTING: Eleven Veterans Affairs Medical Centers. PARTICIPANTS: Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study. MEASUREMENTS: Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary. RESULTS: Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38-0.96), multiple prescribers (AOR=3.35, 95% CI=1.16-9.68), and nine or more medications (AOR=2.24, 95% CI=1.25-3.99). CONCLUSION: A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.     

Prevalence and correlates of sleep-disordered breathing in older men: osteoporotic fractures in men sleep study

OBJECTIVES: To determine the prevalence and distribution of sleep-disordered breathing and associated correlates in a large cohort of older men using several standardized definitions. DESIGN: Cross-sectional analyses. SETTING: Six U.S. communities. PARTICIPANTS: Polysomnography was performed on 2,911 participants of the Outcomes of Sleep Disorders in Older Men Sleep Study (mean age+/-standard deviation 76.38+/-5.53; body mass index 27.17+/-3.8 kg/m(2)). MEASUREMENTS: Three outcomes were assessed: sleep-disordered breathing (respiratory disturbance index > or =15), obstructive apnea (obstructive apnea index > or =5), and central apnea (central apnea index > or =5). RESULTS: The prevalence of moderate-severe sleep-disordered breathing was estimated to be 21.4% to 26.4%. Multivariable logistic regression models demonstrated that age (adjusted odds ratio (AOR) per 5-year increase =1.24, 95% confidence interval (CI)=1.15-1.34), obesity (AOR=2.54, 95% CI=2.09-3.09), Asian versus Caucasian race (AOR=2.14, 95% CI=1.33-3.45), snoring (AOR=2.01, 95% CI=1.62-2.49), sleepiness (AOR=1.41, 95% CI=1.11-1.79), hypertension (AOR=1.26, 95% CI=1.06-1.50), cardiovascular disease (AOR=1.24, 95% CI=1.19-1.29), and heart failure (AOR=1.81, 1.31-2.51) were independently associated with sleep-disordered breathing; snoring (AOR=2.10, 95% CI=1.67-2.70), age (AOR per 5-year increase=1.27, 95% CI=1.18-1.38), obesity (AOR=1.48, 95% CI=1.21-1.82), and heart failure (AOR=1.60, 95% CI=1.15-2.24) were associated with obstructive apnea; and age (AOR=1.33, 1.17-1.50) and heart failure (AOR=1.88, 95% CI=1.17-3.04) were associated with central apnea. CONCLUSION: Regardless of definition, a high prevalence of sleep disorders is observed in community-dwelling older men. Qualitatively similar associations were observed between sleep disorders and snoring, obesity, and comorbidities, as reported for middle aged populations. Asian race was associated with sleep-disordered breathing.     

The Overlap Syndrome of Depression and Delirium in Older Hospitalized Patients

OBJECTIVES: To measure the prevalence, predictors, and posthospitalization outcomes associated with the overlap syndrome of coexisting depression and incident delirium in older hospitalized patients.
DESIGN: Secondary analysis of prospective cohort data from the control group of the Delirium Prevention Trial.
SETTING: General medical service of an academic medical center. Follow-up interviews at 1 month and 1 year post-hospital discharge.
PARTICIPANTS: Four hundred fifty-nine patients aged 70 and older who were not delirious at hospital admission.
MEASUREMENTS: Depressive symptoms assessed at hospital admission using the 15-item Geriatric Depression Scale (cutoff score of 6 used to define depression), daily assessments of incident delirium from admission to discharge using the Confusion Assessment Method, activities of daily living at admission and 1 month postdischarge, and new nursing home placement and mortality determined at 1 year.
RESULTS: Of 459 participants, 23 (5.0%) had the overlap syndrome, 39 (8.5%) delirium alone, 121 (26.3%) depression alone, and 276 (60.1%) neither condition. In adjusted analysis, patients with the overlap syndrome had higher odds of new nursing home placement or death at 1 year (adjusted odds ratio (AOR)=5.38, 95% confidence interval (CI)=1.57–18.38) and 1-month functional decline (AOR=3.30, 95% CI=1.14–9.56) than patients with neither condition.
CONCLUSION: The overlap syndrome of depression and delirium is associated with significant risk of functional decline, institutionalization, and death. Efforts to identify, prevent, and treat this condition may reduce the risk of adverse outcomes in older hospitalized patients.     

Multidrug-resistant gram-negative bacteria in a long-term care facility: prevalence and risk factors

OBJECTIVES: To quantify the prevalence, risk factors, and mode of transmission associated with colonization by multidrug-resistant gram-negative bacteria (MDRGN) in the long-term care (LTC) setting.
DESIGN: Cross-sectional.
SETTING: Four nursing units in a 648-bed LTC facility in Boston, Massachusetts.
PARTICIPANTS: Eighty-four long-term care residents.
MEASUREMENTS: Nasal and rectal swabs were obtained to determine colonization with MDRGN; if present, molecular typing was performed. The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) was also determined. Demographic and clinical characteristics were obtained from the medical record. Multivariable analysis was used to identify factors independently associated with MDRGN colonization.
RESULTS: A total of 51%, 28%, and 4% subjects were colonized with MDRGN, MRSA, and VRE, respectively. After multivariable adjustment, advanced dementia (adjusted odds ratio (AOR)=2.9, 95% confidence interval (CI)=1.2–7.35, P =.02) and nonambulatory status (AOR=5.7, 95% CI=1.1–28.9, P =.04) were the only independent risk factors for harboring MDRGN. Molecular typing indicated person-to-person transmission.
CONCLUSION: Colonization with MDRGN is common in the LTC setting. A diagnosis of advanced dementia is a major risk factor for harboring MDRGN.     

Does Hospice Improve Quality of Care for Persons Dying from Dementia?

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members. DESIGN: Mortality follow‐back survey. SETTING: Death certificates were drawn from five states (AL, FL, TX, MA, and MN). PARTICIPANTS: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death. MEASUREMENTS: Ratings of the quality of end‐of‐life care, perceptions of unmet needs, and opportunities to improve end‐of‐life care. Two questions were also asked about the peacefulness of dying and quality of dying. RESULTS: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33–0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53–2.72). They also noted better quality of dying than those without hospice services. CONCLUSION: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.     

Inappropriate medication use in older adults undergoing surgery: a national study

OBJECTIVES: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery. DESIGN: Retrospective cohort study. SETTING: Three hundred seventy‐nine acute care hospitals participating in the nationally representative Perspective database (2006–2008). PARTICIPANTS: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N=272,351). MEASUREMENTS: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period. RESULTS: One‐quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)=0.98 per year of age, 95% confidence interval (CI)=0.97–0.98) and in men (AOR=0.83, 95% CI=0.81–0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR=1.22, 95% CI=1.08–1.40). Participants undergoing surgery in the West (AOR=1.79, 95% CI=1.02–3.16) and South (AOR=2.24, 95% CI=1.38–3.64) were more likely to receive a PIM than those in the Northeast. CONCLUSION: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts.     

High Uptake of HIV Testing in a Cohort of Male Injection Drug Users in Delhi, India: Prevalence and Correlates of HIV Infection

We report baseline findings from a longitudinal cohort study to examine HIV incidence, high-risk injection and sexual behaviors of 3,792 male injection drug users (IDUs) in Delhi. The majority (95.4 %) accepted HIV testing; HIV prevalence was 21.9 %. In multivariate analysis, belonging to states adjacent to Delhi (AOR: 1.23; 95 % CI: 1.07–1.52), earning INR 500–1,500 (AOR: 2.38; 95 % CI: 1.43–3.96); duration of drug use 2–5 years (AOR: 2.02; 95 % CI: 1.09–3.73), 6–10 years (AOR: 2.81; 95 % CI: 1.55–5.11), ≥11 years (AOR: 3.35; 95 % CI: 1.84–6.11); prior HIV testing (AOR: 1.60; 95 % CI: 1.35–1.91), self-reported risky-injection behavior (AOR: 1.60; 95 % CI: 1.33–1.92), and utilization of harm-reduction services (AOR: 1.32; 95 % CI: 1.11–1.58) were positively associated with HIV infection. Alcohol use ≤2 times/week (AOR: 0.67; 95 % CI: 0.55–0.82) or ≥3 times/week (AOR: 0.74; 95 % CI: 0.54–1.01), unit increase in age (AOR: 0.99; 95 % CI: 0.98–1.00), ≥7 years of schooling (AOR: 0.82; 95 % CI: 0.66–1.02) and unsafe sex with any female partner (AOR: 0.69; 95 % CI: 0.55–0.86) were negatively associated with HIV infection. HIV prevalence remains high among male IDUs in Delhi. HIV prevention programs should include comprehensive package of services for IDUs.     

Satisfaction with end-of-life care for nursing home residents with advanced dementia

OBJECTIVES: To identify factors associated with satisfaction with care for healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia. DESIGN: Cross-sectional study. SETTING: Thirteen NHs in Boston. PARTICIPANTS: One hundred forty-eight NH residents aged 65 and older with advanced dementia and their formally designated HCPs. MASUREMENTS: The dependent variable was HCPs' score on the Satisfaction With Care at the End of Life in Dementia (SWC-EOLD) scale (range 10-40; higher scores indicate greater satisfaction). Resident characteristics analyzed as independent variables were demographic information, functional and cognitive status, comfort, tube feeding, and advance care planning. HCP characteristics were demographic information, health status, mood, advance care planning, and communication. Multivariate stepwise linear regression was used to identify factors independently associated with higher SWC-EOLD score. RESULTS: The mean ages+/-standard deviation of the 148 residents and HCPs were 85.0+/-8.1 and 59.1+/-11.7, respectively. The mean SWC-EOLD score was 31.0+/-4.2. After multivariate adjustment, variables independently associated with greater satisfaction were more than 15 minutes discussing advance directives with a care provider at the time of NH admission (parameter estimate=2.39, 95% confidence interval (CI)=1.16-3.61, P<.001), greater resident comfort (parameter estimate=0.10, 95% CI=0.02-0.17, P=.01), care in a specialized dementia unit (parameter estimate=1.48, 95% CI=0.25-2.71, P=.02), and no feeding tube (parameter estimate=2.87, 95% CI=0.46-5.25, P=.02). CONCLUSION: Better communication, greater resident comfort, no tube feeding, and care in a specialized dementia unit are modifiable factors that may improve satisfaction with care in advanced dementia.     

Effects of provider practice on functional independence in older adults

OBJECTIVES: To examine provider determinants of new-onset disability in basic activities of daily living (ADLs) in community-dwelling elderly. DESIGN: Observational study. SETTING: King County, Washington. PARTICIPANTS: A random sample of 800 health maintenance organization (HMO) enrollees aged 65 and older participating in a prospective longitudinal cohort study of dementia and normal aging and their 56 primary care providers formed the study population. MEASUREMENTS: Incident ADL disability, defined as any new onset of difficulty performing any of the basic ADLs at follow-up assessments, was examined in relation to provider characteristics and practice style using logistic regression and adjusting for case-mix, patient and provider factors associated with ADL disability, and clustering by provider. RESULTS: Neither provider experience taking care of large numbers of elderly patients nor having a certificate of added qualifications in geriatrics was associated with patient ADL disability at 2 or 4 years of follow-up (adjusted odds ratio (AOR) for experience=1.29, 95% confidence interval (CI)=0.81-2.05; AOR for added qualifications=0.72, 95% CI=0.38-1.39; results at 4 years analogous). A practice style embodying traditional geriatric principles of care was not associated with a reduced likelihood of ADL disability over 4 years of follow-up (AOR for prescribing no high-risk medications=0.56, 95% CI=0.16-1.94; AOR for managing geriatric syndromes=0.94, 95% CI=0.40-2.19; AOR for a team care approach=1.35, 95% CI=0.66-2.75). CONCLUSION: Taking care of a large number of elderly patients, obtaining a certificate of added qualifications in geriatrics, and practicing with a traditional geriatric orientation do not appear to influence the development of ADL disability in elder, community dwelling HMO enrollees.