Who Are the Uninsured Elderly in the United States?

Because of the Medicare program, a common assumption is made that virtually all older Americans have health insurance coverage. Data from the 2000 National Health Interview Survey were analyzed to estimate the number of people aged 65 and older without health insurance; their stated reasons for being uninsured; and the associations between lack of insurance and sociodemographic variables, health status, and access to and use of healthcare services. In 2000, there were approximately 350,000 older Americans with no health insurance. Those without insurance were more likely to be younger, Hispanic, nonwhite, unmarried (widowed, divorced, or never married), poor, and foreign-born. They were less likely to hold U.S. citizenship. Despite relatively high rates of chronic medical conditions, they were unlikely to receive outpatient or home healthcare services. The most common reason given for lack of insurance was its cost. This study reveals important gaps in the availability of health insurance for the elderly, gaps that are likely to affect an increasing number of older Americans in the coming decade.     

Rotablation in the Very Elderly – Safer than We Think?

Background/purposeCalcified coronary artery stenosis remains a challenge for Percutaneous Coronary Intervention (PCI). Calcium modification is facilitated by rotablation and is used in 1–3% of cases. Data on rotablation in patients ≥80 years is limited and perceived to be high risk.We compared PCI with rotablation and outcomes between patients ≥80 years and those <80 years.Methods/materialsRetrospective analysis was performed of consecutive patients who underwent rotablation and PCI from 3 United Kingdom (UK) PCI Centres (2014–2017). In-hospital outcomes (composite of stroke, myocardial infarction, death, emergency coronary artery bypass graft surgery, vascular damage, coronary perforation, advanced AV-block, bleeding and renal impairment) and 30 day mortality risk score was compared between groups.Results213 patients were included. 33.3% (n = 71) were ≥80 years. Baseline and angiographic characteristics were similar in the two groups. Older patients were more likely to present with acute coronary syndrome (ACS) (≥80 years 53.5% vs. 33.8% in <80 years, p = 0.006) and had increased hospital stay (≥80 years 2.8 days (±6.0) vs. 1.3 days (±1.9) <80 years, p = 0.009). Majority of PCI were performed through radial access (≥80 years 91.5% vs. 88.0% <80 years, p = 0.43). In-hospital composite outcomes were similar between the groups (≥80 years 5.6% vs. 4.9% <80 years, p = 1.0). The 30-day mortality risk score demonstrated a higher average risk of 2.5% in ≥80 years versus under 1% risk in <80 years (p < 0.001).ConclusionThis study demonstrates that outcomes after rotablation in the very elderly are similar to younger patients despite being high risk and presenting with ACS.     

Using the Apple Watch to Record Multiple-Lead Electrocardiograms in Detecting Myocardial Infarction: Where Are We Now?

Although the outcome after myocardial infarction depends on the time to treatment, a delay between symptom onset and treatment is common. Apple Watch, a popular wearable device, provides the ability to perform an electrocardiogram. We review the progress made in using the Apple Watch to record multiple electrocardiogram leads for diagnosing myocardial infarction. Although the data are encouraging, many limitations remain, and more research is needed. Nevertheless, the Apple Watch could eventually serve as a self-check tool for patients who have chest pains or other symptoms of myocardial infarction, thus substantially decreasing the time to treatment and improving the outcome after myocardial infarction.     

Are All Commonly Prescribed Antipsychotics Associated with Greater Mortality in Elderly Male Veterans with Dementia?

OBJECTIVES: To estimate mortality risk associated with individual commonly prescribed antipsychotics. DESIGN: Five‐year retrospective study. SETTING: Veterans national healthcare data. PARTICIPANTS: Predominantly male, aged 65 and older, with a diagnosis of dementia and no other indication for an antipsychotic. Subjects who received an antipsychotic were compared with randomly selected controls who did not. Exposed and control cohorts were matched according to their date of dementia diagnosis and time elapsed from diagnosis to the start of antipsychotic therapy. MEASUREMENTS: Mortality during incident antipsychotic use. RESULTS: Cohorts who were exposed to haloperidol (n=2,217), olanzapine (n=3,384), quetiapine (n=4,277), or risperidone (n=8,249) had more comorbidities than their control cohorts. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily dose of haloperidol greater than 1 mg (hazard ratio (HR)=3.2, 95% confidence interval (CI)=2.2–4.5, P<.001), olanzapine greater than 2.5 mg (HR=1.5, 95% CI=1.1–2.0, P=.01), or risperidone greater than 1 mg (HR=1.6, 95% CI=1.1–2.2, P=.01) adjusted for demographic characteristics, comorbidities, and medication history using Cox regression analyses. Greater mortality was not seen when a daily dose of quetiapine greater than 50 mg (HR=1.2, 95% CI=0.7–1.8, P=.50) was prescribed, and there was no greater mortality associated with a dose less than 50 mg (HR=0.7, 95% CI=0.5–1.0, P=.03). No antipsychotic was associated with greater mortality after the first 30 days. CONCLUSION: Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with a short‐term increase in mortality. Further investigations are warranted to identify patient characteristics and antipsychotic dosage regimens that are not associated with a greater risk of mortality in elderly patients with dementia.     

Microalbuminuria Screening in the UK: Are We Meeting European Standards?

European guidelines recommend annual screening for microalbuminuria in patients with Type 1 (insulin-dependent) diabetes mellitus (IDDM) of greater than 5 years' duration and in those with Type 2 (non-insulin-dependent) diabetes mellitus (NIDDM) from diagnosis. To determine the current provision of screening for microalbuminuria we performed a postal survey of all diabetologists in the United Kingdom. Of 556 questionnaires sent, 326 (59 %) were returned (246 adult, 57 paediatric, 3 adolescent clinics) and of these 306 (55 %) were suitable for analysis. Screening programmes have been established by 210 (69 %) diabetologists: 70 of these in the last 2 years. 46 more plan to screen patients with IDDM within 2 years. 155 (92 %) of 169 adult programmes perform annual screening in IDDM, 74 % according to European guidelines (39 % in NIDDM). Other clinics use age, type of diabetes or criteria such as blood pressure to target screening. An albumin/creatinine ratio (52 %) on an early morning urine (56 %) or random (29 %) urine sample is most commonly requested. Financial constraint was the principal reason given in 32 (33 %) of 96 clinics that do not currently screen. Other reasons included implementation of other developments with a higher priority (24 %) and doubts about the medical value of screening (46 %). Assuming respondents are representative of current UK practice, we conclude that microalbuminuria screening is available to patients in many clinics, but is neither universal nor always performed according to European guidelines.     

Does Incorporating Medications in the Surveyors' Interpretive Guidelines Reduce the Use of Potentially Inappropriate Medications in Nursing Homes?

OBJECTIVES: To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN: Quasi-experimental. SETTING: One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS: Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION: Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS: Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS: The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION: Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.