Cognitive and behavioural impairment among elderly people in institutions providing different levels of care.

OBJECTIVE: To compare the prevalence and degree of cognitive and behavioural impairment in elderly patients in institutions providing different levels of care. DESIGN: Prevalence study. SETTING: A nursing home, a home for the aged and psychogeriatric wards in a provincial psychiatric hospital. PATIENTS: Only subjects 65 years of age or older were eligible for inclusion. A random sample was selected comprising 25% of the residents in the nursing home and the home for the aged; of the 119 asked to participate 95 agreed (44 in the nursing home and 51 in the home for the aged). All 50 on the psychogeriatric wards agreed to participate. MAIN OUTCOME MEASURES: The Mini-Mental State Examination (MMSE) and the Kingston Dementia Rating Scale (KDRS). RESULTS: An MMSE score of less than 24 (cognitive impairment) was given to 37 (84%) of the residents in the nursing home, 43 (84%) of those in the home for the aged and 48 (96%) of the patients in the psychiatric hospital; the corresponding numbers for a KDRS score of more than 0 (cognitive impairment) were 41 (93%), 48 (94%) and 50 (100%). The seven patients receiving the highest level of care at the home for the aged (special care) had more behavioural problems than those in the psychiatric hospital did (p less than 0.001). CONCLUSIONS: Cognitive and behavioural impairment was widespread in the three institutions regardless of the level of care. When planning services and allocating resources government funding agencies should consider the degree and prevalence of such impairment among elderly people in institutions.     

Incidence of nursing home placement in a defined community

OBJECTIVE: To assess cumulative incidence and non-cognitive factors predicting nursing home placement in a defined older population. DESIGN AND SETTING: Six-year follow-up of a population-based cohort living west of Sydney. PARTICIPANTS: 3654 non-institutionalised residents aged 49 years or older (82.4% of those eligible) participated in baseline examinations during 1992 to 1994. MAIN OUTCOME MEASURES: Permanent nursing home admission for long-term institutionalised aged care in New South Wales, confirmed by records of approvals by the regional Aged Care Assessment Team and subsidy payments by government. RESULTS: After excluding 384 participants who moved from the area or were lost to follow-up, 162 participants (5.0%) had been admitted to nursing homes on a permanent basis by October 1999. Of participants who died since baseline, 20% had been admitted to a nursing home before death. Of those alive, 1.6% were current nursing home residents. Six-year cumulative incidence rates for nursing home placement were 0.7%, 1.1%, 2.4%, 3.9%, 9.0%, 18.3% and 34.9% for people aged 55-59, 60-64, 65-69, 70-74, 75-79, 80-84 and 85 years or older, respectively. Non-cognitive factors at baseline predicting subsequent nursing home admission included each additional year of age (risk ratio [RR], 1.14), fair or poor compared with excellent self-rated health (RR, 2.9, 3.6), walking difficulty (RR, 3.6) and current smoking (RR, 1.9). People owning their homes had a decreased likelihood of nursing home placement (RR, 0.6). CONCLUSIONS: Incidence rates of institutional aged care doubled for each five-year interval from the age of 60 years. A range of non-cognitive factors predict nursing home placement.     

Do frail, disabled, poor, and very old Medicare beneficiaries have higher hospital charges?

To determine whether basing payments on diagnosis related groups (DRGs) results in mispayment for certain classes of patients, we examined the relation between total Medicare charges per hospitalization and eight beneficiary characteristics (including admission from a nursing home, extreme age, Medicaid enrollment, and disability). We controlled for the hospital in which care was given and the DRG to which the discharge was assigned. The largest effects were that average charges were 6.7% higher for beneficiaries who were disabled before the age of 65 years, and 6.2% higher for patients admitted from a nursing home; charges were 1.5% lower for Medicare beneficiaries who were also enrolled in Medicaid, 3.8% higher for those older than 80 years, and 1.3% lower for those older than 85 years compared with those aged from 80 to 84 years. Because these differences are very small compared with the average variation within DRGs, we conclude that using these beneficiary characteristics in the DRG classification system would only slightly improve DRGs. Medicare's DRG-based payments seem to be substantially equitable with regard to these beneficiary characteristics.     

Low bone mineral density and risk of fracture in white female nursing home residents

CONTEXT: Low bone mineral density (BMD) is a strong risk factor for fracture in community-dwelling white women, but the relationship in white female nursing home residents, for whom fracture rates are highest, is less clear. OBJECTIVE: To assess the relative contribution of low BMD to fracture risk in nursing home residents. DESIGN: Prospective cohort study with baseline data collected April 1995 to June 1997, with 18 months of follow-up. SETTING: Forty-seven randomly selected nursing homes in Maryland. PATIENTS: A total of 1427 white female nursing home residents aged 65 years or older. MAIN OUTCOME MEASURE: Documented osteoporotic fracture occurring during follow-up as a function of baseline BMD measurements higher vs lower than the median, and after controlling for demographic, functional, cognitive, psychosocial, and medical factors. RESULTS: A total of 223 osteoporotic fractures occurred among 180 women. Low BMD and transfer independence were significant independent risk factors for fracture in this nursing home sample (P<.001) and the 2 factors acted synergistically (P =.06) to further increase fracture risk. Compared with women whose BMD was higher than the median (0. 296 g/cm(2)), those whose BMD was lower than the median had an unadjusted hazard ratio for risk of fracture of 2.1 (95% confidence interval [CI], 1.5-2.8); women who were independent in transfer had a hazard ratio of 1.6 (95% CI, 1.2-2.2) compared with women dependent in transfer. Among residents independent in transfer, those with BMD below the median had a more than 3-fold increase in fracture risk compared with those with higher BMD (unadjusted hazard ratio, 3.1; 95% CI, 2.2-4.4). Among residents dependent in transfer, those with BMD below the median had a 60% increase in fracture risk (unadjusted hazard ratio, 1.6; 95% CI, 1.1-2.3). Adjustment for covariates did not alter the BMD-fracture relationship. CONCLUSIONS: Our data indicate that low BMD and independence in transfer are significant predictors of osteoporotic fracture in white female nursing home residents. JAMA. 2000;284:972-977     

Lifestyle factors and risk of dementia: Dubbo Study of the elderly

OBJECTIVE: To identify risk factors for dementia in an elderly Australian cohort. DESIGN AND SETTING: A longitudinal cohort study conducted in Dubbo, NSW. PARTICIPANTS: 2805 men and women aged 60 years and older living in the community and initially free of cognitive impairment, first assessed in 1988 and followed for 16 years. MAIN OUTCOME MEASURE: Admission to hospital or nursing home with any kind of dementia. RESULTS: There were 115 cases of dementia in 1233 men (9.3/100) and 170 cases in 1572 women (10.8/100). In a proportional hazards model for dementia, any intake of alcohol predicted a 34% lower risk, and daily gardening a 36% lower risk. Daily walking predicted a 38% lower risk of dementia in men, but there was no significant prediction in women. The lowest tertile of peak expiratory flow predicted an 84% higher risk of dementia, the upper tertile of depression score predicted a 50% higher risk. CONCLUSION: While excess alcohol intake is to be avoided, it appears safe and reasonable to recommend the continuation of moderate alcohol intake in those already imbibing, as well as the maintenance of physical activity, especially daily gardening, in the hope of reducing the incidence of dementia in future years.     

Continuing screening mammography in women aged 70 to 79 years: impact on life expectancy and cost-effectiveness

CONTEXT: Mammography is recommended and is cost-effective for women aged 50 to 69 years, but the value of continuing screening mammography after age 69 years is not known. In particular, older women with low bone mineral density (BMD) have a lower risk of breast cancer and may benefit less from continued screening. OBJECTIVE: To compare life expectancy and cost-effectiveness of screening mammography in elderly women based on 3 screening strategies. DESIGN: Decision analysis and cost-effectiveness analysis using a Markov model. PATIENTS: General population of women aged 65 years or older. INTERVENTIONS: The analysis compared 3 strategies: (1) Undergoing biennial mammography from age 65 to 69 years; (2) undergoing biennial mammography from age 65 to 69 years, measurement of distal radial BMD at age 65 years, discontinuing screening at age 69 years in women in the lowest BMD quartile for age, and continuing biennial mammography to age 79 years in those in the top 3 quartiles of distal radius BMD; and (3) undergoing biennial mammography from age 65 to 79 years. MAIN OUTCOME MEASURES: Deaths due to breast cancer averted, life expectancy, and incremental cost-effectiveness ratios. RESULTS: Compared with discontinuing mammography screening at age 69 years, measuring BMD at age 65 years in 10000 women and continuing mammography to age 79 years only in women with BMD in the top 3 quartiles would prevent 9.4 deaths and add, on average, 2.1 days to life expectancy at an incremental cost of $66773 per year of life saved. Continuing mammography to age 79 years in all 10000 elderly women would prevent 1.4 additional breast cancer deaths and add only 7.2 hours to life expectancy at an incremental cost of $117689 per year of life saved compared with only continuing mammography to age 79 years in women with BMD in the top 3 quartiles. CONCLUSIONS: This analysis suggests that continuing mammography screening after age 69 years results in a small gain in life expectancy and is moderately cost-effective in those with high BMD and more costly in those with low BMD. Women's preferences for a small gain in life expectancy and the potential harms of screening mammography should play an important role when elderly women are deciding about screening.     

Variations de l''incidence des fractures de l''extrémité supérieure du fémur chez les personnes agées de la région de Québec.

To estimate the incidence of fracture of the proximal end of the femur in people aged 50 years or older living in the Quebec area in 1971, 1976 and 1981 we determined the number of admissions for such fractures to the 15 acute care hospitals in the region. From 1971 to 1981 the number of fractures increased by 71%; the increases for those aged 75 to 84 years and 85 years or over were 98% and 118% respectively. The variation is only partly explained by changes in sex and age distribution of the population; the incidence rates also increased. Among men aged 75 to 84 years the incidence rate per 1000 person-years rose from 2.63 in 1971 to 5.22 in 1981, an increase of 98%; the corresponding figures for men aged 85 years or more were 9.76 and 16.91, an increase of 73%. Among women aged 75 to 84 years the rate rose from 7.28 to 8.81, an increase of 21%; the corresponding figures for women aged 85 years or more were 20.40 and 24.27, an increase of 21% and 19% respectively.     

Influence of age on Medicare expenditures and medical care in the last year of life

CONTEXT: Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain. OBJECTIVES: To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon. DESIGN, SETTING, AND PATIENTS: Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996. MAIN OUTCOME MEASURE: Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services. RESULTS: For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states. CONCLUSIONS: Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.     

云南省瑞丽傣族农村老人日常生活活动能力初步研究

目的 对云南省德宏州瑞丽市傣族农村老人失能情况进行调查研究,为边疆地区评估老年人养老服务需求、规划养老事业发展提供有参考价值的建议与意见。 方法 运用多阶段随机整群抽样方法进行样本抽取,采用国际通用的老年人日常生活活动能力(ADL)标准化评定量表-Barthel指数,对瑞丽市12个村民小组的187名傣族农村老人(≥60岁)失能情况进行评定。 结果 傣族农村老人失能率点估计及其95%置信区间分别为:重度失能率为6.95%(6.02%,7.88%),中度失能率为4.28%(3.69%,4.87%),轻度失能率为77.01%(74.47%,79.54%),无失能率为11.76%(10.28%,13.25%),合并重度与中度失能即中重度的失能率为11.23%(9.80%,12.66%)。分年龄段的ADL比较,呈现出明显的趋势:随着年龄的增加,失能越严重(P＜0.001);65岁前女性老人的失能状况比男性老人严重(P＜0.01)。65岁及以上,失能状况的性别差异无统计学意义(P＞0.05)。 结论 本文在国内首次报道了瑞丽傣族农村老人的失能率情况估计及其95%置信区间,为评估民族地区老年人长期照护服务需求和养老事业发展规划决策提供依据。瑞丽傣族农村老人随着年龄的增长,其日常生活活动能力(ADL)逐渐下降,失能率随之升高。女性年幼老人(≥60岁,≤65岁)日常生活活动能力低于男性老人。瑞丽傣族农村老人的中重度失能状况低于全国平均水平。      

综合内科65岁以上老年住院患者贫血发生情况

目的：了解住院老年患者贫血的发生率及对预后的影响。方法：回顾分析2000年1月～2006年6月我院高干科和高干保健科≥65岁老年住院患者821例，统计贫血发生率、可能的原因及死亡率。结果：按国内贫血标准，总的贫血发生率为23．87％，其中男性25．19％，女性21．35％；按WHO标准，总的贫血发生率为43．00％，其中男性43．15％，女性42．70％。同一标准内，男女贫血发生率无统计学意义（均P〉0．05）。按国内和WHO标准，65-74岁、75～84岁和〉85岁3个年龄组的贫血发生率均随年龄增长显著增加（P〈0．05，P〈0．01）。按国内及WHO标准，总死亡率贫血组明显高于非贫血组（36．73％和8％，23．51％和8．33％，均P〈0．01）。结论：在综合内科≥65岁老年住院患者中贫血发生率高．贫血比非贫血患者有更高的死亡率，应引起内科医师的高度重视。应积极查找贫血病因．对贫血进行有效的干预。     

Randomised controlled trial of health assessments for older Australian veterans and war widows

OBJECTIVE: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death. DESIGN: Randomised controlled trial of the effect of health assessments over 3 years. PARTICIPANTS AND SETTING: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans' Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942). INTERVENTION: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner. MAIN OUTCOME MEASURES: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up. RESULTS: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05-1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40-2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01). CONCLUSIONS: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.     

Development and validation of fall risk screening tools for use in residential aged care facilities

OBJECTIVE: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided. DESIGN AND SETTING: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 - June 2003. PARTICIPANTS: 2005 people aged 65-104 years (mean +/- SD, 85.7 +/- 7.1 years). MAIN OUTCOME MEASURES: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models. RESULTS: Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%). CONCLUSIONS: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls. The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia.     

慢性精神分裂症认知功能缺损的临床研究

目的 :调查慢性精神分裂症患者认知功能缺损的有关因素。方法 :应用 MMSE、HDS、BPRS、SANS、SAPS测定患者的认知水平和精神症状严重度。结果 :19.6 1%患者有认知功能缺损 ,与文化程度较低、年龄较大、病程较长、住院时间较长、阴性和阳性精神症状的严重度等密切相关 (P<0 .0 5～0 .0 0 1)。结论 :患者的认知功能缺损是长期患病和精神衰退的结果。     

Proportionate mortality trends: 1950 through 1986

Mortality trends in the United States from 1950 through 1986 were analyzed for the conditions that are or have recently been among the six leading causes of death. The age-adjusted mortality rate for all causes has decreased from 841.5 to 541.7 per 100,000 population. Cause-specific, age-adjusted mortality rates have declined from 1950 through 1986 for cerebrovascular disease, injuries, perinatal conditions, heart disease, and influenza and pneumonia. Time trends in the proportion of persons dying of each of these diseases, however, have varied; the proportion dying of cerebrovascular disease, injuries, and perinatal conditions has decreased, and the proportion of persons dying of heart disease and influenza and pneumonia has remained fairly stable from 1950 through 1986. During this same time, age-adjusted death rates have increased for chronic obstructive pulmonary disease and have remained fairly stable for malignant neoplasms, while the proportions of persons dying of chronic obstructive pulmonary disease and malignant neoplasms have increased dramatically. For people aged 35 to 64 years, malignant neoplasms have now overtaken heart disease as the leading cause of death. For those aged 65 years and older, heart disease remains the leading cause of death, accounting for almost 50% of all deaths in persons 85 years and older.     

上海市奉贤区老年人健康期望寿命及其影响因素的分析

目的计算上海市奉贤区60岁以上老年人的健康期望寿命(healthy life expectancy,HALE),分析HALE的主要影响因素。方法采用两阶段分层整群抽样的方法抽取1 696位奉贤区60岁以上老人进行问卷调查,采用Sullivan法计算HALE。结果 2015年奉贤区男、女性60~岁组老年人HALE分别为19.44岁和20.46岁,HALE损失率分别为15.04%和25.06%。70岁以下年龄组女性HALE均高于男性,差异有统计学意义(P0.05),但女性HALE损失率均大于同年龄组的男性。影响奉贤区老年人HALE的主要影响因素有性别、年龄、婚姻状况、合理体育锻炼、慢性病史,差异均有统计学意义(P0.05)。中风等脑血管疾病导致的HALE平均损失率最大。结论为提高老年人的HALE,应提倡健康的生活方式,重点防治中风等脑血管疾病,加强老年人尤其是女性老年人的健康保健服务。     

Relation of falls efficacy scale (FES) to quality of life among nursing home female residents with comparatively intact cognitive function in Japan

The purpose of this study was to investigate the relation of the Falls Efficacy Scale (FES) to quality of life (QOL) among nursing home residents. The subjects were 133 institutionalized women aged 70 years or older. They had comparatively intact cognitive function, with a Mini-Mental State Examination (MMSE) score of 15 or more, and could provide sufficient informed consent for a questionnaire survey. We evaluated their age, height, weight, body-mass index, history of hip fracture, history of fall(s) within the past year, complicating conditions, MMSE, Medical Outcomes Study 8-Item Short-Form Health Survey (SF-8), FES, and their subscores for Functional Independence Measure (FIM) motor items (self care, sphincter control, transfer, locomotion). There was a significant relationship between the Physical Component Summary (PCS) of SF-8 and FES. In each subscale, FES showed significant relations that were especially close in physical functioning (PF) and role physical (RP), with those relations proving stronger than those of the subscores of transfer and locomotion. In conclusion, the present results suggested that taking account of mental confidence is important for physical QOL, and that falls self-efficacy, including not only physical activity per se but also mental confidence, should be given prominence in the physical QOL of the institutionalized elderly.     

Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988-2002

Context  Pneumonia causes significant mortality and morbidity among persons aged 65 years or older. However, few studies have explored trends according to age groups, which may affect intervention strategies. Objectives  To examine trends in hospitalizations for pneumonia among persons aged 65 years or older and to compare characteristics, outcomes, and comorbid diagnoses. Design, Setting, and Patients  Data from 1988 through 2002 on pneumonia and comorbid diagnoses among patients aged 65 to 74 years, 75 to 84 years, and 85 years or older from the National Hospital Discharge Survey. Main Outcome Measures  Hospitalization rates by first-listed and any-listed discharge codes for pneumonia; proportions of hospitalizations reporting comorbid diagnoses for the 3 age groups (65-74 years, 75-84 years, 85 years). Results  Hospitalization rates by both first-listed and any-listed discharge codes for pneumonia increased by 20% from 1988-1990 to 2000-2002 for patients aged 65 to 74 years (P = .01) and for patients aged 75 to 84 years (P<.001). Rates of hospitalization for pneumonia were 2-fold higher for patients aged 85 years or older (51 per 1000 population for first-listed discharge code of pneumonia; 95% confidence interval [CI], 46-55 per 1000 population) than among patients aged 75 to 84 years (26 per 1000 population; 95% CI, 24-28 per 1000 population), but did not significantly increase from 1988-1990 to 2000-2002. The proportion of patients aged 65 years or older diagnosed with pneumonia and a chronic cardiac disease, chronic pulmonary disease, or diabetes mellitus increased from 66% (SE, 1.0%) in 1988-1990 to 77% (SE, 0.8%) in 2000-2002. The risk of death during a hospitalization for pneumonia compared with the risk of death during a hospital stay for the 10 other most frequent causes of hospitalization was 1.5 (95% CI, 1.4-1.7) and remained constant from 1988-1990 to 2000-2002. Conclusions  Hospitalization rates for pneumonia have increased among US adults aged 64 to 74 years and aged 75 to 84 years during the past 15 years. Among those aged 85 years or older, at least 1 in 20 patients were hospitalized each year due to pneumonia. Concomitantly, the proportion of comorbid chronic diseases has increased. Efforts to prevent pneumonia should include reducing preventable comorbid conditions and improving vaccine effectiveness and vaccination programs in elderly persons.      

Management of Pain in Elderly Patients With Cancer

Context.— Cancer pain can be relieved with pharmacological agents as indicated by the World Health Organization (WHO). All too frequently pain management is reported to be poor. Objective.— To evaluate the adequacy of pain management in elderly and minority cancer patients admitted to nursing homes. Design.— Retrospective, cross-sectional study. Setting.— A total of 1492 Medicare-certified and/or Medicaid-certified nursing homes in 5 states participating in the Health Care Financing Administration's demonstration project, which evaluated the implementation of the Resident Assessment Instrument and its Minimum Data Set. Study Population.— A group of 13625 cancer patients aged 65 years and older discharged from the hospital to any of the facilities from 1992 to 1995. Data were from the multilinked Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database. Main Outcome Measures.— Prevalence and predictors of daily pain and of analgesic treatment. Pain assessment was based on patients' report and was completed by a multidisciplinary team of nursing home personnel that observed, over a 7-day period, whether each resident complained or showed evidence of pain daily. Results.— A total of 4003 patients (24%, 29%, and 38% of those aged 85 years, 75 to 84 years, and 65 to 74 years, respectively) reported daily pain. Age, gender, race, marital status, physical function, depression, and cognitive status were all independently associated with the presence of pain. Of patients with daily pain, 16% received a WHO level 1 drug, 32% a WHO level 2 drug, and only 26% received morphine. Patients aged 85 years and older were less likely to receive either weak opiates or morphine than those aged 65 to 74 years (13% vs 38%, respectively). More than a quarter of patients (26%) in daily pain did not receive any analgesic agent. Patients older than 85 years in daily pain were also more likely to receive no analgesia (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.13-1.73). Other independent predictors of failing to receive any analgesic agent were minority race (OR, 1.63; 95% CI, 1.18-2.26 for African Americans), low cognitive performance (OR, 1.23; 95% CI, 1.05-1.44), and the number of other medications received (OR, 0.65; 95% CI, 0.5-0.84 for 11 or more medications). Conclusions.— Daily pain is prevalent among nursing home residents with cancer and is often untreated, particularly among older and minority patients.      

Demographic and epidemiologic considerations for developing preventive strategies in the elderly

More than 29 million Americans are aged 65 and older, over 12 percent of the US population. This number is expected to increase to 35 million by the turn of the century and to 67 million by the year 2050. Growth is expected to be greatest among the oldest and most disabled members of this group, those aged 85 and older. Persons 65 and older are the largest consumers of medical care; their care needs will be even greater as we enter and move through the twenty first century. Most persons needing long-term care will reside in the community, not in nursing homes. In light of these projections, we must be concerned with community based prevention at all levels.     

Health literacy among Medicare enrollees in a managed care organization

CONTEXT: Elderly patients may have limited ability to read and comprehend medical information pertinent to their health. OBJECTIVE: To determine the prevalence of low functional health literacy among community-dwelling Medicare enrollees in a national managed care organization. DESIGN: Cross-sectional survey. SETTING: Four Prudential HealthCare plans (Cleveland, Ohio; Houston, Tex; south Florida; Tampa, Fla). PARTICIPANTS: A total of 3260 new Medicare enrollees aged 65 years or older were interviewed in person between June and December 1997 (853 in Cleveland, 498 in Houston, 975 in south Florida, 934 in Tampa); 2956 spoke English and 304 spoke Spanish as their native language. MAIN OUTCOME MEASURE; Functional health literacy as measured by the Short Test of Functional Health Literacy in Adults. RESULTS: Overall, 33.9% of English-speaking and 53.9% of Spanish-speaking respondents had inadequate or marginal health literacy. The prevalence of inadequate or marginal functional health literacy among English speakers ranged from 26.8% to 44.0%. In multivariate analysis, study location, race/language, age, years of school completed, occupation, and cognitive impairment were significantly associated with inadequate or marginal literacy. Reading ability declined dramatically with age, even after adjusting for years of school completed and cognitive impairment. The adjusted odds ratio for having inadequate or marginal health literacy was 8.62 (95% confidence interval, 5.55-13.38) for enrollees aged 85 years or older compared with individuals aged 65 to 69 years. CONCLUSIONS: Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. Low health literacy may impair elderly patients' understanding of health messages and limit their ability to care for their medical problems.