A pilot investigation of the short-term effects of an interdisciplinary intervention program on elderly patients with hip fracture in Taiwan

OBJECTIVES: To evaluate an interdisciplinary intervention program for older people with hip fracture in Taiwan. DESIGN: Randomized experimental design. SETTING: A 3,800-bed medical center in northern Taiwan. PARTICIPANTS: Elderly patients with hip fracture (N=137) were randomly assigned to an experimental (n=68) or control (n=69) group. INTERVENTION: An interdisciplinary program of geriatric consultation, continuous rehabilitation, and discharge planning. MEASUREMENTS: Demographic and outcome variables were measured. Outcome variables included service utilization, clinical outcomes, self-care abilities, health-related quality-of-life (HRQOL) outcomes, and depressive symptoms. RESULTS: Subjects in the experimental group improved significantly more than those in the control group in the following outcomes: ratio of hip flexion 1 month after discharge (P=.02), recovery of previous walking ability at 1 month (P=.04) and 3 months (P=.001) after discharge, and activities of daily living at 1 month (P=.01) and 2 months (P=.001) after discharge. Three months after discharge, the experimental group showed significant improvement in peak force of the fractured limb's quadriceps (P=.04) and the following health outcomes: bodily pain (P=.03), vitality (P<.001), mental health (P=.02), physical function (P<.001), and role physical (P=.006). They also had fewer depressive symptoms (P=.008) 3 months after discharge. CONCLUSION: This intervention program may benefit older people with hip fractures in Taiwan by improving their clinical outcomes, self-care abilities, and HRQOL and by decreasing depressive symptoms within 3 months after discharge.     

A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients

OBJECTIVES: To evaluate the effectiveness of an enhanced balance training program in improving mobility and well-being of elderly people with balance problems. DESIGN: Prospective, single-blind, randomized, controlled trial. SETTING: District general hospital. PARTICIPANTS: One hundred ninety-nine patients aged 60 and older with a Berg Balance Scale (BBS) score of less than 45. INTERVENTIONS: Six weeks enhanced balance training consisting of a series of repetitive tasks of increasing difficulty specific to functional balance. The control group received physiotherapy conforming to existing practice in elderly patients with mobility problems. MEASUREMENTS: Ten-meter timed walk test (TWT), BBS, Frenchay Activities Index (FAI), Falls Handicap Inventory (FHI), and European Quality of Life questionnaire (Euroqol) measured at 6, 12, and 24 weeks after intervention. RESULTS: The mean age +/- standard deviation of subjects was 82.7 +/- 5.6, and baseline characteristics were comparable between the groups. Both groups showed improvements in TWT (intervention: 22.5-16.5 seconds, P =.001; control: 20.5-15.8 seconds, P =.054), BBS (intervention: 33.3-42.7, P =.001; control: 33.4-42.0, P <.0001), FAI (18-21, P =.02 in both groups), FHI score (intervention: 31-17, P =.0001; control: 33-17, P =.0001) and Euroqol score (intervention: 58-65, P =.04; control: 60-65, P =.07). There were no intergroup differences at any time. More patients reported increased confidence in walking indoors (36% vs 28%; P =.04) and outdoors (27% vs 18%; P =.02) in the enhanced balance-training group. CONCLUSION: Exercise programs significantly improve balance and mobility in patients with balance problems, independent of strategy. Enhanced balance training may, in addition, improve confidence and quality of life but needs further investigation.     

Cardiac rehabilitation in patients with myocardial infarction: a 10-year follow-up study

INTRODUCTION AND OBJECTIVES: Very little information is available on the effect of cardiac rehabilitation programs on long-term survival. The primary aim of this study was to assess the effect of a structured cardiac rehabilitation program on mortality in patients who had suffered acute myocardial infarction. The secondary endpoint was the effect on morbidity. PATIENTS AND METHOD: The study included 180 low-risk male patients aged under 65 years. Patients were randomly assigned to one of 2 groups: 90 entered into a comprehensive cardiac rehabilitation program, and 90 served as a control group. The mean follow-up period was 10 years. RESULTS: All-cause mortality was significantly lower in the intervention group: the 10-year survival rate was 91.8% in the intervention group compared with 81.7% in the control group (P=.04). There was also a decrease in cardiovascular mortality, though it was not statistically significant: the 10-year survival rate was 91.8% in the intervention group compared with 83.8% in the control group (P=.10). The incidence of non-fatal complications was lower in the intervention group (35.2% vs 63.2%, P=.03), as was the incidence of unstable angina (15.7% vs 33.9%, P =.02) and cardiac heart failure (3.0% vs 14.4%, P=.02), and the need for coronary intervention (8.4% vs 22.9%, P=.02). CONCLUSIONS: The application of a comprehensive cardiac rehabilitation program significantly decreased long-term mortality and morbidity in low-risk patients after acute myocardial infarction.     

Recurrent Falls and Dual Task–Related Decrease in Walking Speed: Is There a Relationship?

OBJECTIVES: To determine whether dual task–related changes in walking speed were associated with recurrent falls in frail older adults.
DESIGN: Twelve-month prospective cohort study.
SETTING: Thirteen senior housing facilities.
PARTICIPANTS: Two hundred thirteen subjects (mean age 84.4±5.5).
MEASUREMENTS: Usual and dual-tasking walking speeds (m/s) were calculated on a 10-m straight walkway at baseline. Information on incident falls during the follow-up year was collected monthly, and participants were divided into three groups based on the occurrence of falls (0, 1, and ≥2). Recurrent falls were defined as two or more falls during the 12-month follow-up period.
RESULTS: Twenty subjects (9.4%) were classified as recurrent fallers. The occurrence of recurrent falls was associated with age (crude odds ratio (OR)=1.11, P =.02), number of drugs (crude OR=1.28, P =.002), and walking speed under both walking conditions (crude OR=0.96, P =.002 for usual walking and crude OR=0.60, P =.005 for walking while counting backward). Multiple Poisson regression showed that only walking speed while dual tasking and number of drugs were associated with incident falls (incident rate ratio (IRR)=0.84, P =.045 and IRR=1.10, P =.004).
CONCLUSION: Slower walking speed while counting backward was associated with recurrent falls, suggesting that changes in gait performance while dual tasking might be an inexpensive way of identifying frail older adults prone to falling.     

Older People Contact More Obstacles When Wearing Multifocal Glasses and Performing a Secondary Visual Task

OBJECTIVES: To determine whether wearing multifocal glasses affects obstacle avoidance and eye and head movements during walking with and without a secondary visual task in older people.
DESIGN: Randomized order, cross-over, controlled comparison.
SETTING: Falls laboratory, medical research institute.
PARTICIPANTS: Thirty community-living adults aged 65 and older.
MEASUREMENTS: Obstacle contacts, secondary-task errors, average head angle (HA) in pitch, and peak-to-peak pitch amplitude of the eye (PA-E) and the head (PA-H) were assessed during obstacle-only and dual-task trials that required participants to read a series of letters presented in front of them at eye level under multifocal and single-lens glasses conditions.
RESULTS: When wearing multifocal lens glasses, participants performed the obstacle-only trials more slowly ( P =.004) and contacted more obstacles in the dual-task trials ( P =.001) than when wearing single-lens glasses. For the dual task trials under the multifocal glasses condition, greater PA-E was associated with more obstacle contacts (ρ=0.409, P =.02) and greater PA-H was associated with more secondary-task errors (ρ=0.583 P =.002). Lower HA was associated with more secondary-task errors (ρ=0.608, P =.002) and increased PA-H (ρ=0.426, P =.02).
CONCLUSION: The findings demonstrate that older adults contact more obstacles while walking with their attention divided when wearing multifocal glasses. This is probably because of a failure to adopt a compensatory increase in pitch head movement, resulting in blurred vision of obstacles viewed through the lower segments of multifocal glasses.     

Physical and mental health status of older long-term cancer survivors

OBJECTIVES: To assess the physical and mental health status of older long-term cancer survivors. DESIGN: Cohort study using propensity score methods to control for baseline differences between cancer survivors and controls. SETTING: General community population in the United States. PARTICIPANTS: Nine hundred sixty-four cancer patients who had survived for more than 4 years and 14,333 control patients who had never had cancer from a population-based sample of Americans aged 55 and older responding to the 2002 Health and Retirement Study. MEASUREMENTS: Medical conditions, symptoms, health behaviors, health status, mobility, activities of daily living, mental health diagnoses, self-rated memory, depressive symptoms, cognitive function, and self-reported life expectancy. RESULTS: Cancer survivors reported higher rates of lung disease (13.9% vs 9.6%; P=.001), heart condition (29.3% vs 22.9%; P<.001), arthritis (69.4% vs 59.4%; P<.001), incontinence (26.6% vs 19.7%; P=.001), frequent pain (36.4% vs 29.4%; P=.005), and obesity (27.0% vs 24.2%; P=.001) than individuals without cancer but lower rates of smoking (12.0% vs 14.8%; P=.03). Cancer survivors were less likely than persons without cancer to report excellent or very good health status (37.2% vs 44.6%; P<.001) and had more mobility (P<.001) and activity of daily living (P=.01) limitations. Cancer survivors did not differ from persons without cancer in rates of depression or cognitive function (both P>.2) but were less optimistic about their life expectancy (P=.004). CONCLUSION: The physical health status of older long-term cancer survivors is somewhat worse than that of comparable persons who have never had cancer, but they have surprisingly similar mental health status. Future research is needed to understand factors contributing to poorer health status and identify patients at highest risk of long-term cancer-related problems.     

Does a depression intervention result in improved outcomes for patients presenting with physical symptoms?

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1). depression management and outcomes under usual care conditions, and 2). the impact of an intervention to improve management and outcomes. DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P =.06), receipt of any antidepressant (63.0% vs 20.1%; P =.001), and an adequate antidepressant trial (34.9% vs 5.9%; P =.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P =.01) and an adequate antidepressant trial (46.0% vs 23.8%; P =.004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.     

Yoga Decreases Kyphosis in Senior Women and Men with Adult-Onset Hyperkyphosis: Results of a Randomized Controlled Trial

OBJECTIVES: To assess whether a specifically designed yoga intervention can reduce hyperkyphosis.
DESIGN: A 6-month, two-group, randomized, controlled, single-masked trial.
SETTING: Community research unit.
PARTICIPANTS: One hundred eighteen women and men aged 60 and older with a kyphosis angle of 40° or greater. Major exclusions were serious medical comorbidity, use of assistive device, inability to hear or see adequately for participation, and inability to pass a physical safety screen.
INTERVENTION: The active treatment group attended hour-long yoga classes 3 days per week for 24 weeks. The control group attended a monthly luncheon and seminar and received mailings.
MEASUREMENTS: Primary outcomes were change (baseline to 6 months) in Debrunner kyphometer-assessed kyphosis angle, standing height, timed chair stands, functional reach, and walking speed. Secondary outcomes were change in kyphosis index, flexicurve kyphosis angle, Rancho Bernardo Blocks posture assessment, and health-related quality of life (HRQOL).
RESULTS: Compared with control participants, participants randomized to yoga experienced a 4.4% improvement in flexicurve kyphosis angle ( P =.006) and a 5% improvement in kyphosis index ( P =.004). The intervention did not result in statistically significant improvement in Debrunner kyphometer angle, measured physical performance, or self-assessed HRQOL (each P >.1).
CONCLUSION: The decrease in flexicurve kyphosis angle in the yoga treatment group shows that hyperkyphosis is remediable, a critical first step in the pathway to treating or preventing this condition. Larger, more-definitive studies of yoga or other interventions for hyperkyphosis should be considered. Targeting individuals with more-malleable spines and using longitudinally precise measures of kyphosis could strengthen the treatment effect.     

Interdisciplinary intervention for hip fracture in older Taiwanese: benefits last for 1 year

BACKGROUND: Little is known about the effects of interventions for elderly patients with hip fracture in Asian countries, particularly beyond the short term. METHODS: Outcomes (service utilization, clinical outcomes, self-care ability, and depressive symptoms) were assessed at 1, 3, 6, and 12 months after discharge. Self-care ability (ability to perform activities of daily living [ADLs]), was measured by the Chinese Barthel Index. Depressive symptoms were measured by the Chinese Geriatric Depression Scale, short form. RESULTS: The experimental group (n = 80) had a significantly better ADL trajectory than the control group (n = 82) during the 1st year after discharge (p =.002). More participants in the experimental group than in the control group recovered their previous walking ability both at 6 months (81% vs 58%, respectively) and 12 months (84% vs 66%, respectively) after discharge. Overall, the odds ratio for the experimental group recovering their previous walking ability was 2.72 (p <.001) compared to the control group. The experimental group had significantly fewer depressive symptoms than the control group during the 1st year following discharge (p =.004). CONCLUSION: An interdisciplinary intervention for hip fracture with a discharge support component benefited elderly persons with hip fracture by improving both self-care ability and walking ability, and by decreasing depressive symptoms during the 1st year after hospital discharge.     

Exercising body and mind: an integrated approach to functional independence in hospitalized older people

OBJECTIVES: To evaluate the effect of a structured, multi-component, early rehabilitation program on functional status, delirium, and discharge outcomes of older acute medical inpatients.
DESIGN: Prospective controlled trial with blinded outcome evaluation.
SETTING: Internal medicine service of a metropolitan tertiary teaching hospital in Brisbane, Australia.
PARTICIPANTS: One hundred twenty-four consecutive inpatients aged 65 and older admitted from the emergency department to control or intervention medical ward. Exclusions included patients completely dependent before admission or admitted from a nursing home, patients too ill to participate or terminally ill, and patients with length of stay less than 72 hours.
INTERVENTION: Early physiotherapy review with provision of an individualized graduated exercise program and activity diary, progressive encouragement of functional independence by nursing staff and other members of the multidisciplinary team, and cognitive stimulation sessions.
MEASUREMENTS: Modified Barthel Index (MBI) at admission and discharge, timed up-and-go at admission and discharge, incidence of delirium and falls, measured activity, length of hospital stay, discharge destination, 30-day readmission rate.
RESULTS: Intervention and control participants were well matched in terms of age, sex, diagnosis, and functional status. The intervention group had greater improvement in functional status than the control group, with a median MBI improvement of 8.5 versus 3.5 points ( P =.03). In the intervention group, there was a reduction in delirium (19.4% vs 35.5%, P =.04) and a trend to reduced falls (4.8% vs 11.3%, P =.19). Length of stay, timed up-and-go, discharge destination, and readmissions did not differ between the groups.
CONCLUSION: This intervention was effective in improving function in a vulnerable patient group.     

Effectiveness of multidimensional exercises for the treatment of stress urinary incontinence in elderly community-dwelling Japanese women: a randomized, controlled, crossover trial

OBJECTIVES: To evaluate the effectiveness of pelvic floor muscle (PFM) and fitness exercises in reducing urine leakage in elderly women with stress urinary incontinence (UI).
DESIGN: Randomized, crossover, follow-up trial.
SETTING: Urban community in Japan.
PARTICIPANTS: Seventy women aged 70 and older who reported urine leakage one or more times per month; 35 were randomly assigned to intervention and the other 35 to control.
INTERVENTION: The intervention group attended an exercise class aimed at enhancing PFMs and fitness. Duration of the exercise was 60 minutes per session twice a week for 3 months. After 3 months of exercise, the intervention group was followed for 1 year.
MEASUREMENTS: Body mass index (BMI), urine leakage, walking speed, and muscle strength were measured at baseline, after the intervention, and at follow-up.
RESULTS: In the intervention group, maximum walking speed and adductor muscle strength increased significantly after the intervention; there were no significant changes in the control group. After 3 months of exercise, 54.5% of the intervention group and 9.4% of the control group reported being continent. Within the cured group of UI, a significantly higher proportion had decreased their BMI at 3 months ( P =.03) and increased walking speed at 3 ( P =.04) and 12 ( P =.047) months.
CONCLUSION: Decrease in BMI and increase in walking speed may contribute to the treatment of UI, although the data do not support a positive correlation between strengthening of adductor muscle and improvement of UI, which needs more research.     

Healthcare Proxies of Nursing Home Residents with Advanced Dementia: Decisions They Confront and Their Satisfaction with Decision-Making

OBJECTIVES: To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.
DESIGN: Prospective cohort study.
SETTING: Twenty-two Boston-area NHs.
PARTICIPANTS: Three hundred twenty-three NH residents with advanced dementia and their HCPs.
MEASUREMENTS: Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0–100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).
RESULTS: Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score±standard deviation was 78.4±19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit ( P =.002), greater resident comfort ( P =.004), and the HCP not being the resident's child ( P =.02).
CONCLUSION: HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.     

Knowledge and attitudes regarding cardiovascular disease risk and prevention in patients with coronary or peripheral arterial disease

BACKGROUND: We compared perceptions regarding risk of cardiovascular events and benefits of cardiovascular disease (CVD) risk factor reduction between patients with peripheral arterial disease (PAD), patients with coronary artery disease (CAD), and patients without atherosclerosis (no disease). METHODS: Participants with no disease (n = 142) had a normal ankle-brachial index and no clinically evident atherosclerosis (group 1). The PAD participants (n = 136) had an ankle-brachial index less than 0.90 and no other clinically evident atherosclerosis (group 2). Participants with CAD (n = 70) had a normal ankle-brachial index and a history of heart disease (group 3). Participants were interviewed regarding risk of mortality, CVD, and the importance of CVD risk factor reduction for hypothetical patients with PAD and CAD. RESULTS: All groups reported that risks of myocardial infarction, stroke, and death were higher for a patient with CAD than for a patient with PAD. Group 2 was less likely than group 3 to believe that PAD is associated with an extremely high risk of stroke (13.3% vs 28.7%; P =.005) or mortality (10.9% vs 26.6%; P =.003). Group 2 was less likely than group 1 to believe that a patient with PAD has a very high risk of myocardial infarction (13.1% vs 23.8%; P =.02), stroke (13.3% vs 27.5%; P =.003), or mortality (10.9% vs 24.3%; P =.004). Compared with group 3, a smaller percentage of patients in group 2 reported that cholesterol lowering was very important in PAD (57.5% vs 75.8%; P =.005). CONCLUSIONS: Compared with other patients, those with PAD underestimated the high risk of cardiovascular events associated with PAD and the benefits of cholesterol-lowering therapy. These findings may help explain the low rates of CVD risk factor control previously reported in patients with PAD.     

Detection of Mild Hyposalivation in Elderly People Based on the Chewing Time of Specifically Designed Disc Tests: Diagnostic Accuracy

OBJECTIVES: To compare sialometry with chewing time (including swallowing) of specifically designed disc tests.
DESIGN: Index test versus reference standard (sialometry; 60 patients); reliability study (10 patients).
SETTING: Outpatient dental clinic and geriatric ward, Nice University Hospital, France.
PARTICIPANTS: Thirty adults and 30 older patients (mean ages 47 and 84).
INTERVENTION: Index test assessment in patients with and without hyposalivation.
MEASUREMENTS: Data from medical files, interviews and oral examination were collected. Sialometry (stimulated salivary flow rate (SSFR) mL/min) and disc chewing times (seconds) were measured.
RESULTS: Sialometry was too long and was inappropriate for five of the 30 older persons. Chewing times were negatively correlated to sialometry results (Spearman correlation coefficient ( R )=0.77, P <.001). The threshold to diagnose hyposalivation (SSFR <1 mL/min) was 40 seconds (area under the receiver operating characteristic curve (AUC)=0.921, 100% sensitivity, 72% specificity). Twenty-seven subjects with a SSFR less than 1.5 mL/min had a chewing time longer than 40 seconds, suggesting that mild hyposalivation and eating difficulties were related (AUC=0.941, 93% sensitivity, 88% specificity). Mean chewing time was greater with xerostomia (51.9 vs 30.7 seconds, P <.001) but not with dental pain (39.5 vs 39.9, P =.96). Masticatory percentage (e.g., pairs of antagonistic teeth) had no effect on chewing time (SSFR <1 mL/min, AUC=0.921; SSFR <1.5 mL/min, AUC=0.950). Reliability was better for the disc test than for sialometry (intraclass correlation 0.85 vs 0.70).
CONCLUSION: This disc test was conceived to detect mild hyposalivation in geriatric patients with impaired dental health. Early detection of hyposalivation could help to suppress or avoid xerostomia-inducing drugs and to prevent oral infections and dental caries.     

Dementia undiagnosed in poor older adults with functional impairment

OBJECTIVES: To identify variables associated with diagnosing dementia in poor older adults by comparing older people with dementia who were diagnosed by their primary care physicians (PCPs) with those not diagnosed by their PCP.
DESIGN: Observational study.
SETTING: Community-based, in-home cognitive assessment program.
PARTICIPANTS: Four hundred eleven adults aged 55 and older with cognitive impairment.
MEASUREMENTS: Instrumental activities of daily living (IADLs), activities of daily living (ADLs), Mini-Mental State Examination, Short Blessed Memory Orientation and Concentration Test, and Clinical Dementia Rating.
RESULTS: Alzheimer's disease was the most common diagnosis in this group of primarily African-American (73%) older people. Of the 411 participants, 232 (56%) were not diagnosed by their PCP. Participants without a previous diagnosis were older (mean age 81.7 vs 78.7, P =.01), more independent in IADLs ( P <.001), and more likely to live alone ( P =.001) than persons diagnosed by their PCP. Of the 201 who lived alone, 66% were not diagnosed with dementia by their PCP. Variables associated with PCP diagnosis were more severe cognitive impairment ( P <.001), spouse caregiver ( P =.009), younger age ( P =.02) and care from a university-based PCP ( P =.04).
CONCLUSION: Persons with dementia who were older and lived alone were less likely to be diagnosed by their PCP. Although persons not diagnosed by their PCP had less cognitive impairment, they had substantial impairment in activities, including handling finances, cooking, and managing medications.     

Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial

OBJECTIVES: To evaluate whether an early multidisciplinary geriatric intervention in elderly patients with hip fracture reduced length of stay, morbidity, and mortality and improved functional evolution. DESIGN: Randomized, controlled intervention trial. SETTING: Orthopedic ward in a university hospital. PARTICIPANTS: Three hundred nineteen patients aged 65 and older hospitalized for hip fracture surgery. INTERVENTION: Participants were randomly assigned to a daily multidisciplinary geriatric intervention (n=155) or usual care (n=164) during hospitalization in the acute phase of hip fracture. MEASUREMENTS: Primary endpoints were in-hospital length of stay and incidence of death or major medical complications. Secondary endpoints were the rate of recovery of previous activities of daily living and ambulation ability at 3, 6, and 12 months. RESULTS: Median length of stay was 16 days in the geriatric intervention group and 18 days in the usual care group (P=.06). Patients assigned to the geriatric intervention showed a lower in-hospital mortality (0.6% vs 5.8%, P=.03) and major medical complications rate (45.2% vs 61.7%, P=.003). After adjustment for confounding variables, geriatric intervention was associated with a 45% lower probability of death or major complications (95% confidence interval=7-68%). More patients in the geriatric intervention group achieved a partial recovery at 3 months (57% vs 44%, P=.03), but there were no differences between the groups at 6 and 12 months. CONCLUSION: Early multidisciplinary daily geriatric care reduces in-hospital mortality and medical complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital stay or long-term functional recovery.     

A comparative study of community- and nursing home-acquired empyema thoracis

OBJECTIVES: To compare the clinical presentation, microbiological features, and outcomes of patients with community-acquired empyema (CAE) with those of patients with nursing home-acquired empyema (NHAE).
DESIGN: A retrospective observational study.
SETTING: Three tertiary care centers.
PARTICIPANTS: One hundred fourteen patients admitted from the community and 55 patients transferred from nursing homes.
MEASUREMENTS: Baseline sociodemographic information, activities of daily living, Charlson Comorbidity Index score, and clinica, and microbiologic data were obtained. Outcome was assessed at hospital discharge and 6 months postdischarge.
RESULTS: Patients admitted from nursing homes had a delayed presentation, with dyspnea, weight loss, and anemia as the predominant manifestation. Patients with CAE presented more acutely, with fever, cough, and chest pain. Anaerobic organisms were more commonly isolated from patients with NHAE. The success rate of nonsurgical intervention was significantly lower for the NHAE patients than for the CAE group (39% vs 63; P =.01). In-hospital mortality was not significantly different between the two groups (NHAE, 18%; CAE, 8%; P =.09). In a Cox regression analysis, preadmission functional status (hazard ratio (HR)=1.26, 95% confidence interval (CI)=1.19–1.4; P <.001) and surgical intervention (HR=0.47, 95% CI=0.24–0.92; P =.03) were the only variables highly correlated with long-term outcome.
CONCLUSION: Patients admitted with NHAE have distinctly different clinical and microbiological presentation from that of patients with CAE. Because of the delayed presentation in patients with NHAE, medical treatment alone may be associated with higher rate of failure. Surgical therapy should be considered for selected cases, with the aim of improving long-term survival.     

Effects of a Multicomponent Cognitive Behavioral Group Intervention on Fear of Falling and Activity Avoidance in Community-Dwelling Older Adults: Results of a Randomized Controlled Trial

OBJECTIVES: To evaluate the effects of a multicomponent cognitive behavioral intervention on fear of falling and activity avoidance in older adults.
DESIGN: Randomized controlled trial.
SETTING: Community-dwelling adults in the Netherlands.
PARTICIPANTS: Five hundred forty adults aged 70 and older who reported fear of falling and fear-induced activity avoidance (280 intervention, 260 control).
INTERVENTION: A multicomponent cognitive behavioral group intervention consisting of eight weekly sessions and a booster session. The sessions were aimed at instilling adaptive and realistic views on falls, reducing fall risk, and increasing activity and safe behavior.
MEASUREMENTS: Data on fear of falling, activity avoidance, concerns about falling, perceived control over falling, and daily activity were collected at baseline and at 2, 8, and 14 months.
RESULTS: At 2 months, there were significant between-group differences in fear of falling (odds ratio (OR)=0.11; P <.001), activity avoidance (OR=0.26; P <.001), concerns about falling (adjusted mean difference=−1.51; P =.02), and daily activity (adjusted mean difference=0.95; P =.01). At 8 months, there were significant between-group differences in all outcomes and at 14 months in fear of falling ( P =.001), perceived control over falling ( P =.001), and recurrent fallers ( P =.02) but not in activity avoidance ( P =.07), concerns about falling ( P =.07), daily activity ( P =.24), or fallers ( P =.08).
CONCLUSION: This multicomponent cognitive behavioral intervention showed positive and durable effects on fear of falling and associated activity avoidance in community-dwelling older adults. Future research should focus on improving intervention uptake and adherence, reaching frailer populations, and determining potential intervention effects on functional outcomes.     

Sex differences in peripheral arterial disease: leg symptoms and physical functioning

OBJECTIVES: To compare lower extremity functioning and leg symptoms between women and men with peripheral arterial disease (PAD). DESIGN: Cross-sectional. SETTING: Three Chicago-area medical centers. PARTICIPANTS: One hundred eighty-seven women and 273 men with PAD identified consecutively in patients in the noninvasive vascular laboratories and a general medicine practice at the three medical centers. MEASUREMENTS: Walking speed, 6-minute walk, accelerometer-measured 7-day physical activity, and a summary performance score. The summary performance score combines data on walking velocity, time for five repeated chair rises, and standing balance to achieve a score on a 0 to 12 scale (12 = best). RESULTS: Women with PAD were older and had a lower prevalence of prior leg revascularization, a higher prevalence of spinal stenosis, and a lower prevalence of other cardiovascular disease than men with PAD. Mean ankle brachial index (ABI) values +/- standard deviation were similar in women and men with PAD (0.64 +/- 0.15 vs 0.66 +/- 0.14, P =.15). Women with PAD were significantly more likely than men with PAD to have exertional leg pain that sometimes begins at rest (27.8% vs 13.2%, P <.001). Women with PAD had slower walking speed (0.81 vs 0.92 m/s, P <.001), shorter 6-minute walk distance (1,047 vs 1,182 feet, P <.001), and a poorer summary performance score (8.9 vs 9.8, P <.001) than men with PAD, adjusting for age, race, height, comorbid disease, and leg symptoms. After adjusting for leg strength, sex differences in 6-minute walk performance and summary performance score were attenuated modestly (1,089 vs 1,177 feet for 6-minute walk, P =.022 and 9.2 vs 9.8 for summary performance score, P =.027). CONCLUSION: Women with PAD had a higher prevalence of leg pain on exertion and rest, poorer functioning, and greater walking impairment from leg symptoms than men with PAD. A higher prevalence of spinal stenosis in women may explain the observed sex differences in leg symptoms. Poorer leg strength in women may contribute to poorer lower extremity functioning in women with PAD than in men with PAD.     

Nonagenarian Siblings and Their Offspring Display Lower Risk of Mortality and Morbidity than Sporadic Nonagenarians: The Leiden Longevity Study

OBJECTIVES: To compare the risk of mortality of nonagenarian siblings with that of sporadic nonagenarians (not selected on having a nonagenarian sibling) and to compare the prevalence of morbidity in their offspring with that of the offsprings' partners.
DESIGN: Longitudinal (mortality risk) and cross-sectional (disease prevalence).
SETTING: Nationwide sample.
PARTICIPANTS: The Leiden Longevity Study consists of 991 nonagenarian siblings derived from 420 Caucasian families, 1,365 of their offspring, and 621 of the offsprings' partners. In the Leiden 85-plus Study, 599 subjects aged 85 were included, of whom 275 attained the age of 90 (sporadic nonagenarians).
MEASUREMENTS: All nonagenarian siblings and sporadic nonagenarians were followed for mortality (with a mean±standard deviation follow-up time of 2.7±1.4 years and 3.0±1.5 years, respectively). Information on medical history and medication use was collected for offspring and their partners.
RESULTS: Nonagenarian siblings had a 41% lower risk of mortality ( P <.001) than sporadic nonagenarians. The offspring of nonagenarian siblings had a lower prevalence of myocardial infarction (2.4% vs 4.1%, P =.03), hypertension (23.0% vs 27.5%, P =.01), diabetes mellitus (4.4% vs 7.6%, P =.004), and use of cardiovascular medication (23.0% vs 28.9%, P =.003) than their partners.
CONCLUSION: The lower mortality rate of nonagenarian siblings and lower prevalence of morbidity in their middle-aged offspring reinforce the notion that resilience against disease and death have similar underlying biology that is determined by genetic or familial factors.